RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03500
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20080827

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E3, Supply Clerk, medically separated for “bilateral lower limb pains from stress reactions evaluated as periostitis” with a disability rating of 0%.

CI CONTENTION:  Legs, shoulder and elbow.  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:  

SERVICE PEB - 20090829	VARD - 20080918	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Lower Limb Pains…	5099-5022	0%	Tibial Stress Fracture, Left Knee	5299-5262	10%	20080715	
			Tibial Stress Fracture, Left Knee	5299-5262	10%		
Chronic Left Shoulder Pain	Not Unfitting 	Shoulder Strain, Left	5201	20%		
Chronic Nonradicular Low Back Pain	Not Unfitting	Lumbosacral Strain	5237	10%		
Ganglion Cyst, Left Foot	Not Unfitting	Ganglion Cyst, Left Foot	5299-5020	0%		
Intermittent Knee Pain	Not Unfitting	Knee Strain, Left Knee	5260	10%		
		Knee Strain, Right Knee	5260	10%		
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

Bilateral Lower Limb Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s bilateral lower limb pain condition began in October 2006 during her first few weeks of basic training.  With a profile and rest the pain improved.  However, during an AIT [advanced individual training] run she noted her legs locked up and she could not move.  With rest, willpower, and motivation over the following month, she improved somewhat, but symptoms never completely disappeared.  In September 2007 the CI was diagnosed with patellar tendonitis and shin splints and was given a temporary profile and had physical therapy.  In early 2008 the CI collapsed after running 3 miles.  Medications including Percocet (oxycodone, a narcotic and acetaminophen, a pain reliever), Vicodin (hydrocodone, a narcotic and APAP (acetaminophen, a pain reliever), and ibuprofen (a nonsteroidal anti-inflammatory drug (NSAID)) did not provide relief.  Despite bearing up under her pain until February 2008, she made insufficient progress and was referred for a MEB.  At the NARSUM examination the CI’s lower extremities demonstrated no deformity, swelling, erythema, or ecchymosis.  She had a full range of motion (ROM) at the hips, knees, ankles and feet with no limitations with repetition.  There was tenderness to palpation over both of the patellae (knee caps), both tibiae (lower legs) and the malleoli (ankles).  Muscle strength of the extremities was normal bilaterally.  Neurologic evaluation was unremarkable.  The CI was able to stand on her toes, stand on her heels, squat and get back up unassisted and had a normal, causal non-antalgic gait.  Electrophysiologic testing of the left lower extremity was normal and there was no evidence of a left lumbar radiculopathy, focal neuropathy, lumbosacral plexopathy or generalized polyneuropathy.  The CI described a constant ache in both legs from her knees down to her toes, which was worse after physical exertion.  During times of exertion, her legs felt weak, uncoordinated and unstable and she limped, and fell down, but sustained no secondary injuries.  She was able to perform administrative duties at a desk but could not perform many aspects of physical fitness testing.

At the MEB examination (recorded on DD Forms 2807 and 2808) dated February 2008, 16 months prior to separation, the CI reported swelling of the knees and ankles.  Physical examination showed mild tenderness to pressure over the patellae, tibiae, malleoli with pain on tuning fork testing over the same areas.  There was no deformity, swelling, or erythema and the ROM was full with 5/5 muscle strength and normal deep tendon reflexes.  The commander’s statement dated 26 February 2008 indicated the CI’s condition of chronic pain and swelling in her knees, ankles and shins severely limited her functionality as a member of the unit and the Army.  A permanent U2L3 profile was issued on 24 April 2008 for chronic leg and foot pain due to stress reactions and chronic left shoulder pain and instability (see below) with limitations of the 2 mile run and all military functional activities except rushes under direct and indirect fire.  Additional restrictions included no running, no alternate physical fitness tests, no bicycle, no lifting greater than 40 pounds, no standing more than 10 minutes without a break to reposition and stretch, no marching, no jumping or impact activities, and no wearing armor, load-bearing equipment or rucksack.      

