RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03811
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20061219

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E2, Basic Trainee, medically separated for “chronic bilateral lower extremity pain” 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 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 - 20061201	VARD - 20071024	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Bilateral Lower Extremity Pains 	5099-5022	0%	Bilateral Pelvis Stress Fracture	5299-5255	0%	20070821	
			Bilateral Knee Condition	5257	NSC	20070821	
			Bilateral Leg Condition	5260	NSC	20070821	
			Bilateral Ankle Condition	5271	NSC	20070821	
			Bilateral Plantar Fasciitis	5099-5020	10%	20070821	
			Bilateral Pes Planus	5276	10%	20070821	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Chronic Bilateral Lower Extremity Pains.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s bilateral lower extremity pains condition began in May 2006 during basic training without specific trauma.  The CI presented with pelvic pain (left greater than right groin pain) and bone scan showed a stress fracture of the left inferior pubic ramus and right calcaneous (ankle/foot).  During physical therapy the CI also developed bilateral knee and ankle pain.  
There was no surgical indication, and conservative treatment did not result in improvement sufficient to allow unrestricted return to training.  The MEB forwarded “healing calcaneal stress fracture, right,” “healing inferior pubic ramus stress fracture left,” “chronic anterior knee pain bilaterally” and “ankle pain bilaterally” for PEB adjudication.  

The MEB NARSUM examination by podiatry on 11 October 2006, followed by an MEB Addendum by orthopedics on 16 October 2006, 2 months prior to separation, noted complaints of bilateral heel, foot, ankle, knee, and pelvic pain.  She was unable to run, jump, or march.  

Bone scan performed on 9 August·2006 showed healing stress fracture of the left inferior pubic ramus and right calcaneus with mild stress changes at bilateral ankles.  Physical examination showed a normal gait.  Bilateral hips had full active range of motion (ROM) without pain, deformity, laxity or crepitus.  There was tenderness to palpation of the left pubic ramus.  Bilateral knees had full painless ROM with positive patellar grind and no crepitus, laxity or instability.  There was tenderness below the patellas.  The ankle ROMs were full without tenderness, deformity or laxity.  There was mild tenderness to palpation along the right calcaneous with squeeze, with no deformity or swelling of the feet.  The orthopedic diagnoses were “healing stress fracture, left inferior pubic ramus and right calcaneus, and mild stress changes in bilateral ankles.”  

At the VA Podiatry consult dated 2 May 2007, the CI reported painful feet, ankles, and knees.  She had had an orthosis for a short time that helped a lot.  Podiatry examination showed “biomechanically the (CI) exhibits rear foot varus, plantar fascistic, acquired equines, difficulty in gait,” and a foot orthosis was ordered.  

At the 21 August 2007 VA Compensation and Pension (C&P) evaluation, performed 8 months after separation, the CI complained of bilateral ankles; bilateral plantar fasciitis; compression arthralgias of bilateral knees, tibia and fibula; and pelvis fracture with pain on activities.  Physical examination showed a normal gait.  There was bilateral ankle, heels, and subpatellar tenderness.  Hips and knees had bilaterally symmetric ROMs without painful motion.  The ankles had symmetric motion and painful motion on inversion with mild inversion laxity bilaterally.  There was anatomic alignment with wearing shoes and in bear feet there was mild valgus alignment bilaterally.  There was complaint of pain with bilateral heel strike.  Diagnostic imaging of the feet showed mild pes planus deformity with minor degenerative changes, without calcaneal spurring or fascial calcification.  X-rays of the ankles and knees were normal.  Whole body bone scan showed symmetrical distribution throughout the skeleton with no localized activity noted about the pelvis.  Diagnosis was “Arthralgias of the knees, ankles and feet secondary to pelvic stress fracture in the military.  Pelvic stress fracture resolved - ·continued report of lower extremity myalgias most likely associated with bilateral foot condition described above (planter fasciitis, pes planus).  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB combined the “healing calcaneal stress fracture, right;” “healing inferior pubic ramus stress fracture, left;” “chronic anterior knee pain bilaterally” and “ankle pain bilaterally” conditions as a single unfitting condition coded analogously to 5022 (Periostitis), and rated 0%, citing profile preventing re-entry into training, full motion, good stability of all joints and “rated for no mechanical loss of motion.”  The approach by the PEB not uncommonly reflected its judgment that the constellation of conditions was unfitting, and there was no need for separate fitness adjudications.  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 VA ratings were based on the VA C&P examination 8 months after separation.  They were:  bilateral pelvis stress fracture condition at 0% coded 5299-5255 0% (Femur, impairment of), citing a normal examination and bone scan; and bilateral knee condition as 5257 (Knee, other impairment of), bilateral ankle condition as 5257 (Knee, other impairment of) and bilateral ankle condition as 5271 (Ankle, limited motion of) all as not service connected (NSC) due to “pain alone, without a diagnosed or identifiable underlying malady or condition.”  The VA also rated the bilateral plantar fasciitis condition at 10% coded 5099-5020 (Synovitis), citing myofascial pain with palpation around the bilateral heels; and the bilateral pes planus condition at 10% coded 5276 (Flatfoot, acquired), citing weight bearing line over or medial to the great toe with pain and mild degeneration.  

The Board adjudged that the “healing calcaneal stress fracture, right” and “ankle pain bilaterally” were unfitting and ratable while the “healing inferior pubic ramus stress fracture, left,” and “chronic anterior knee pain bilaterally” were not separately unfitting or ratable.  Regarding rating of the “healing calcaneal stress fracture, right” and “ankle pain bilaterally,” the bilateral posterior calcanei, bilateral ankles and bilateral central arches were tender to palpation and there was pronation on stance and gait documented on the NARSUM examination.  There was no painful or limited ankle ROM.  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 right healing calcaneal stress fracture and bilateral ankle pain condition coded 5299-5276.  

BOARD FINDINGS:  In the matter of the chronic bilateral lower extremity pains condition, the Board unanimously recommends an unfitting right healing calcaneal stress fracture and bilateral ankle pain condition with a disability rating of 10%, coded 5299-5276 IAW VASRD §4.71a.  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	
Chronic Bilateral Lower Extremity Pain	5299-5276	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140515, with attachments
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

21 NOV 2016

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for 
, AR20160017351 (PD201403811)

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 10% 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.

 BY ORDER OF THE SECRETARY OF THE ARMY:

CF: 
(  ) DoD PDBR
(  ) DVA