RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00425
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20061018

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Automated Logistics Specialist, medically separated for “chronic left knee pain since a fall in basic training” and “shin splints,” rated 0% and 0%, respectively, with a combined disability rating of 0%.

CI CONTENTION:  “I am currently having the same problems and they are affecting the quality of life.  Review 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 - 20060905	VARD - 20070824	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Left Knee Pain…	5099-5003	0%	Left Knee Disability	5257	0%	20070719	
Shin Splints	5022	0%	Bilateral Shin Splints	5299-5262	0%	20070719	
Bilateral Pes Planus	Not Unfitting	No VA Placement	
Ocular Hypertension	Not Unfitting	No VA Placement	
Obesity	Not Unfitting	No VA Placement	
Hypercholesteremia	Not Unfitting	No VA Placement	
	Not Unfitting 	No VA Placement	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Chronic Left Knee Pain.  According to service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI fell on her left knee during a run in basic training in September 2003.  Surgical intervention was not indicated.  Radiographic imaging was normal.  She received long-term conservative treatment to include physical therapy (PT) and physical restrictions.  Over time, her physical condition worsened in having constant pain with subjective “give out” of her left knee.  Despite aggressive treatment, the left knee condition could not be adequately rehabilitated to meet the physical requirements of her military specialty.  She was issued a permanent L3 profile and was referred for a MEB.  The MEB forwarded “left knee pain” for PEB adjudication.
   
The MEB NARSUM examination on 10 May 2006 (5 months prior to separation), noted continued left knee pain aggravated by running, jumping and marching.  Application of ice and less weight upon the left lower extremity were noted as “easing factors” in reducing painful symptoms.  Her physical examination (PE) was positive for left knee crepitus and a tender patellar (knee cap) grind.  There was decreased range of motion (ROM) with knee flexion to 105 degrees (normal = 140).  No joint instability was in evidence.  The VA Compensation and Pension (C&P) PE on 19 July 2007 (9 months after separation), documented a completely normal left knee examination.  Additionally, the provider documented “normal left knee and resolved bilateral shin splints” under the heading of [DIAGNOSIS OR ETIOLOGY OF THE PROBLEM].  Her activities of daily living were not adversely effected.    

The Board directed attention to its rating recommendation based on the above evidence.  Although utilizing different primary VASRD codes, both the PEB and VA rated the left knee condition at 0% citing minimal/constant pain and normal examination, respectively.  Board members agreed there was no limitation of flexion or extension that supported a minimum rating under the VASRD diagnostic codes for limitation of motion (5260 or 5261).  However, the physical finding of tenderness with patellar grinding was indicative of painful motion and therefore, coupled with functional loss (decreased flexion) did support a 10% rating.  There was no evidence of subluxation or lateral instability to support a separate 10% rating under the 5257 code (knee, other impairment).  There was no fracture, non-union, or mal-union of the femur or tibia to support consideration under the respective codes for knee impairment related to long bone conditions (5255, 5262).  After due deliberation, and in consideration of all the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the left knee pain analogously coded 5099-5003 IAW §4.59, §4.40 and §4.45.
 
Shin Splints.  Although absent an original report, the STR noted bone-scan positive evidence of moderate bilateral shin splints in July 2005 (15 months pre-separation).  Clinical records indicated that her painful bilateral shin splint symptoms resolved while she ceased running due to pregnancy for a 3-month period.  After pregnancy, her bilateral leg pain symptoms returned in February 2006 (8 months prior to separation) upon the continuation of running.  Without additional radiographic imaging, she again was clinically diagnosed with bilateral shin splints on 3 March 2006 (7 months prior to separation).  The NARSUM examination (5 months prior to separation), revealed continued tenderness over the upper portion of both tibia bones.  Her gait was documented as “unremarkable”.  As previously stated above, the VA C&P examination performed 9 months after separation reported “resolved bilateral shin splints” as a diagnosis.  

The Board directed attention to its rating recommendation based on the above evidence.  Although utilizing different primary VASRD codes, both the PEB and VA rated the bilateral shin splints at 0% citing constant bilateral aching a resolved condition, respectively.  The PEB chose to bundle both lower extremities in assigning its 0% impairment rating.  The Board first considered whether each lower extremity condition remained separately unfitting, having decoupled them from the combined PEB adjudication.  The Board must apply separate codes and ratings in its recommendations if compensable ratings for each extremity condition are achieved IAW VASRD §4.71a.  If the Board judges that two or more separate ratings are warranted in such cases, however, it must satisfy the requirement that each ‘unbundled’ condition was unfitting in and of itself.

In light of pre-separation physical examination findings of continued tenderness to the upper portion of both legs, Board members considered whether each leg could be reasonably justified as separately unfitting.  Five months prior to separation, the case revealed minimal, but equivocal findings for each leg.  Although it is speculative to conclude that the disability confined to the either leg would have rendered the CI incapable of performing within her occupational rating, member consensus was that it was also reasonable to surmise that it was the overall effect of both lower extremities (tibia bone) which rendered her unfit.  

In determining a final impairment rating, the Board considered and agreed that the 3-month avoidance of physical activity (during pregnancy) that resulted in resolution of her shin splint symptoms would support the same result after being permanently profiled and a repeat avoidance of activities during the 5-month period prior to separation.  In consideration of the above, disability at the time of separation would be minimal or non-existent at best.  

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 condition of bilateral shin splints.    

Contended PEB Conditions. Bilateral pes planus (flat feet), ocular hypertension, obesity, and hypercholesteremia (elevated cholesterol).  The conditions were not profiled, implicated in the commander’s statement or were not judged to fail retention standards.  There was no performance-based evidence from the record that none of the contended conditions significantly interfered with satisfactory duty performance at or near separation.  After due deliberation, the Board concluded that there was insufficient cause to recommend a change in the PEB’s fitness determination for any of the above conditions and so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the left knee condition, the Board unanimously recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a.  In the matter of the bilateral shin splints condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended bilateral pes planus, ocular hypertension, obesity, and hypercholesteremia 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 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%	
Shin Splints	5022	0%	
COMBINED	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150601, 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

03 MAR 2017

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for 
XXXXXXXXXXXXXXXXXX, AR20160019845 (PD201500425)

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