RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-04285
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20071226

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an Reserve E5, Automated Logistical Specialist, medically separated for “bilateral tibial stress reactions” with a disability rating of 10%.

CI CONTENTION:  The CI contends for his unfitting bilateral tibial stress fractures, his not unfitting low back pain and bilateral knee pain, and conditions not identified by either the MEB or PEB.  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 IPEB – 20071105	VARD – 20080930	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Tibial Stress Reactions	5099-5022	10%	Bilateral Tibial Stress Fractures	5022	NSC	20080108	
Bilateral Knee Pain with Osgood-Schlatter Disease	Not Unfitting	Bilateral Chronic Knee Pain	5260	NSC		
Right -Sided Low Back Pain	Not Unfitting	Chronic Low Back Pain	5237	NSC		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:   NSC	

ANALYSIS SUMMARY:  

Bilateral Tibial Stress Reactions.  The PEB combined the right and left tibial stress reactions as a single unfitting condition coded 5022 (periostitis) with a disability rating of 10%.  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 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 right and left tibial stress reactions are presented together, with attendant recommendations regarding separate unfitness and rating in the rating discussion.

According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the bilateral tibial stress condition began approximately 4 months prior to referral for MEB.  Bilateral knee diagnostic imaging (X-ray) studies on 21 July 2006 showed changes consistent with old Osgood-Schlatter's disease (OSD) chronic traction avulsion of proximal tibial tubercle at patellar tendon insertion).  In the 5 December 2006 MEB consultation by orthopedic surgery, the CI complained of bilateral shin pain (right greater than left).  Pain was exacerbated by deep knee bends, heavy lifting, walking, jumping, ruck marching, and running.  Symptoms were not significantly relieved by activity modification, physical therapy (PT), change in shoe wear, or medication (Vicodin and Robaxin).  The physical examination documented a normal posture.  The bilateral knee examination revealed prominent and tender tibial tubercles (boney prominences below kneecaps), tenderness about the patellar tendons, and crepitus (grating sensation or sound) with range of motion (ROM).  There was no effusion (fluid collection) or significant joint line tenderness.  Bilateral active ROM was flexion of 130 degrees (140 degrees normal) and extension of 0 degrees (0 degrees normal).  There was a 1A (less than 5mm translation/firm endpoint) Lachman (assesses anterior cruciate ligament (ACL)) test.  The anterior/posterior drawer (ACL and posterior cruciate ligament (PCL) and valgus/varus stress (assesses medial collateral ligament (MCL)/lateral collateral ligament (LCL)) tests were negative.  The right anteromedial shin had some tenderness to deep palpation.  Strength, sensation, and deep tendon reflexes (DTRs) were normal and pathologic reflexes were absent.  The assessment listed bilateral tibial stress changes (right greater than left) manifesting as shin pain.  Bilateral lower extremity X-rays showed fragmented, non-fused ossification centers of the tibial tubercles with some associated soft tissue swelling/tendinopathy.  A bone scan showed findings in the tibias consistent with stress reaction with probable stress injury in the right anterior tibial tubercle.  

In the 26 February 2007 NARSUM, 10 months before separation, the CI complained of bilateral upper shin pain since December 2006.  Pain was located just below the tibial tubercles and felt like "a kid kicking you in the shins."  Symptoms occurred 1 to 2 times per week, depending on activity, and lasted several minutes.  Sharp pain was exacerbated by prolonged walking, climbing, impact activities, and moderate to heavy load bearing.  Symptoms were decreased by activity avoidance, not weight bearing, and medication (Vicodin).  The bilateral knee examination revealed prominent and tender tibial tubercles with no effusion or joint line tenderness.  Bilateral active ROM was flexion of 130 degrees (140 normal) and extension of 0 degrees (0 normal).  A Lachman test was mildly positive and the drawer and valgus/varus stress tests were negative.  There was no significant tenderness to palpation over the anterior tibial shafts.  The examiner recounted the findings of the 5 December 2006 orthopedic surgery MEB consultation, X-rays, and bone scan.  The diagnosis listed tibial stress reactions (right greater than left).  The 21 June 2007 MEB addendum by orthopedic surgery documented “His medical evaluation board consultation is up-to-date.  There have been no changes over the interim.  Please follow the previously dictated orthopaedic consultation… Again, there are no changes to this MEB.”  Bilateral tibia-fibula X-rays were normal except for evidence of old OSD disease involving the tibial tubercles.  

