RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00542
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20080602

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Cable Systems Installer/Maintainer, medically separated for “bilateral ankle pain and shin splints” with a disability rating of 0%.

CI CONTENTION:  “Review all conditions.”  The 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 - 20080215	VARD - 20081203	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Ankle Pain and Shin Splints	5099-5022	0%	Shin Splints Left Leg with Ankle Pain	5271-5262	0%	20080730	
			Shin Splints Right Leg with Ankle Pain	5271-5262	0%	20080730	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Bilateral ankle pain and shin splints.  The panel noted that the Medical Evaluation Board (MEB) proceedings, MEB narrative summary (NARSUM) and the commander’s statement were not available in the evidence and could not be located after the appropriate inquiries.  A further attempt at obtaining the relevant documentation would likely be futile and introduce additional delay in processing the case. It is was judged by the members that the missing evidence would not materially alter the panel’s recommendations.  

The panel also noted that the PEB combined the bilateral ankle pain and shin splint conditions as a single unfitting condition coded analogously to 5022 (periostitis) and rated 0%.  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 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 bilateral ankle pain and shin splints condition is presented with attendant recommendations regarding separate unfitness, and separate rating if indicated.  

According to the service treatment record (STR), the CI’s bilateral ankle pain and shin splints conditions began in 2005.  A temporary L2 profile for bilateral shin splints dated 25 January 2006.  Foot and ankle X-rays a year later (January 2007) were normal.  At the next primary care (PC) visit on 20 February 2007 the CI reported bilateral leg and foot pain and examination showed a normal gait and normal ankle and feet except for flexible flatfoot bilaterally.  A 26 February 2007 PC visit again noted complaints of bilateral ankle pain with physical activity.  In 24 April 2007 magnetic resonance imaging of both ankles was normal.  The CI participated in physical therapy but in July 2007, 11 months prior to separation, she reported no improvement and was discharged.  The CI was given a permanent L2 profile on 23 July 2007 for chronic bilateral ankle pain with the limitation of no running.  

A bone scan performed on 24 August 2007, 10 months prior to separation, noted diffuse uptake in the knees, ankles, and bilateral midfoot, and focal uptake in the bilateral tibial shafts interpreted as “mild shin splints.”  At a profile review visit on 8 October 2007, 8 months prior to separation, the CI reported that walking with combat equipment increased her leg pain.  She could walk a mile or more if required and could pass the physical fitness walk, bicycle, or swim test.  There was a temporary L2 profile for chronic shin splints dated 22 October 2007. 

Primary care visits in November and December 2007 noted complaints of bilateral leg pain for the past 18 months; the former visit noted pain with ankle range of motion (ROM) and the latter noted normal ankle examination with tenderness of both tibial shafts.  Orthopedic evaluation on 7 December 2007, 6 months before separation, noted complaints of bilateral ankle pain that started simultaneously.  The CI reported pain with weight-bearing activities and denied numbness/tingling or foot drop.  The physical examination noted bilateral ankle ROM with dorsiflexion (DF) of 10 degrees and plantar flexion (PF) of 15 degrees, with tenderness of the anterior aspect of the tibia bilaterally.  There was no weakness of either ankle and no evidence of nerve-related injury.  Evaluations for impingement syndrome and exertional compartment syndrome were negative.  Bilateral ankle X-rays in December 2007 were normal.  The orthopedic examiner indicated he could not identify the etiology of the CI’s ankle pain.  He indicated the CI could not run, walk fast, carry any weight, or jump.  

At the January 2008 MEB examination (recorded on DD Forms 2807-1 and 2808), 5 months prior to separation, the CI reported “bilateral pains.”  Physical examination showed the ankles were normal in appearance with good pulses.  No tenderness was noted.  Ankle ROM was “excellent in all planes.”  The MEB examiner assigned a permanent L3 profile for chronic ankle pain also dated January 2008.  

