RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00340
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20040401

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Human Resources Specialist, medically separated for “chronic left knee pain” and “stress reactions both ankles,” rated 0% and 0%, respectively, with a combined disability rating of 0%.  

CI CONTENTION:  “Not all issues were given proper attention.  Future complications arose.  Unfair determination.”  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 - 20040213	VARD - 20040902	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Left Knee Pain	5099-5003	0%	Residuals, Left Knee Tendon Injury	5260-5024	10%	20050426	
Stress Reactions Both Ankles	5022	0%	Residuals, Severe Overuse Syndrome, Right Ankle	5271	10%		
			Residuals, Severe Overuse Syndrome, Left Ankle	5271	10%		
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Chronic Left Knee Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s left knee condition began in October 2002 while running.  A magnetic resonance imaging (MRI) at that time showed quadriceps tendinitis, but a subsequent repeat study was essentially normal.  Despite treatment, the left knee condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for MEB.  The MEB forwarded “chronic left knee pain” for PEB adjudication.

A physical examination in the sports medicine clinic on 1 May 2003 (11 months prior to separation) found left knee flexion of 100 degrees (normal 140 degrees) and normal extension of 0 degrees.  Tenderness at the site of quadriceps muscle insertion at the patella (kneecap) was present.  The anterior cruciate ligament was intact and a test for patellar instability was negative.

An orthopedic physical examination on 22 October 2003 (5 months prior to separation) noted diffuse tenderness of the left knee with light touching.  Left knee flexion was 60 degrees and extension was 0 degrees.  Painful motion was present.  There was no joint swelling, and the anterior cruciate and collateral ligaments were intact.

The MEB NARSUM examination on 19 November 2003, approximately 4 months prior to separation, noted complaints of chronic left knee pain and use of a knee brace and crutches.  Knee pain prevented running, jumping or moving freely.

At the 24 April 2004 VA Compensation and Pension (C&P) evaluation, performed approximately 1 month after separation, the CI reported daily pain, swelling, buckling, popping and grinding.  She reported use of a brace and cane.  She could not stand for more than 10 minutes, squat, walk more than 1/8-mile or run.  Physical examination showed use of a cane and a limping gait.  The left knee joint displayed some swelling, although the exact location and degree were not described.  Left knee flexion was 70 degrees and extension was 0 degrees.  “Some anterior instability” was reported but further details were not provided.  Painful motion was present.  A radiographic (X-ray) was normal.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the left knee condition 0%, coded analogously to 5003 (arthritis, degenerative), with likely application of the US Army Physical Disability Pain Policy.  The VA rated the left knee condition 10% under a combination 5260-5024 code (leg, limitation of flexion of; tenosynovitis), citing painful, limited motion.  There was no limitation of flexion or extension that supported a rating higher than 0% under the VASRD diagnostic codes for limitation of motion (5260 or 5261).  Although the C&P examiner reported some “anterior instability” it is unclear if the examiner was referring to a ligament or the kneecap.  However, prior examiners specified normal ligament findings and patellar stability and imaging studies did not support the presence of ligament injury.  The Board concluded therefore that rating for the presence of ligamentous instability or laxity (5257) was not warranted.  

There was likewise no history of dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258) or history of surgery to remove a meniscus (5259) to support a rating under those respective codes.  There was no fracture, non-union, or malunion of the femur or tibia to support consideration under the respective codes for knee impairment related to long bone conditions (5255, 5262).  However, Board member concluded that there was evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45).  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 knee condition, coded 5099-5003.

Stress Reactions Both Ankles.  The PEB combined the right and left ankle conditions under a single service disability rating, coded 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’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 the STR, the CI experienced an acute right foot injury in early July 2003 while walking down stairs.  Although X-rays were initially normal, persistent right foot pain was evaluated with a nuclear medicine study on 24 July 2003, which showed stress changes in both ankles and the left mid-foot, and findings consistent with a stress fracture of the right second metatarsal bone (mid-foot).  Despite treatment, the bilateral feet condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for an MEB.  The MEB forwarded “severe overuse syndrome, bilateral feet, with stress fracture in right foot with delayed healing and continued pain” for PEB adjudication.