In the 8 January 2008 VA Compensation and Pension (C&P) examination, 13 days after separation, the CI complained bilateral proximal tibiae pain just distal to the tubercles for 1 year.  He denied a history of injury or trauma.  The constant symptoms were characterized as burning, aching, and sharp pain.  Pain was exacerbated by walking and relieved by rest and medication (Motrin).  At the time of pain, the CI could function without medication.  The physical examination documented a normal gait without an assistive device.  The bilateral knee examination revealed slight medial joint line tenderness with no edema, effusion, weakness, redness, heat, subluxation (incomplete or partial dislocation), crepitus, locking pain, or guarding of movement.  Bilateral active ROM was flexion of 140 and extension of 0 degrees.  Repetitive ROM was not additionally limited by pain, fatigue, weakness, lack of endurance, or incoordination.  Medial and lateral meniscus tests, and ligament stability tests, were normal.  The bilateral tibia examination revealed prominent and tender tibial tubercles and mild proximal lateral edge tibial tenderness.  The bilateral ankle examination revealed no deformity, edema, effusion, weakness, tenderness, redness, heat, subluxation, or guarding of movement.  Bilateral active ROM was flexion dorsiflexion of 20 degrees (20 degrees normal) and plantar flexion of 45 degrees (45 degrees normal) degrees.  Repetitive ROM was not additionally limited by pain, fatigue, weakness, lack of endurance, or incoordination.  The bilateral foot examination revealed no signs of abnormal weight bearing.  Strength, sensation, and DTRs were normal.  The examiner recounted the findings of the X-rays.  For the claimed condition of bilateral tibial stress fracture, the examiner documented there was no diagnosis because there was no pathology to render a diagnosis. 

The Board directed attention to its rating recommendation based on the above evidence.  As previously elaborated, the Board must first consider whether each tibial stress reaction remains separately unfitting, having been de-coupled from a combined PEB adjudication.  The PEB assigned a 10% rating under an analogous 5022 code (periostitis) citing bilateral tibial stress reactions by bone scan alone, onset in 2002, secondary to repetitive strain injury, no joint instability, no loss of joint motion, and rated as periostitis.  The VA denied service-connection for the bilateral tibial stress fractures under the 5022 code (periostitis) based on the VA C&P examination 13 days after separation, citing the condition neither occurred in, nor was caused by service.  The ROM values in the proximate exams were normal and did not support a minimum rating under the limitation of knee flexion (5260), knee extension (5261), and ankle limited motion (5271) codes.  There was no dislocated meniscus (5258), symptomatic removed meniscus (5259), knee ankylosis (5256), knee recurrent subluxation/lateral instability (5257), tibia and fibula nonunion/malunion (5262), or genu recurvatum (5263) for consideration under the respective codes.  There was no ankle ankylosis (5270), subastragalar or tarsal joint ankylosis (5272), os calcis or astragalus malunion (5273), or excision of the astragalus (5274) for consideration under the respective codes.  Board members agreed a 10% rating was justified IAW §4.40 (functional loss) and §4.59 (painful motion).  The Board carefully considered the option of rating both legs together versus each leg separately.  Members concluded that the evidence did not provide sufficient grounds for recommending separate leg disability ratings and that a bilateral rating of 10%, coded 5099-5022, is a good analogy to both the pathology and disability.  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 tibial stress reaction condition.  

Contended PEB Conditions:  Bilateral Knee Pain with Osgood-Schlatter Disease and Right -Sided Low Back Pain.  The Board’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  The contended right-sided low back pain condition was not profiled or implicated in the commander’s statement and was not judged to fail retention standards.  It was reviewed and considered by the Board and there was no performance based evidence from the record that this condition significantly interfered with satisfactory duty performance.  While the contended bilateral knee pain with OSD condition was profiled and judged to fail retention standards by the MEB, it was not implicated in the commander’s statement, and symptoms resolved so it was deemed not unfitting by the PEB.  It was reviewed and considered by the Board and there was no performance based evidence 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 conditions and so no additional disability ratings are recommended.

BOARD FINDINGS:  In the matter of the bilateral tibial stress reactions condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended bilateral knee pain with OSD and right-sided low back 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, 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 20141004, 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 
XXXXXXXXXXXXXXXXXX, AR20160018338 (PD201404285)

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