RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXXX	      CASE:  PD-2014-03260
BRANCH OF SERVICE:  Army                                                                   SEPARATION DATE:  20020626                                                                          

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E1, Basic Trainee, medically separated for “chronic pain due to right patellofemoral, right tibial shaft stress reaction and right foot and ankle pain condition” with a  disability rating of 0%. 

CI CONTENTION:  The CI requests the board consider all conditions.  The CI’s complete submission is at Exhibit A

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44.  It is limited to those conditions determined by the Physical Evaluation Board (PEB) to be unfitting for continued military service and when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting.  Any conditions outside the Board’s defined scope of review and any contention not requested in this application may remain eligible for future consideration by the Board for Correction of Military Records.  Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The Board’s assessment of the PEB rating determinations is based on review of medical records and all available evidence for application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards to the unfitting medical condition at the time of separation.  The Board has neither the role nor the authority to compensate for post-separation progression or complications of service-connected conditions.  That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws.  The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation.  

RATING COMPARISON:  

SERVICE PEB - 20020516	VARD - 20021213	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Pain due to Right Patellofemoral, Right Tibial Shaft Stress Reaction and Right Foot and Ankle Pain	5099-5003	0%	Patellofemoral Syndrome	5257	0%	20021031	
			Residuals, Stress Fracture Right Tibia	5010-5022	0%	20021031	
			Right Ankle Strain	5299-5271	0%	20021031	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:   0%	

ANALYSIS SUMMARY:  

Chronic Pain due to Right Patellofemoral, Right Tibial Shaft Stress Reaction and Right Foot and Ankle Pain Condition.  The record shows that the CI entered active duty on 16 October 2001 and developed bilateral lower extremity pain at multiple sites while in basic training.  The initial record in evidence is an X-ray request dated 17 December 2001 which noted a history of bilateral knee, leg, and ankle pain for over 3 weeks (week 4 of basic training).  The pain was aggravated by running and marching.  He was tender over both knees and the shin bones.  The X-ray of the right leg was normal.  The next record in evidence is a primary care note date 29 January 2002 when the CI presented for a 3-4 day history of right ankle pain and a 2-month history of knee pain.  Tenderness was noted over both knees and feet.  A bone scan on 4 February 2002 showed stress changes in both knees and feet and early stress fractures in both shins (shin splints).  He was treated with medications and duty restrictions.  His pain persisted and he was then evaluated in orthopedics on 5 April 2002.  The CI also reported right ankle pain at that visit.  His examination was normal and no injury was reported.  No etiology for the pain was determined.  An X-ray was normal.  At an orthopedic follow-up appointment on 22 April 2002, the CI reported that he had started running after his profile ended and had increased pain over the right shin and knee.  He was thought to have right patello-femoral syndrome, a right tibial stress fracture (shin splint), and right foot and ankle pain.  A Medical Evaluation Board was initiated.  At the narrative summary (NARSUM) dated 9 May 2002, 7 weeks prior to separation, the CI reported persistent pain of the right ankle, shin, and knee since prior to Thanksgiving 2001.  Treatment had been unsuccessful.  He was noted to have slight, occasional pain.  On examination, he was noted to have tenderness over the right shin and tenderness to compression of the right kneecap and ankle.  Both the knee and ankle were stable.  The last record in evidence prior to separation was a primary care note dated 20 May 2002.  The CI reported right ankle pain with elevation and some motion.  It was tender on the lateral ankle bone (away from the midline), but signs of swelling or bruising were absent.  

At the VA Compensation and Pension (C&P) examination performed on 31 October 2002, 4 months after separation, the CI reported continued pain in the right shin and ankle.  On examination, he had a normal gait.  Knee flexion was reduced to 90 degrees (VA normal 140 degrees) with normal extension.  Pain was not reported.  The reason for the limitation in motion was not recorded.  There was no fluid in the joint and the knee was stable.  Crepitus (an audible or palpable sensation of grinding on movement) was noted.  Mild tenderness to palpation over the right shin was present.  The right ankle examination was normal other than plantar flexion (toes down) being limited to 30 degrees (normal 45).  X-rays of the right knee were normal.  Following separation, the record does not show that the CI was treated for any of these conditions for over a year.  An emergency room visit on 12 December 2003, 18 months after separation, after the CI bumped his right leg against a concrete barrier, showed that the right knee, ankle, and foot were non-tender.  The gait was normal.  A bone scan done a year later on 9 December 2004, showed no uptake (no stress changes) in either lower extremity.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic pain due to right patellofemoral syndrome (PFS), right tibial shaft stress reaction, and right foot and ankle pain at 0%, coded 5099-5003 using the since rescinded US Army Physical Disability Agency pain policy.  The Board adjudicated the case IAW the VASRD in effect at the time of separation.  The VA rated the conditions separately, but each was rated at 0% providing the same combined rating.  The right knee, PFS, was coded 5257, other impairment of the knee.  The stress fracture was coded 5010-5022, arthritis due to trauma and periostitis.  The clinical picture is best described as an overuse syndrome associated with the increased activity in basic and advanced infantry training.  The right ankle was coded 5299-5271, limited motion of the ankle.  The Board considered the findings.  While tenderness and pain were reported, no pathology was noted on X-rays other than increased uptake on a bone scan.  This indicated stress related changes which would be expected to resolve once the stress was removed.  Post-separation evidence shows that this did in fact happen as noted in the December 2003 examination and December 2004 bone scan.  The Board considered if each condition was separately unfitting.  The CI was referred to the PEB due to ongoing pain despite duty restrictions and medications.  He was not able to complete training due to this.  However, it was also noted that at the time of the NARSUM, the pain was slight and occasional.  The X-rays of the right knee, shin, and ankle were normal.  An initial bone scan showed increased uptake, but a post-separation study, done away from the rigors of training, was normal.  The gait was normal.  The loss of motion of the knee was non-compensable and painful motion was not documented.  
The right shin was mildly tender at the time of the C&P examination and non-tender at a post-separation evaluation.  The ankle showed limitation in plantar flexion at 30 degrees; however, the gait was normal as were X-rays.  The evidence does not support separate compensable findings for any of these joints rendering any finding of separately unfitting as of no benefit to the CI and therefor moot.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the chronic pain due to right PFS, right tibial shaft stress reaction, and right foot and ankle pain condition.  

BOARD FINDINGS:  In the matter of the chronic pain due to right PFS, right tibial shaft stress reaction, and right foot and ankle pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  There were no other conditions within the Board’s scope of review for consideration.  The Board, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140513, with attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR Commander, US Army Physical Disability Agency
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation
for XXXXXXXXXXXXXXXXXXXXXXX AR20160011320 (PD204-03260)

I have reviewed the enclosed Department of Defense Physical Disability Board of
Review (DoD PDBR) recommendation and record of proceedings pertaining to the
subject individual. Under the authority of Title 10, United States Code, section 1554a,
I accept the Board's recommendation and hereby deny the individual's application.
This decision is final. The individual concerned, counsel (if any), and any Members of
Congress who have shown interest in this application have been notified of this decision
by mail.

BY ORDER OF THE SECRETARY OF THE ARMY:

Enclosure

CF:
( ) DoD PDBR
( ) DVA