RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00574
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070402

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E2, Medical Specialist, medically separated for “chronic right knee pain and pain from left pubic ramus stress fracture with associated stress changes in left foot,” with a disability rating of 10%.

CI CONTENTION:  The CI contends that she still has pains to include severe leg pain that precludes her from doing certain physical activities.  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 – 2007020	VARD - 20080325	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Right Knee Pain and Pain from Left Pubic Ramus Stress Fracture with Associated Stress Changes in Left Foot	5099-5003	10%	Residuals, Right Knee Strain	5299-5260	0%	20080204	
			Residuals, Left Pubic Rami Fracture	5299-5252	0%	20080204	
			Residuals, Left Foot Stress Changes of the Calcaneal Cuboital Joint	5299-5284	0%	20080204	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Right Knee Condition.  The PEB combined the right knee, left pubic ramus, and left foot conditions as a single unfitting condition coded analogously to 5003 and rated 10%.  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 or implied adjudication that each condition was separately unfitting.  The Board 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 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 DES 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.  The evidence for the right knee, left pubic ramus, and left foot conditions are presented separately, with attendant recommendations regarding separate unfitness and rating in the rating discussion.

According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the right knee pain began approximately 6 weeks prior to referral for MEB.  A 6 October 2006 right knee X-ray was normal.  A 12 October 2006 whole body diagnostic imaging (bone scan) study showed stress changes (precursor lesion to stress fracture) of the knees.  On 22 February 2007, right knee range of motion (ROM) was measured with a goniometer.  Pain-limited, repetitive (X3), right knee active ROM was flexion of 120/120/125 (140 normal) and extension of 10/10/10 (0) degrees.  The Lachman (assesses anterior cruciate ligament [ACL]) test was negative.  In the 22 February 2007 NARSUM, 5 weeks before separation, the CI complained of developing right knee pain approximately 6 weeks prior with no history of direct trauma.  “Her conditions are directly related to physical activity since enlisting in the US Army.”  She denied feelings of instability and controlled her pain with daily Percocet and Motrin.  The examiner documented “Please see DD Form 2808 for the majority of normal findings.”  The right knee examination revealed medial tenderness with no effusion (fluid collection), edema (excess tissue fluid swelling), quadriceps atrophy, patellar tilt, laxity, or crepitus (grating sensation or sound).  Active ROM was measured by goniometer and was limited by pain.  Average of repetitive (X3) ROM was flexion of 122 (140) and extension of 10 (0) degrees.  The Lachman, McMurray (assesses menisci), patellar grind (assesses abnormal patellar movement and painful crepitation), valgus/varus stress (assesses medial collateral ligament [MCL]/lateral collateral ligament [LCL]), and drawer (assesses ACL and posterior cruciate ligament [PCL]) tests were negative.  Strength, sensation, and pulses were normal.  The diagnosis listed right knee pain due to arthralgia.  In the 4 February 2008 VA Compensation and Pension (C&P) examination the CI complained of right knee pain and use of a knee brace.  The physical examination documented a normal gait with no assistive aids.  The right knee examination revealed no evidence of inflammatory arthritis, joint ankylosis, loss of bone, abnormal weight bearing, or motor loss.  Right knee ROM was flexion of 140 (140) and extension of 0 (0) degrees.  There was no additional loss of motion with repetitive use.  A right knee X-ray was negative.  The diagnosis listed history of right knee pain which had resolved without evidence of significant residuals.  

