RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00502
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20071009

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E2, Basic Trainee, medically separated for “periostitis, bilateral ankles and knees,” with a disability rating of 0%.

CI CONTENTION:  “Review all Conditions.”  The CI’s complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The panel’s scope of review is defined in DoDI 6040.44.  It is limited to review of disability ratings assigned 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 or non-compensable.  Any conditions outside the panel’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 panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The panel’s assessment of the PEB rating determination 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(s) at the time of separation.  The panel 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 panel 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 - 200070926	VARD - 20080710	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Periostitis, Bilateral Ankles and Knees	5022	0%	Bilateral Stress Reactions of Knees (Claimed as Bilateral Knee Condition and Bilateral Shin Splints)	5299-5262	0%	STR	
			Bilateral Stress Reactions of Ankles (Claimed As Bilateral Ankle Condition)	5299-5271			
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Periostitis Bilateral Ankles and Knees Diagnosis. The PEB combined the left knee pain and the right knee pain, and also combined the left ankle pain and right ankle pain conditions as a single unfitting condition coded analogous to 5022 and rated 0%, with application of the US Army Physical Disability Agency (USAPDA) pain policy and AR 635-40, paragraph B24.f.  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 panel 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 panel’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 panel 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 panel 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 left knee pain and right knee pain conditions, as well as the left ankle pain and right ankle pain conditions are presented separately, with attendant recommendations regarding separate unfitness, and separate rating if indicated

According to the service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s “periostitis, bilateral ankles and knees” condition began in January 2007 after strenuous activities in the second week of Basic Training.  Both knees and ankles began hurting during increased and strenuous activities.  Medication used at the time was a non-steroidal pain agent occasionally.  His American Medical Association rating was slight and constant.  He reported a hairline fracture of the left ankle in 2005, but it was never confirmed.  Despite profiles and restricted duty over a 10-week period, the pain did not improve.  

At the September 2007 MEB examination (recorded on DD Forms 2807-1 and 2808), 1 month prior to separation, the CI reported tenderness in the knees and ankles.  Physical examination showed tenderness to both knees and around one of the medial ankles.  

The MEB NARSUM examination on 21 August 2007, 3 months prior to separation, noted complaints of pain associated with his condition.  He had pain with normal ambulation and was unable to run or jog.  X-rays showed moderate uptake in the bilateral medial tibial plateaus as well as mild uptake in the ankles, more marked on the right.  Physical examination showed a moderate antalgic gait.  Both knees were without effusion and had full range of motion (ROM) with mild discomfort.  CI had significant tenderness over the medial tibial plateaus in both knees.  There was no tenderness around the shins.  Knees were stable to stress.  There was no swelling or effusions in the ankles.  No laxity was noted.  CI had mild to moderate tenderness over the anterior and medial portions of the ankles.  There was no VA Compensation and Pension evaluation in evidence proximate to separation.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the periostitis, bilateral ankles and knees condition 0%, coded 5022 (periostitis), citing no mechanical loss of motion.  The VA rated the “bilateral stress reactions of knees (claimed as bilateral knee condition and bilateral shin splints)” coded 5299-5262 (tibia and fibula, impairment of) and the “bilateral stress reactions of ankles (claimed as bilateral ankle condition)” coded 5299-5271 (Ankle, limited motion of) both at 0%, based on the failure to report for examination.  

The panel first considered whether each the bilateral knee and bilateral knee conditions remained separately unfitting, having de-coupled them from a combined PEB adjudication.  Available STR and examinations summarized above reflected symptoms of both knees without distinguishing between the sides.  The commander referred to an “ankle stress fracture” without specifying which ankle, although he was presumably referring to the left ankle, which the CI reported (unconfirmed) had a hairline fracture in 2005.  With this exception, the NARSUM, PEB adjudication and profile specified bilateral knees and ankle conditions.  Bone scan did show moderate uptake intake in the bilateral knees as well as mild uptake in the ankles, more marked on the right.  Examination showed a moderate antalgic gait with mild discomfort in the knees with motion.  The panel agreed, therefore, that the knees were reasonably conceded as a significant factor in rendering the CI unfit.  Members concluded, however, that it was speculative to resume that the disability confined to either the knees or the ankles would have rendered the CI incapable of completing training and pursuing her assigned MOS.  It was thus reasonable to surmise the effect of both bilateral knees and ankles conditions rendered him unfit.    

The panel then considered its rating recommendation for the unfitting bilateral knee and bilateral ankle stress fractures at the time of separation.  While there was evidence of multiple stress fractures, there was no non-union or mal union of the tibia and no limitation of motion of the ankle or knee to support consideration for ratings under 5262 (impairment of tibia) or diagnostic codes for the knee or ankle.  The panel noted that the approach by the PEB using 5022 (5022 code is rated according to the 5003 guidelines) allows for rating a major joint when there is pain on motion (§4.59).  It was not possible to distinguish the specific stress factors that resulted in the moderately antalgic gait.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel majority recommends a disability rating of 10% for the periostitis, bilateral knees and ankles condition, coded 5099-5022.  

BOARD FINDINGS:  In the matter of the condition, the panel majority recommends a disability rating of 10% for the periostitis, bilateral knees and ankles condition, coded 5099-5022.  There are no other conditions within the panel’s scope of review for consideration.  

The panel 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	
Periostitis, Bilateral Ankles and Knees	5099-5022	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

AR20170006454, XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found that your disability rating should be modified but not to the degree that would justify changing your separation for disability with severance pay to a permanent retirement with disability.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed) and I accept its recommendation.  This will not result in any change to your separation document or the amount of severance pay.  A copy of this decision will be filed with your Physical Evaluation Board records.  I regret that the facts of the case did not provide you with the outcome you may have desired.
  
	This decision is final.  Recourse within the Department of Defense or the Department of the Army is exhausted; however, you have the option to seek relief by filing suit in a court of appropriate jurisdiction. 

	A copy of this decision has also been provided to the Department of Veterans Affairs.

Sincerely,