The commander’s statement on 11 September 2003 specified the left knee and the right foot conditions as interfering with job performance.  There was no mention of a left ankle or foot problem.  At a family practice clinic evaluation on 17 September 2003 (6 months prior to separation) the examiner concluded that the right 2nd metatarsal stress fracture was healed on the basis of the absence of swelling or tenderness of the right foot.  The left knee condition was also addressed, but there was no mention of left ankle or left foot symptoms.  However, the CI presented to the emergency room 1 week later with complaints of worsening right foot pain.  There was no mention of right or left ankle symptoms.  Tenderness of the right 2nd metatarsal was present.

A podiatry evaluation on 1 October 2003 recorded complaints of left knee and right foot pain.  The examiner also referenced left dorsal midfoot pain, but did not report left foot examination findings.  There was no mention of right or left ankle pain, examination findings or diagnosis.  The right 2nd metatarsal was tender.  A right foot X-ray showed mild changes compatible with a stress fracture.  Left foot or ankle imaging studies were not performed.  A follow-up podiatry examination one month later found mild right mid-foot tenderness.  There was no mention of right ankle problems; and no report of left ankle or foot symptoms or examination findings.  Repeat X-ray showed a healing right 2nd metatarsal stress fracture.

The MEB NARSUM examination on 19 November 2003 (4 months prior to separation) recorded a chief complaint of “my left knee and right foot hurt.”  The CI stated that the altered gait associated with the use of assistive devices for her left knee “affected her feet, right greater than left.”  There was no mention of ankle problems.  Physical examination showed tenderness of the forefoot bilaterally.  The examiner rendered a diagnosis of severe overuse syndrome (bilateral feet) with a stress fracture of the right foot.

The permanent L4 profile on 3 February 2004 identified left knee pain and right foot pain as the only medical conditions.  In an undated letter to “Members of the Board” the CI described the impact of the left knee condition on her life and indicated that her right foot hurt “every day.”  She did not mention the ankles or left foot.

At a family practice clinic visit on 25 March 2004 (1 week prior to separation) the CI reported to the provider that her foot pain resolved, but that she had bilateral ankle fractures and was having ankle pain.  Physical examination documented full range of ankle motion with no overlying swelling or redness.

A bone scan performed the following week (on the day of separation) showed diffuse moderate stress changes in the right ankle joint and areas of the right mid-foot (though not the 2nd metatarsal).  However, the bone scan findings of the left foot and ankle were normal.

At the 26 April 2004 VA Compensation and Pension (C&P) evaluation, performed 1 month after separation, the CI reported a history of stress fractures of both feet and both ankles.  She wore an air splint on both ankles and experienced daily pain, swelling, and popping.  She was unable to roll her feet and was unable to hop or jump due to ankle and foot pain.  Physical examination showed an abnormal gait with use of a cane, as described previously.  Air splints were present on each ankle. The right ankle displayed tenderness and painful motion.  Dorsiflexion was 15 degrees (normal 20 degrees) and plantar flexion was 20 degrees (normal 45 degrees).  Tenderness over the right instep was also present.  Left ankle swelling, tenderness and painful motion were absent, but left instep tenderness was present.  Left ankle dorsiflexion was 10 degrees and plantar flexion was 20 degrees.  Bilateral feet and ankle X-rays were normal.  The examiner diagnosed stress fractures of each ankle and each foot.

At an emergency room visit on 10 September 2004 (5 months after separation) the CI complained of right hip, knee and ankle pain for 3 days.  The clinical entry reflected a normal right ankle examination.  The CI followed up in the family practice clinic 3 days later, at which time examination found a non-tender right ankle with full range of motion.  At physical therapy evaluations for improving low back pain in November and December 2004 (9 months after separation), the CI reported that she was enjoying bike riding and ice skating.  

