RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00548
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20051221

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E1, Trainee, medically separated for “bilateral lower extremity stress fractures” with a disability rating of 0%.

CI CONTENTION:  The CI made no specific contention.  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 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 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 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 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 - 20051209	VARD - 20070205	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Lower Extremity Stress Fractures	5099-5022	0%	Multiple Stress Fractures Lower Extremities	5299-5262	NSC	STR	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  NA	

ANALYSIS SUMMARY:  

Bilateral Lower Extremity Stress Fractures.  The panel provided the following clarification regarding its approach to PEB consolidated ratings.  The PEB combined conditions affecting the right and left lower extremities under a single service disability rating, coded 5099-5022, analogous to periostitis, defaulting to criteria of 5003 (degenerative arthritis).  This approach by the PEB not uncommonly reflected its judgment that the constellation of conditions was unfitting, and that 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 VASRD criteria of 5003, and that this approach does not necessarily 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 that it alone would not have caused the member to be referred into the DES or be found unfit because of physical disability.

According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI began developing bilateral lower extremity pain in October 2005 during the second week of basic training.  This began with ankle pain, right more than left, and extended to the shins and knees; and, it forced cessation of training.  A bone scan demonstrated stress fractures of the bilateral distal tibias and left medial tibial plateau, a stress fracture of the right distal femur, and bilateral mid-foot stress reactions.  There was confirmation in STR clinical notes of grossly normal range of motion (ROM) and joint stability of the right ankle and knee, and there was no STR entry that documented significant ROM limitation or other separately ratable finding for any affected joint.

Surgery was not indicated and conservative treatment did not result in sufficient improvement to allow a timely resumption of training.  The CI was referred for an MEB which in turn forwarded “multiple stress fractures of both lower extremities” to the PEB.  The NARSUM examination on 1 December 2005, 3 weeks before separation did not elaborate pain severity or detail functional limitations, other than to confirm the inability to tolerate the rigors of training; and, it noted the CI’s lack of desire to pursue a prolonged rehabilitation and further military service.  The physical examination recorded “using crutches with minimal pain on ambulation,” areas of tenderness over the tibias and right femur, the absence of any swelling, “strength 4+/5 bilateral because of pain,” and “full active knee and ankle ROM.”  There was no MEB history and physical (DD Forms 2808 or 2807-1), profile, or commander’s performance statement in evidence.  There was no VA Compensation and Pension examination in evidence proximate to separation. 

The panel directed attention to its rating recommendation based on the above evidence.  The PEB’s bilateral 0% rating under criteria of 5003 did not state a rationale and did not comport with VASRD §4.71a which confers a 10% rating under 5003 for the involvement of “2 or more major joints” without specifying a need for additional criteria.  The VA did not service-connect the condition, citing the lack of contemporary VA examination evidence.  The stress fractures in this case affected both ankles and both knees, but there was no compensable ROM limitation or any other ratable criterion in evidence that would provide for a rating higher than 10% under any applicable joint code.  There was also no malunion or fracture complication that would justify rating under code 5262 (tibia and fibula, impairment of), even for analogous rating, given the overall benign and self-limited nature of stress fractures.  The panel confronted decisions in this case as to whether, based on the fitness principles elaborated in the introduction, it could justify recommendations for separate ratings of each extremity or even separate ratings for each affected joint.  The PEB’s 5022 code for periostitis was a good clinical match with the pathology and it offers the latitude for rating all affected joints under the above collective criterion for a 10% rating, as well as being applicable for separate coding and rating.  

In this case, there was no evidence that one joint or extremity caused more functional impairment than any other, and the overall functional impairment at separation was confined to the completion of strenuous military training.  Panel member consensus was, given the clinical acuity and functional limitations described above, that it was reasonable to conclude that the performance limitations confined to any single joint or extremity would not have rendered the CI incapable of continuing military service.  More likely, it was the combined effect of all the stress fractures which rendered the CI unfit.  Therefore, member consensus was that an overall 10% rating under the “2 or more major joints” criterion of 5003 was appropriate.   

After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel’s consensus recommendation is a 10% rating for the bilateral lower extremity stress fractures under code 5022.

BOARD FINDINGS:  In the matter of the bilateral lower extremity stress fractures and IAW VASRD §4.71a, the panel, by a majority vote recommends a disability rating of 10%, coded 5022 IAW VASRD §4.71a.  The single voter for dissent recommended a modification to 20% (separate extremity ratings), and did not elect to submit a minority opinion.  There were 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	
Bilateral Lower Extremity Stress Fractures	5022	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150502, with attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAF/MRB

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2015-00548.

After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was not appropriate under the guidelines of the Veterans Affairs Schedule for Rating Disabilities.  Accordingly, the Board recommended modification of your assigned disability rating without re-characterization of your separation with severance pay. 

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding, accept their recommendation and direct that your records be corrected as set forth in the attached copy of a Memorandum for the Chief of Staff, United States Air Force.  The office responsible for making the correction will inform you when your records have been changed.

Sincerely,

Attachment:
1.  Directive 
2.  Record of Proceedings 

cc:
SAF/MRBR