RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00578
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20071023

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a National Guard E3, Medical Specialist medically separated for “bilateral grade I tibial stress fractures…” and “bilateral foot pain…” each rated 0%, with a combined disability rating of 0%.  

CI CONTENTION:  The CI contends her unfitting conditions continue to negatively impact her life.  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 - 20071002	VARD – N/A	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral… Tibial Stress Fractures	5022	0%	No VA Claim in Evidence	
Bilateral Foot Pain…	5399-5310	0%		
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  N/A	

ANALYSIS SUMMARY:  

Bilateral Grade I Tibial Stress Fractures.  The PEB separately combined the right and left tibial stress fractures and the right and left foot pain conditions as single unfitting conditions, respectively coded 5022 (periostitis) and 5399-5310 (muscle group X), and rated 0% each.  This approach by the PEB not uncommonly reflected its judgment that the constellation of conditions were unfitting, and there was no need for separate fitness adjudications or implied adjudication that each condition was separately unfitting.  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 and right stress fracture conditions are presented, with attendant recommendations regarding separate unfitness, and separate rating if indicated.

According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s bilateral tibial stress fractures began in July 2007 while in Basic Combat Training.  Radiographic evaluations (bone scan) in August 2007 documented bilateral grade I tibial stress fractures.  Despite treatment, the bilateral lower extremity condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for an MEB.  The MEB forwarded “bilateral grade I tibial stress fractures” for PEB adjudication.  

According to the commander’s statement dated 30 August 2007, her collective “condition” (presumably referring to both the bilateral tibial stress fractures and bilateral foot pain) prevented bending, lifting, running, and “performing critical field duties such as carrying patient and medical equipment.”  During the 10 September 2007 MEB NARSUM examination (a month prior to separation) the CI reported that the pain in her legs was “present approximately 70% of the time” during the day and that her tibial stress fractures caused numbness, tingling, and swelling, with knee and foot trouble.  She took anti-inflammatory and narcotic medications, each once a day, for control of pain.  Physical examination showed a non-antalgic gait, with tenderness over the mid shins bilaterally.  Range of motion at the knees was 0-135 degrees (normal 0-140) bilaterally.  There was no evidence of right or left knee edema, effusion, grinding, crepitus, muscle atrophy, meniscal injury, instability or laxity.  The right and left ankles showed no tenderness and no evidence of ligamentous laxity.  Dorsiflexion (lifting the forefoot up) was to 5 degrees (normal 20) on the right and 10 degrees on the left.  Bilateral plantar flexion (pressing the forefoot down, as in pressing on the gas pedal of a car) was normal.  Duty limitations dated 11 September 2007 prohibited running, walking, jumping, marching, standing more than 15 minutes, lifting greater than 20 pounds, and carrying farther than 100 feet.  

There was no VA Compensation and Pension (C&P) evaluation in evidence for review.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated 0% for the bilateral grade I tibial stress fracture condition, citing tenderness over the shins, normal gait, with radiographic confirmation.  There was no available evidence that the VA rated the bilateral tibial stress fractures.  The panel first considered if the right and left tibial stress fractures, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  In this case, both were considered to fail retention standards; both were implicated by the NARSUM and in the commander’s statement; and, both were profiled.  Panel members agreed that evidence reasonably justified that the functional limitations of the individual right and left stress fractures contributed to the CI’s inability to perform her military duties, were reasonably justified as separately unfitting, and therefore eligible for Service rating.  

The panel next considered the rating and discussed if there was sufficient evidence of painful motion IAW VASRD §4.59 (painful motion) and §4.40 (functional loss) to warrant minimal compensable ratings for the bilateral shins.  VASRD §4.59 stipulates that painful motion “…be related to the affected joints, and be entitled to at least the minimum compensable rating.”  VASRD §4.40 stipulates that functional loss must be supported by adequate pathology and evidenced by the visible behavior of the claimant undertaking the motion.  

