RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX                                                                             	CASE:  PD-2014-03374		
BRANCH OF SERVICE:  Army	Separation Date:  20050729  

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E4, Telecommunications Operator-Maintainer, medically separated for “chronic bilateral lower leg pain…,” with a disability rating of 0% 

CI CONTENTION:  “Vocal cord dysfunction listed on the MEB was not evaluated…”  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 confined to 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:  
IPEB - Dated 20050505	VA* - (~3 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Bilateral Lower Leg Pain	5022	0%	Bilateral Stress Fractures, Pain	5299-5255	Non Service Connected (NSC)	20051101	
Vocal Cord Dysfunction	Not Unfitting	Vocal Cord Dysfunction	6599-6516	10%	20051101	
Other MEB/PEB Conditions x 0 (Not in Scope)	Other x 0	
RATING:  0%	RATING:  10%	
*Derived from VA Rating Decision (VARD) dated 20060120 (most proximate to date of separation [DOS]).  

ANALYSIS SUMMARY:  

Chronic Bilateral Lower Leg Pain.  The CI developed bilateral knee, shin and ankle pain which was worse with running a week after Basic Training started in March 2003.  The examiner in April 2003 noted a 6-week history of bilateral leg pain with physical exam findings of bilateral shin, knee and ankle tenderness to palpation.  The examiner diagnosed bilateral patellar tendonitis, bilateral shin splints and bilateral tibial tendonitis.  The CI reported right foot marked tenderness and swelling in July 2004.  A right foot X-ray done in September 2004 showed no evidence of posterior tibial tendon dysfunction.  The medical provider in November 2004 documented bilateral pretibial edema (swelling) and pedal swelling, moderate tenderness in the posterior lateral malleolus and bilateral tibial areas.  A bone scan done in November 2004 demonstrated a right distal tibia Grade I stress fracture.  The CI continued to report bilateral ankle pain with activity despite a profile, crutches, orthotics and medication.  A left X-ray done on March 2005 for worsening left mid tibial pain with weight bearing if standing for greater than 5 minutes was normal.  A bilateral foot X-ray done in April 2005 was normal. The commander’s statement contained detailed documentation of the CI’s bilateral lower leg condition and that despite her condition; she remained highly motivated and completed the APFT by walking instead of running.  

The MEB Narrative Summary (NARSUM) exam approximately 4 months prior to separation documented that the CI reported daily constant bilateral sharp pain with walking that was rated 6-8.5/10.  The pain was worse with standing, walking running and going upstairs and interfered with her sleep.  There were physical exam findings of tenderness in the entire anterior shins, trace swelling and some posterior right greater than left distal tenderness with full range of motion.  There were functional limitations of an inability to march, walk short distances, an inability to stand more than five minutes without severe pain and an inability to bend or kneel.  She was unable to carry a light load or carry a fighting load and she was unable to do three to five second rushes.  A right ankle radiographic imaging showed a fibroma, without evidence of a stress fracture or significant shin abnormality.  

The VA Compensation and Pension (C&P) exam approximately 3 months after separation, documented that the CI reported intermittent bilateral lower extremity pain with a fair response to medication.  There were physical exam findings of a normal gait with pain on the bilateral lower extremities with normal motor, sensory and reflexes exams.  A tibia-fibula X-ray showed an unusual appearance of the distal right tibia possibly related to an old injury and a normal left tibia-fibula.  The diagnoses were stress fracture of the right tibia, resolved; and stress fracture of the left leg, resolved.  The examiner indicated that there was no chronic disability caused by residuals of the leg stress fractures.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB coded the chronic bilateral lower leg pain condition as 5022 (periostitis) and rated at 0%.  The VA coded the bilateral stress fractures, pain condition as 5299 analogous to 5255 (femur, impairment of) and rated as NSC [not service connected].  The Board, IAW VASRD §4.7 (higher of two evaluations), must consider separate ratings for PEB bilateral joint adjudications; although, separate fitness assessments must justify each Service disability rating.  In this case, both lower legs were considered to fail retention standards; both were implicated by the NARSUM and in the commander’s statement; and, both were profiled.  Members agreed therefore that each lower leg should be conceded as separately unfitting; and, that coding and rating features were logically identical.  There was evidence throughout the service treatment record that the CI had bilateral lower extremity pain with all activities and tenderness to palpation.  The commander’s statement documented a detailed description of the CI’s activity-induced bilateral lower extremity pain.  

The post-separation VA exam documented improvement of the CI’s lower leg conditions, and the Board adjudged the Service exam best represented the CI’s disability picture at separation.  VASRD §4.71a specifies for 5003 that “satisfactory evidence of painful motion” constitutes limitation of motion and specifies application of a 10% rating “for each such major joint or group of minor joints affected by limitation of motion” and VASRD §4.59 (painful motion) provides justification for a 10% rating with no limit to range of motion.  Alternative rating analogous to 5262 (tibia and fibula, impairment of) at 10% for “slight knee or ankle disability” was also considered.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommended a that each lower leg be considered unfitting with a disability rating of 10% for the left leg; and 10% for the right leg; each coded 5099-5022 IAW VASRD §4.71a.  

Contended PEB Conditions.  The contended condition adjudicated as not unfitting by the PEB was “vocal cord dysfunction.”  The Board’s first charge with respect to this condition is an assessment of the appropriateness of the PEB’s fitness adjudication.  The Board’s threshold for countering fitness determinations is preponderance of the evidence, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  Although this condition was named in the profile the permanent profile was P1; vocal cord dysfunction was not implicated in the commander’s statement; and, was not judged to fail retention standards.  The condition was reviewed and considered by the Board.  The CI’s primary complaints from this condition were shortness of breath and there was no complaint of speech difficulty.  The CI was evaluated by pulmonary specialists with normal pulmonary function tests and a negative Methacholine Challenge Test (no reversible airway disease, or provocation of respiratory symptoms).  The CI was able to complete an exercise tolerance test documenting normal exercise capacity without any pulmonary limit.  There was insufficient indication from the record that this condition significantly interfered with satisfactory duty performance.  After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the contended condition vocal cord dysfunction; and, therefore, no additional disability rating can be recommended.  

BOARD FINDINGS:  In the matter of the chronic bilateral lower leg pain condition, the Board unanimously recommends that each joint be separately adjudicated as follows:  an unfitting left chronic lower leg pain condition coded 5099-5022 and rated 10%, and an unfitting right lower leg pain condition, coded 5099-5022 and rated 10%, both IAW VASRD §4.71a.  In the matter of the contended vocal cord dysfunction condition, the Board unanimously recommends no change from the PEB determinations as not unfitting.  There were no other conditions within the Board’s scope of review for consideration.  The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of her prior medical separation:  

UNFITTING CONDITION	VASRD CODE	RATING	
Chronic Bilateral Lower Leg Pain	Left	5099-5022	10%	
	Right	5099-5022	10%	
COMBINED (w/ BLF)	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140718 w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20160007999, XXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found that your disability rating should be modified but not to the degree that would justify changing your separation for disability with severance pay to a permanent retirement with disability.   I have reviewed the Board's recommendation and record of proceedings (copy enclosed) and I accept its recommendation.  This will not result in any change to your separation document or the amount of severance pay.  A copy of this decision will be filed with your Physical Evaluation Board records. I regret that the facts of the case did not provide you with the outcome you may have desired.

This decision is final.  Recourse within the Department of Defense or the Department of the Army is exhausted; however, you have the option to seek relief by filing suit in a court of appropriate jurisdiction.

A copy of this decision has also been provided to the Department of Veterans Affairs.

Sincerely,