The Board directed attention to its rating recommendation based on the above evidence.  The VA rated each ankle condition at 10% under the 5271 code (ankle, limited motion of), citing moderate limited motion of each ankle, but also assigned 0% ratings for each foot under the 5284 code (other foot injuries).  It was noted that the only diagnosed clinical conditions leading up to and during the MEB process were the stress fracture of the right 2nd metatarsal (foot) bone and “severe overuse syndrome, bilateral feet” (NARSUM).  Although the July 2003 bone scan noted stress changes in both ankles, those changes were appropriately never correlated by the CI’s providers with the actual presence of clinical injury or disease.  The first mention of ankle pain in the STR was at the March 2004 family practice visit, which occurred after the PEB determination.  All prior entries, including the NARSUM, were silent regarding complaints referable to the ankles or to an ankle diagnosis.  Nevertheless, the PEB cited “stress reactions both ankles” as the unfitting condition rated at 0%, under the 5022 code (periostitis), citing no significant loss of ankle joint motion.  

As previously elaborated, the Board must first consider whether each ankle remains separately unfitting, having been de-coupled from a combined PEB adjudication.  The right foot was permanently profiled, was implicated in the commander’s statement and was considered to fail retention standards.  Despite ultimate (and expected) right metatarsal stress fracture healing, Board members concluded that continued pain, whether in the right foot or right ankle, was integral to the CI’s inability to perform her military occupational specialty (MOS); and, accordingly a separate service rating is recommended.  

Regarding a rating recommendation, the Board agreed that a 10% rating was reasonably conceded IAW §4.40, §4.45 (functional loss) under the 5022 code.  A rating was also considered under the 5284 code, and it was agreed that the impairment more nearly approximated a ‘moderate’ condition to support a 10% rating via this pathway.  The Board also considered a rating under the 5271 code for ‘moderate’ limitation of ankle motion noted by the VA C&P examiner a month after separation.  However IAW §4.14 (avoidance of pyramiding; more than one rating based on the same impairment is prohibited) separate ratings under 5271, 5022 or 5284 were not warranted in this case.  Moreover, the VA C&P examination was assigned little probative value by the Board since the examiner did not recognize a history of bilateral ankle or left foot stress fractures and there was no evidence of current stress fractures; and there was no attempted explanation for persistent left ankle or foot symptoms in the face of normal bone scan and X-rays.  There was no ankylosis of the ankle or subastragalar (sub-tarsal) joints, no malunion of the os calcis (calcaneus) or astragalus (talus) or astragalectomy for consideration under the respective diagnostic codes (5270, 5272, 5273 or 5274).  After due deliberation, and considering all of the evidence, the Board recommends a disability rating of 10% for the right ankle stress reaction condition, coded 5022.

Next, the Board turned its attention to the left ankle stress reaction condition.  The Board could not find evidence in the commander’s statement or elsewhere in the STR that indicated any significant interference of left ankle (or foot) pain with the performance of duties.  Although the MEB submitted bilateral foot overuse syndrome, only the right foot was profiled and only the right foot was implicated by the commander.  Moreover, there were no physical findings documented by service providers prior to separation which would logically be associated with significant disability (whether of the foot or the ankle), and a bone scan on the day of separation documented resolution of all stress changes in the left foot and ankle.  Therefore, the Board concluded that the preponderance of evidence does not support a conclusion that left ankle stress reaction, as an isolated condition, would have rendered the CI incapable of continued service within her MOS and accordingly cannot recommend a separate rating for it.

BOARD FINDINGS:  In the matter of the chronic left knee pain condition, the Board unanimously recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a.  In the matter of the stress reactions both ankles condition, the Board unanimously recommends that it be adjudicated for two separate conditions.  In the matter of the right ankle stress reaction condition, the Board unanimously recommends a disability rating of 10%, coded 5022.  In the matter of the left ankle stress reaction condition, the Board unanimously agrees that it cannot recommend a finding of unfit for additional disability rating.  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 Left Knee Pain	5099-5003	10%	
Stress Reactions Right Ankle	5022	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150527, w/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

03 MAR 2017

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for 
XXXXXXXXXXXXXXXXXX, AR20170002063   (PD201500340)

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