At the VA Compensation and Pension (C&P) examination in July 2008, performed 13 months before separation, the CI reported shin splints clear up to her tibial tuberosities if she had to run.   
On physical examination she had an antalgic gait with limping on her left leg, but she did not use a cane, crutches or any assistive devices.  The ROM of the knees was 0 to 145 degrees bilaterally with no loss of motion with repetition.  Patellar crepitus on the right was worse than the left with pain on both sides with patellar motion, but no fluid was present.  There was no evidence of meniscal tears or instability.  However, there was tenderness in the lower third of the anterior tibial compartment without edema, redness or real tenderness on either side.  She had no pain with dorsiflexion or plantar flexion of the ankles.  

The Board directed attention to its rating recommendation based on the above evidence.  The IPEB assigned a 0% rating using code 5099-5022 (periostitis) for bilateral lower limb pains from stress reactions.  The VA assigned a 10% rating using code 5299-5262 (tibia and fibula, impairment) for tibial stress fracture, right leg and a 10% rating using code 5299-5262 for tibial stress fracture, left leg.  

The PEB combined the left lower limb pain and the right lower leg limb pain conditions as a single unfitting condition coded 5099-5022 and rated 0%.  The approach by the PEB commonly reflected its judgment that the constellation of conditions was unfitting, and there was no need for separate fitness adjudications or implied adjudication that each condition was separately unfitting.  The Board’s initial charge in this case was therefore directed at determining if the PEB’s approach of combining conditions under a single rating was justified in lieu of separate ratings.  When considering a separate rating for each condition, the Board considers each bundled condition to be reasonably justified as separately unfitting unless a preponderance of evidence indicates the condition would not cause the member to be referred into the DES or be found unfit because of physical disability.  When the Board recommends separate fitness recommendations in this circumstance, its recommendations may not produce a lower combined rating than that of the PEB.  The evidence for the bilateral lower limb pain condition was presented above.  

The Board first considered whether each lower leg pain was reasonably justified as separately unfitting and concluded that each lower leg pain condition was reasonably supported by the record as separately unfitting.  The Board then considered its rating recommendation for the left lower leg pain condition and noted that code 5299-5262 more accurately addressed the condition than code 5099-5022 and a rating of 10% for an analogous malunion with slight knee or ankle disability was not unreasonable based on bone scan findings in the left tibia and left calcaneus as well tenderness to palpation over the left knee and left malleolus (ankle).  The right lower leg pain condition likewise warrants a 10% rating using code 5299-5262 also based bone scan findings of the right tibia, right ankle and calcaneus as well as tenderness to palpation over the right knee and right malleolus.  The Board considered whether a 20% rating for each lower extremity was applicable; however, members agreed neither lower extremity rose to the level of a moderate disability at the time of separation despite bone scan findings of moderate to severe enthesopathies since the bilateral stress reactions were mild.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the left lower leg pain condition, coded 5299-5262 and a disability rating of 10% for the right lower leg pain condition, coded 5299-5262.  

Contended PEB Conditions.  Chronic left shoulder pain, chronic nonradicular low back pain, ganglion cyst of the left foot, and intermittent knee pain.  The chronic non-radicular low back pain, ganglion cyst, and intermittent knee pain were not profiled, but the chronic left shoulder pain and foot pain were, although not specifically the left foot pain related to the ganglion.  The commander noted the CI experienced chronic pain and swelling in her knees and had difficulty working on her feet and lifting when it involved the legs; however, all of the contended conditions met retention standards.   

