RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00193
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20020716

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Armor Crewman, medically separated for “pain due to stress fractures [bilateral] of the medial tibial plateaus and medial femoral condyles,” with a disability rating of 0%.  

CI CONTENTION:  The CI requested consideration of 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 based on 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 - 20020625	VARD - 20020719	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Pain Due to Stress Fractures of the Medial Tibial Plateaus and Medial Femoral Condyles	5099-5003	0%	Left Knee Stress Fractures with Functional Impairment	5299-5014	10%	STR	
			Right Knee Stress Fractures with Functional Impairment	5299-5014	10%	STR	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  There was no VA Compensation and Pension examination within the case file, and therefore, only the clinical encounters of the service treatment record (STR) as well as the Medical Evaluation Board (MEB) narrative summary (NARSUM) were utilized in determining an impairment rating.  

Pain Due to (Bilateral) Stress Fractures of the Medial Tibial Plateaus and Medial Femoral Condyles.  The PEB combined the right and the left stress fractures of the medial tibial plateaus and medial femoral condyles conditions as a single unfitting condition coded analogously to 5003 and rated 0% with application of the U.S. Army Physical Disability Agency (USAPDA) pain policy.  This 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, 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 disability evaluation system 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.  

According to STR and the MEB NARSUM, the CI’s bilateral knee stress fractures condition began in March 2002 after running and marching.  The CI had chronic pain in both knees and bone scan studies showed increased uptake over the bilateral medial tibial plateaus and medial femoral condyles, indicating stress fractures.  Arch supports, soft knee braces, and profile restrictions did not alleviate the bilateral knee pain.  

There was no surgical indication, and conservative treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “stress fractures of the medial tibial plateaus and medial femoral condyles,” for PEB adjudication.  

The MEB NARSUM examination on 29 May 2002 (2 months prior to separation) noted the CI complained of bilateral knee pain going up and down stairs and with standing for prolonged periods of time.  Physical examination showed bilateral knee swelling and tenderness to palpation.  There was full active range of motion.  There was slight pain on bilaterally patellofemoral compression.  There was no effusion, no joint line tenderness, and no instability.  A Lachman's test (for laxity) was negative.  He had slight medial facet tenderness on the left.  The VA used STRs to evaluate the medical finding.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB bundled and rated the left and right knee conditions 0%, coded analogously to 5003 (degenerative arthritis) citing pain as “slight and occasional” with application of the USAPDA pain policy and AR 635-40.  The VA rated each knee at 10% analogously to 5014 (osteomalacia) citing functional loss, using the Service evidence.  

The Board first considered whether each painful knee condition remained separately unfitting, having decoupled them from the combined PEB adjudication.  In this case, both knees were considered to fail retention standards; both were implicated by the NARSUM and in the commander’s statement; and, both were profiled.  The objective clinical evidence nearest to separation remained similar for both knees without indication of one leg more impaired than the other.  The preponderance of clinical evidence throughout the documented exams overwhelmingly described adverse findings as bilateral.  Board members concluded that each knee condition was separately unfitting, and rating considerations were essentially the same for each knee.  

There was diagnostic imaging of stress fractures of the tibia and femoral condyles, with knee swelling, pain, tenderness, positive patellar compression, and functional impairment (IAW §4.40, and §4.45) which best aligned with slight knee disability.  Similar to shin splints, these knee stress fractures are best analogously rated (IAW §4.20) under the 5262 code (tibia and fibula impairment), and justify a 10% rating for slight knee disability for each knee.  In considering routes to a higher rating, there was no limitation of flexion or extension, meniscal injury, laxity or instability to support any rating higher than 10% for each knee.  The knee could not additionally be rated analogously for femoral stress fractures ((5255) femur, impairment) IAW §4.14 (avoidance of pyramiding), as all knee symptoms were considered under the 5262 rating.  

After due deliberation, and considering all of the evidence, the Board recommends a disability rating of 10% for the right knee condition and 10% for the left knee pain condition, coded 5099-5262.  

BOARD FINDINGS:  In the matter of the bilateral knee pain condition, the Board unanimously recommends that each joint be separately adjudicated as follows:  an unfitting right knee condition coded 5099-5262 and rated 10%, and an unfitting left knee condition, coded 5099-5262 and rated 10%, both 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	
Pain Due to Stress Fractures of the Medial Tibial Plateaus and Medial Femoral Condyles	Left	5099-5262	10%	
	Right	5099-5262	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150219, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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 XXXXXXXXXXXXXXXXXXXXX AR20160014236  (PD201500193)

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.

 BY ORDER OF THE SECRETARY OF THE ARMY:

CF: 
(  ) DoD PDBR
(  ) DVA