At the 30 July 2008 VA Compensation and Pension (C&P) evaluation, 2 months after separation, the CI reported bilateral ankle pain provoked by running or walking long distances.  At the time of pain she could function without medication.  She reported no functional impairment from the condition.  Physical examination showed a normal gait and posture.  The CI did not use a cane or a crutch for ambulation.  There was no sign of abnormal wear of the feet or shoes and no callosities.  There was no swelling, effusion, tenderness, weakness, subluxation, or guarding of movement of either ankle.  Bilateral ankle ROM was DF 20 degrees and PF 45 degrees.   There was no additional loss of ROM with repetition of motion.  There was no indication of malunion of either ankle.  Pulses and strength, sensation, and reflexes of both lower extremities were normal.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral ankle pain and shin splints condition 0%, coded analogously to 5022, as noted above, citing abnormal bone scan with normal ankle ROM without pain.  The VA rated the right leg shin splints and left leg shin splints each 0%, both coded 5271-5262 (limitation of ankle motion-impairment of the tibia), based on the C&P examination 2 months after separation, citing no diagnosis of chronic disability of either ankle, but with bone scan findings of shin splints, with no objective evidence of disability.  
  
The panel first considered if the bilateral ankle pain and shin splint conditions, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The permanent profile was for chronic bilateral ankle pain.  The two temporary L2 profiles in record noted bilateral shin splints.  The CI was evaluated and treated for bilateral leg and ankle pain.  Alternating complaints of bilateral ankle pain and bilateral leg pain were noted throughout the STR.  The panel concluded that there was not a preponderance of evidence of the service records that overcame the panel’s presumption that each leg/ankle condition was reasonably considered separately unfitting.  

The panel next considered if either leg/ankle pain condition could be further unbundled into shin splints and an ankle condition and remain separately unfitting.  The panel noted that the CI reported leg pain and ankle pain interchangeably at alternating visits.  There was no objective evidence of any pathology for either ankle; and the bilateral shin splint conditions could account for the ankle joint pain.  There was no indication in the STR that two separately identifiable conditions of the lower leg/ankle existed for either extremity.  The panel concluded that the disability due to both the “ankle pain” and “shin splints” was pain with weight-bearing activities and the two conditions referred to the same disability and therefore they could not be separated for individual contributions to fitness and separate disability rating.  

The panel then considered its rating recommendation for the unfitting right and left ankle pain and shin splints conditions at the time of separation.  The clinical findings of both the right and left leg/ankle conditions were identical and therefore the rating of the right and left lower extremity conditions were considered together.  The panel noted that the ROM at the time of the MEB and VA examinations was normal and therefore did not attain a minimum rating under VASRD diagnostic code 5271; and neither examination noted painful joint motion for individual 10% ratings under 5271, 5022 or 5299- 5260 (analogous to limitation of leg flexion, based on §4.59, §4.40 and §4.45.  The panel considered coding the conditions as 5299-5262, analogous to tibia impairment, which is an analogous code for shin splints.  Although there was evidence on the bone scan consistent with mild bilateral shin splints, there was no clinical evidence at the MEB or VA examinations of knee or ankle limitation of motion or painful motion to support a 10% rating for each condition for tibia impairment with slight knee or ankle disability.  

At the VA examination 2 months after separation, no abnormalities of the lower legs or ankles were noted.  Members agreed this was consistent with improvement in the lower extremity symptoms related to impact activities or carrying heavy equipment following separation when the CI was no longer subject to the physical demands  of the military lifestyle.  The panel then noted there was no rating higher than 0% for the right and left “ankle pain and shin splint” conditions with any applicable VASRD code.  After having unbundled the lower extremity conditions, the panel found there was no ratings benefit to the CI and therefore no change to the PEB combined adjudication is recommended.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded that there was insufficient cause to recommend a change in the PEB adjudication for the “bilateral ankle pain and shin splints” condition.  

BOARD FINDINGS:  In the matter of the “bilateral ankle pain and shin splints” condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  There are no other conditions within the panel’s scope of review for consideration.  The panel, 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 20150602, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170006505, XXXXXXXXXXXXXXXXXX 

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Dear XXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found your separation disability rating and your separation from the Army for disability with severance pay to be accurate.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed), and I accept its recommendation.  I regret to inform you that your application to the DoD PDBR is denied.  

	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.

Sincerely,					       
						      					
Enclosure