Chronic Left Shoulder Pain.  An X-ray series of the left shoulder in February 2008 showed normal alignment of the shoulder and acromioclavicular joints without any bony abnormality.  A note dated 20 March 2007 indicated the CI had pain in the left shoulder joint with a clicking sensation and catching on lateral movement; however, the joint did not feel unstable.  On examination there was no swelling, erythema, warmth, deformity or muscle atrophy.  There was tenderness on palpation without Codman’s sign (to determine a rotator cuff tear).  ROM testing was normal without pain and an apprehension test was negative.  There was tenderness on palpation of the left clavicle, but the left acromioclavicular joint showed no tenderness on palpation.  Sensation and strength of the left shoulder were normal.  Cyclobenzaprine (a muscle relaxer) and naproxen (an NSAID) were prescribed.  A MEB consultation dated 19 March 2008 indicated the CI had left shoulder pain for approximately a year without an acute injury.  She stated the pain was improving and her ROM was greatly improved over the prior several months without physical therapy and only 2 days of anti-inflammatory medication.  On examination she had tenderness to palpation over the anterior aspect of the shoulder in the region of the biceps tendon and minimal tenderness in the acromioclavicular joint.  There was positive pain with an impingement test and minimal pain with other testing.  Flexion was to 170 degrees and abduction to 110 degrees with pain.  She had normal strength with internal and external rotation, no apprehension, and no significant translation with load and shift exams.  The CI was diagnosed with a status post frozen shoulder, improving.  There were no surgical criteria and she was to go for physical therapy and consider a course of oral anti-inflammatory medication and a shoulder injection.  

Chronic Nonradicular Low Back Pain.  An X-ray series in February 2008 of the lumbar spine taken for chronic low back pain with a history of sciatica demonstrated the vertebrae were normally aligned and no abnormality was identified.  Electrodiagnostic studies (see above) in March 2008 of the left lower extremity were normal.  

Ganglion Cyst, Left Foot. The CI presented to the podiatry clinic with the history of a “bump” at the outside/top of the left foot without trauma.  In January/February 2008 it was drained, got bigger, and then decreased in size.  Examination revealed a healed injection site on the dorsal-lateral left foot at the 4th/5th metatarsal base/cuboid area.  There were no palpable masses and no tenderness.  Muscle strength was normal and there was no tenderness with the ROM of the feet or ankles bilaterally.  X-rays of the left foot were normal with no exostoses (bony projections) or cortical erosions at the 4th/5th metatarsal/cuboid area.  The CI was instructed to return to the clinic for any recurrence.

Intermittent Knee Pain.  In December 2006 the CI reported left knee pain for 7 weeks with all weightbearing with swelling noted after a day of exercise.  On examination there was no effusion, swelling, erythema, warmth, crepitus, or tenderness on palpation of the left knee.  Motion was normal without pain and there was no instability.  Physical therapy was instituted in January 2007.  In August 2007 the CI complained of bilateral knee, leg, and ankle pain for 10 days.  Examination of the knees was normal.  The CI was counseled about heat/cold applications and elevation of the extremities.  Tenderness was observed on ambulation of the knees in November 2007 and a bone scan demonstrated stress fracture features of the tibia as noted above and the CI was referred to physical therapy.  Physical examination in February 2008 revealed full ROM of the hips, knees, ankles and feet without any pain on repetition with mild tenderness to palpation over both patellae.  X-rays of the knees bilaterally were unremarkable.

There was no performance-based evidence from the record that any of the conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, and 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 any of the contended condition; and so, no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the left lower leg pain condition, the Board unanimously or majority recommends a disability rating of 10%, coded 5299-5262 IAW VASRD §4.71a.  In the matter of the right lower leg pain condition, the Board unanimously or majority recommends a disability rating of 10%, coded 5299-5262 IAW VASRD §4.71a.  In the matter of the contended chronic left shoulder pain, chronic nonradicular low back pain, ganglion cyst of the left foot, and intermittent knee pain conditions, 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 the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Left Lower Limb Pain	5299-5262	10%	
Right Lower Limb Pain	5299-5262	10%	
COMBINED (w/ BLF)	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140723, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB										

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 XXXXXXXXXX, AR20160011478 (PD201403500)

1.  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, accept the Board’s recommendation to modify the individual’s disability rating to 20% without re-characterization of the individual’s separation.  This decision is final.  

2.  I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum.   

3.  I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures.

			     

CF: 
(  ) DoD PDBR
(  ) DVA