The Board directed attention to its rating recommendation based on the above evidence.  As previously elaborated, the Board must first consider whether the right knee condition remains separately unfitting, having been de-coupled from a combined PEB adjudication.  The PEB assigned a 10% rating under an analogous 5003 code (arthritis, degenerative) citing chronic right knee pain and ROM limited by pain.  The VA assigned a 0% rating under an analogous 5260 code (leg, limitation of flexion of) based on the VA C&P examination 10 months after separation, citing right knee strain, without evidence of significant residuals, normal X-ray, normal gait, normal ROM, and no objective evidence of painful motion, swelling, tenderness, instability, or weakness.  While the CI became symptomatic with physical stressors, subjective symptoms and objective examination and imaging findings resolved when she desisted from the activity and rigors attendant to a military lifestyle.  While the ROM values in the MEB examination were consistent with the 10% rating under the limitation of knee extension (5261) code, the VA C&P examination did not support a minimum rating.  The ROM values in the proximate exams (MEB & VA C&P) did not support a minimum rating under the limitation of knee flexion (5260) and extension (5261) codes.  There was no dislocated meniscus (5258) or symptomatic removed meniscus (5259) for consideration under the respective codes.  There was no knee ankylosis (5256), knee recurrent subluxation/lateral instability (5257), tibia and fibula nonunion/malunion (5262), or genu recurvatum (5263) for consideration under the respective codes.  The Board agreed a 10% rating was not supported based on VASRD §4.40 (functional loss) or §4.59 (painful motion).  The Board concluded that the evidence did not provide sufficient grounds for recommending separate disability ratings in this case, and that the combined rating of 10%, coded 5099-5003, is a good analogy to both the pathology and disability.  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 right knee condition.  

Left Pubic Ramus Stress Fracture Condition.  According to STRs and the MEB NARSUM, the left pubic ramus stress fracture condition began approximately 4-5 months prior to referral for MEB.  A 12 October 2006 bone scan showed left inferior and superior pubic rami stress fractures (repetitive stress induced fractures).  Serial left hip and pelvis X-rays showed a healing fracture of the left inferior pubic ramus.  A 14 December 2006 bone scan showed a left inferior pubic ramus stress fracture.  On 22 February 2007 left hip ROM was measured with a goniometer.  Pain-limited, repetitive (X3), left hip active ROM was flexion of 70/70/75 (125), extension of 5/5/5 (0), and abduction of 20/25/25 (45) degrees.  In the NARSUM the CI complained of developing left hip pain approximately 4-5 months prior with no history of direct trauma.  “Her conditions are directly related to physical activity since enlisting in the US Army.”  She denied radicular symptoms or feelings of instability and controlled her pain with daily Percocet and Motrin.  The examiner documented “Please see DD Form 2808 for the majority of normal findings.”  The left hip examination revealed inguinal region and greater trochanter (proximal lateral femur bony prominence) tenderness.  Active ROM was measured by goniometer and was limited by pain.  Average of repetitive (X3) ROM was flexion of 72 (125), extension of 5 (0), and abduction of 23 (45) degrees.  Strength, sensation, and pulses were normal.  The diagnosis listed left pubic rami stress fracture.  The C&P examination documented a history of left inferior and superior pubic rami stress fractures.  The physical examination documented a normal gait with no assistive aids.  Hip and pelvis X-rays were normal.  The diagnosis listed history of left inferior and superior pubic rami stress fractures which had resolved without evidence of significant residuals.

The Board directed attention to its rating recommendation based on the above evidence.  As previously elaborated, the Board must first consider whether the left pubic ramus stress fracture condition remains separately unfitting, having been de-coupled from a combined PEB adjudication.  The PEB assigned a 10% rating under an analogous 5003 code (arthritis, degenerative) citing left pubic ramus stress fracture pain and ROM limited by pain.  The VA assigned a 0% rating under an analogous 5252 code (thigh, limitation of flexion of) based on the VA C&P examination citing resolved left pubic rami stress fracture, without evidence of significant residuals, and normal X-ray.  While the CI became symptomatic with physical stressors, subjective symptoms and objective examination and imaging findings resolved when she desisted from the activity and rigors attendant to a military lifestyle.  The ROM values in the MEB examination were consistent with the 10% rating under the limitation of thigh extension (5251) code.  There was no thigh limitation of flexion (5252), hip ankylosis (5250), thigh impairment of abduction, adduction, or rotation (5253), hip flail joint (5254), or femur fracture nonunion/malunion (5255) for consideration under the respective codes.  Board members agreed a 10% rating was not justified IAW §4.40 (functional loss) and §4.59 (painful motion).  The Board concluded that the evidence did not provide sufficient grounds for recommending separate disability ratings in this case, and that the combined rating of 10%, coded 5099-5003, is a good analogy to both the pathology and disability.  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 left pubic ramus stress fracture condition.  

Left Foot Condition.  According to STRs and the MEB NARSUM, the left foot condition began approximately 4-5 months prior to referral for MEB.  A 12 October 2006 bone scan showed left midfoot stress changes.  A 14 December 2006 bone scan showed left foot calcaneocuboid joint stress changes and plantar fasciitis.  The Report of Medical Examination (DD Form 2808) documented asymptomatic feet with normal arches.  In the NARSUM the CI complained of developing left foot pain approximately 4-5 months prior with no history of direct trauma.  “Her conditions are directly related to physical activity since enlisting in the US Army.”  She denied feelings of instability and controlled her pain with daily Percocet and Motrin.  The examiner documented “Please see DD Form 2808 for the majority of normal findings.”  The left foot examination revealed midfoot tenderness with intact skin and no edema, effusion, or erythema (redness).  The Achilles tendon was intact and nontender.  The CI was able to fire her extensor hallucis longus, flexor hallucis longus, extensor digitorum brevis, and flexor digitorum brevis.  Strength, sensation, and pulses were normal.  The diagnosis listed left foot calcaneal cuboidal joint stress changes.  The C&P examination documented a history of left foot stress changes.  The physical examination documented a normal gait with no assistive aids.  The left foot examination revealed no swelling, skin abnormality, vascular abnormality, pes cavus (clawfoot), flatfoot, muscle atrophy, hammertoes, hallux valgus, hallux rigidus, other foot deformity, or tarsal/metatarsal bones malunion/nonunion.  There was no objective evidence of abnormal weight bearing, tenderness, instability, weakness, or painful motion.  Left foot X-rays were normal.  The diagnosis listed history of left foot stress changes which have resolved without evidence of significant residuals.

The Board directed attention to its rating recommendation based on the above evidence.  As previously elaborated, the Board must first consider whether the left foot condition remains separately unfitting, having been de-coupled from a combined PEB adjudication.  The PEB assigned a 10% rating under an analogous 5003 code (arthritis, degenerative) citing left foot stress changes and ROM limited by pain.  The VA assigned a 0% rating under an analogous 5284 code (foot injuries, other) based on the VA C&P examination citing left foot stress changes, without evidence of significant residuals, normal X-ray, normal gait, normal ROM, and no objective evidence of painful motion, swelling, tenderness, instability, or weakness.  While the CI became symptomatic with physical stressors, subjective symptoms and objective examination and imaging findings resolved when she desisted from the activity and rigors attendant to a military lifestyle.  There was no weak foot (5277), claw foot (5278), metatarsalgia (5279), hallux valgus (5280), hallux rigidus (5281, hammer toe (5282), or metatarsal bones malunion/nonunion (5283) for consideration under the respective codes.  The code (5284) used by the VA characterizes and rates impairment as moderate (10%), moderately severe (20%), and severe (30%).  Board members agreed a 10% rating was not justified IAW §4.40 (functional loss) and §4.59 (painful motion).  The Board agreed that the foot symptoms did not approach the moderate (10%) under 5284 (foot injuries, other).  The Board concluded that the evidence did not provide sufficient grounds for recommending separate disability ratings in this case, and that the combined rating of 10%, coded 5099-5003, is a good analogy to both the pathology and disability.  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 left foot condition.  

BOARD FINDINGS:  In the matter of the right knee, left pubic ramus, and left foot conditions and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  There were no other conditions within the Board’s scope of review for consideration.  The Board, 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 20150601, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB						

MEMORANDUM FOR Commander

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for 
XXXXXXXXXXXXXXXXXX, AR20160018763 (PD201500574)

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, I accept the Board’s recommendation and hereby deny the individual’s application. This decision is final.  The individual concerned, counsel (if any), and any Members of Congress who have shown interest in this application have been notified of this decision by mail.

 BY ORDER OF THE SECRETARY OF THE ARMY:

Enclosure

CF: 
(  ) DoD PDBR
(  ) DVA