In this case, each anterior shin had clinical findings of tenderness to palpation along with radiographic evidence of stress fracture.  However, the NARSUM examination documented a normal gait with no evidence of painful motion at the knees or feet.  The bilateral diagnosis supported a single 5003 based rating without compensable limitations or painful motion.  The panel agreed, therefore, that the evidence did not support a higher rating and that separate 0% disability ratings for the right and left tibial stress fractures would offer no benefit to the CI.  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 shins condition.  

Bilateral Foot Pain.  According to the STR and the MEB NARSUM, the CI’s bilateral foot pain condition also began in July 2007 while in Basic Combat Training.  Radiographic evaluations (bone scan) in August 2007 documented extensive stress changes of the feet.  Despite treatment, the bilateral foot condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for an MEB.  The MEB forwarded “bilateral foot pain due to plantar fasciitis” for PEB adjudication.  According to the commander’s statement dated 30 August 2007, her “condition,” (presumably referring to both the bilateral tibial stress fractures and the bilateral foot pain) prevented bending, lifting, running, and “performing critical field duties such as carrying patient and medical equipment.”  

During the 10 September 2007 MEB NARSUM examination (a month prior to separation) the CI reported that the pain in her feet was “present approximately 70% of the time” during the day, and she took anti-inflammatory and narcotic medications, each once a day, for control of pain.  Physical examination showed a non-antalgic gait, bilaterally tender flexible arches, with tenderness at the insertion of the plantar fascia (the rearmost arch of the foot at the centerline of the sole).  Flexion and extension of the toes were normal bilaterally.  There were no hind foot deformities or evidence of abnormal pronation.  Duty limitations dated 11 September 2007 prohibited running, walking, jumping, marching, standing more than 15 minutes, lifting greater than 20 pounds, and carrying farther than 100 feet.  

There was no VA C&P evaluation in evidence for review.  

The panel directed attention to the rating recommendation based on the above evidence.  The PEB rated 0% for the bilateral foot pain condition, coded 5399-5310 (analogous to muscle injury, group X), citing tenderness at the plantar fascia.  There was no available evidence that the VA rated the bilateral plantar fasciitis.  The panel first considered if the right and left foot pain, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  In this case, both were considered to fail retention standards, both were implicated by the NARSUM and in the commander’s statement, and both were profiled.  Each foot was documented to have had stress changes and resultant pain consistent with bilateral plantar fasciitis.  Panel members agreed that the evidence of the record reasonably justified that the functional limitations of the individual right and left foot conditions contributed to the CI’s inability to perform her military duties, supporting each foot condition as separately unfitting; and, thus eligible for separate disability ratings.  

The panel considered several coding avenues to include pathology extending along the entire foot and ankle.  There was no evidence of abnormal weight bearing, or bowing of the Achilles for analogous coding under 5299-5276 (flatfoot, acquired).  There was no weakness in evidence to support code 5277.  Unilateral codes (such as 5284, foot injuries, other) were also considered.  There was no documentation of significant or chronic range of motion deficits for rating under the 5270 and 5271 ankle codes.  There was no evidence of malunion or nonunion of the tarsal or metatarsal bones for coding under 5283.  The NARSUM examination documented a normal gait, with bilateral tenderness of the plantar fascia, and radiographic evidence of stress fracture, but there was no documentation of painful motion.  The bilateral diagnosis supported a single 5003 based rating without compensable limitations or painful motion.  The panel agreed, therefore, that the evidence did not support a higher rating and that separate 0% disability ratings for the right and left foot stress fractures would offer no benefit to the CI.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded there was insufficient cause to recommend a change in the PEB adjudication for the bilateral foot condition.  

BOARD FINDINGS:  In the matter of the bilateral shin and bilateral foot conditions and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  There were no other conditions within the panel’s scope of review for consideration.  The panel, therefore, recommends there be no modification or re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150604, w/atchs
Exhibit B.  Service Treatment Record

AR20170006523, XXXXXXXXXXXXXXXXXX 

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