RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-04216
BRANCH OF SERVICE:  Navy 	SEPARATION DATE:  20050215

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E2, Seaman Recruit, medically separated for “bilateral proximal tibial stress reactions,” with a disability rating of 0%.

CI CONTENTION:  The CI contends for patella pain.  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 upon a 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 - 20050104	VARD - 20050304	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Proximal TIbial Stress Reactions	5099-5022	0%	Left Proximal Tibia Stress Reaction Claimed as Knee Pain	5262	10%	STR	
			Right Proximal Tibia Stress Reaction Claimed as Knee Pain	5262	10%	STR	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Bilateral Proximal Tibial Stress Reactions.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI initially presented for bilateral knee pain after physical training in August 2004.  A right tibial stress fracture was diagnosed in September 2004.  Following a period of rehabilitation, return to activity led to a relapse.  A bone scan on 10 November 2004 showed stress changes involving the bilateral proximal tibias.  Despite treatment, the bilateral proximal stress reactions could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and she was referred for an MEB.  The MEB forwarded “bilateral proximal tibial stress reactions” for PEB adjudication.

The MEB physical examination recorded on the DD Form 2808 Report of Medical Examination on 17 November 2004, 3 months prior to separation, recorded “pain with weight bearing c/w (consistent with) stress fracture.”  Location of the pain was not described.  On the profiling section of the DD Form 2808 “bilateral tibial stress fx (fracture)” was specified.  The MEB NARSUM on 1 December 2004 noted that the CI could run one-quarter mile without pain.  She was unable to run, walk or stand for a prolonged period of time without right lower extremity pain.  Current pain was rated at 1/10 severity.  The examiner noted that the November 2004 bone scan showed stress-induced changes of the bilateral proximal tibias, but not stress fractures.  Physical examination showed a normal gait.  Range of motion (ROM) evaluation of each knee showed extension of 0 degrees (normal 0 degrees) and flexion of 130 degrees (normal 140 degrees).  Complete examination of each knee was normal.  Ankle plantar flexion was 40 degrees bilaterally (normal 45 degrees) and dorsiflexion was 20 degrees (normal 20 degrees).  Complete examination of each ankle was normal.  Tenderness of each tibia was present, with right worse than left.  There was no mention of painful motion.  Lower extremity muscle strength was normal.

The non-medical assessment (NMA) on 7 December 2004 stated that the CI was unable to complete training due to stress fractures in both shins.  There was no VA examination in evidence proximate to the time of separation.

The PEB combined the right and left tibial stress reaction conditions under a single service disability rating, coded analogously to 5022 (periostitis) and rated 0%.  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 also noted that “bundling,” the combining of two or more major joints, may be permissible under the VASRD 5003 rating requirements (which the 5022 code defaults to), and that this approach does not compromise the VASRD §4.7 directive to choose the higher of two valid ratings.  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 Board directed attention to its rating recommendation based on the above evidence.  As previously elaborated, the Board must first consider whether right and left tibial stress reactions remain separately unfitting, having been de-coupled from a combined PEB adjudication.  Bilateral stress reactions were implicated in the NMA and were identified by the NARSUM and on the MEB DD Form 2808.  Board members agreed that, as isolated conditions, each stress reaction condition would have rendered the CI incapable of continued service, and accordingly each condition merits separate service ratings.  Coding and rating features were logically identical.  The VA assigned a 10% rating for both the right and left tibial stress reaction using the 5262 code (tibia and fibula, impairment of) based on the STR, citing slight lower extremity disability.   

There was no limitation of motion of the ankles or knees under relevant codes (5271, 5260, and 5261) sufficient to warrant a 10% rating for limitation of motion.  The Board debated if there was support for a 10% rating on the basis of §4.40 (functional loss) or §4.59 (painful motion), given a normal gait and the sole abnormality of tenderness on the NARSUM examination, in the context of an ability to run one-quarter mile without pain however, it was concluded that this route was not warranted.  Finally, the Board deliberated a rating using the 5262 coding approach.  Although the language of 5262 specifies malunion or nonunion complications of fracture, analogous application is commonly employed for rating the attendant knee or ankle disability as countenanced by VASRD §4.7 (higher of two evaluations).  This approach offers a 10% rating for “slight” joint disability.  Board members considered that there was no fracture in this case, and no malunion or nonunion complications.  Furthermore there was no objective evidence of ankle or knee disability related to the stress reactions.  Members agreed, therefore, that rating under 5299-5262 was not justified in this case.  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 bilateral proximal tibial stress reactions condition.

BOARD FINDINGS:  In the matter of the bilateral proximal tibial stress reactions 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 20141027, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR DIRECTOR, SECRETARY OF THE NAVY COUNCIL OF REVIEW
               BOARDS 

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS
 
Ref:   (a) DoDI 6040.44
       (b) CORB ltr dtd 22 Sep 16

      In accordance with reference (a), I have reviewed the cases forwarded by reference (b), and, for the reasons provided in their forwarding memorandums, approve the recommendations of the PDBR that the following individual’s records not be corrected to reflect a change in either characterization of separation or in the disability rating previously assigned by the Department of the Navy’s Physical Evaluation Board:

		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN