RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00607
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20030621

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Administrative Specialist, medically separated for “bilateral stress reactions of the tibias and left medial malleolus,” with a disability rating of 10%.

CI CONTENTION:  “I had a P3 upper profile for carpal tunnel both hands, was not included in evaluation for discharge.” 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 - 20030414	VARD – 20030910	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Stress Fracture Tibias and Left Medial Malleolus	5099-5003	10%	Stress Fractures, Bilateral Pretibial Areas	5299-5262	NSC	20030822	
			Left Ankle, Residual Fracture	5271	0%		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Bilateral Stress Reactions of the Tibias and Left Medial Malleolus.  According to service treatment records (STRs) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s experienced bilateral leg pain for 3 years.  Radiographic (X-rays) studies of the left leg in April 1999, ordered to rule out a fracture after the CI fell on his ankle while playing football, were normal.  In February 2000 the CI complained his left ankle still hurt to walk and run.  On examination the CI was tender at the fibula.  He underwent a bone scan in October 2000, which was ordered for left ankle pain of 17 months duration and a 10 month history of left shin pain.  The bone scan showed mild generalized stress reactions involving the left greater than the right ankle with more focal reactivity at the medial malleolus (the prominence on the inner side of the ankle formed by the lower end of the tibia) suggestive of repetitive stress injury and mild stress related periosteal reactions of both tibiae with no evidence of a recent stress fracture.  Left ankle pain was treated with a CAM (controlled ankle motion) walker in December 2000.  In March 2001 the CI’s stress fractures had improved.  

An orthopedic note in January 2003 indicated the bone scans [of December 2002] were reviewed and demonstrated bilateral stress reactions of the shins and left medial malleolus.  Examination revealed bilateral leg tenderness at the medial aspect of the tibia and tenderness of the medial malleolus.  X-rays to rule out a medial malleolus fracture based on a positive bone scan, were within normal limits on 21 January 2003.  Despite treatment, the bilateral leg pain could not be adequately rehabilitated to meet the physical requirements of his MOS and he was referred to an MEB.  The MEB forwarded “bilateral stress reactions of tibia” and “stress reaction of the medial malleolus of left tibia” for PEB adjudication.

At the MEB NARSUM examination on 21 January 2003, performed 5 months prior to separation, the CI stated he had bilateral leg pain for over 3 years, which was worse with activity and improved somewhat with rest.  He had been on profile intermittently during that time without improvement although he ran a physical fitness test 3 months earlier and completed the two miles in less than 15 minutes.  On examination of the lower extremities, the CI had symmetric bulk and tone of his muscles with no skin color or consistency of irregularities.  He was tender to palpation about the medial aspect to both tibia and non-tender to the remainder of the mid-leg and was tender to palpation about the mid-aspect of the medial malleolus on the left side.  At the MEB examination (recorded on DD Forms 2807-1 and 2808) dated 28 March 2003, 3 months prior to separation, the CI reported stress fractures/legs.  The examiner checked lower extremities normal on the clinical evaluation.

At the 22 August 2003 VA Compensation and Pension (C&P) examination, performed 2 months after separation, the CI reported a “partial fracture” of the left ankle in April 1999, which was treated with a walking cast in 1999 and again in 2001.  The CI also complained of pain in his bilateral shins since 1999, the left being worse than the right.  He required no medication for either the shin or ankle areas and the conditions did not appreciably interfere with his daily activities unless he overexerted himself.  On examination the bilateral pretibial areas revealed no abnormalities.  There was no tenderness or deformity.  The left ankle revealed location of the pain when it occurred in the bilateral malleolar areas, but there was no swelling, tenderness, deformity or pain on motion; however, dorsiflexion was limited to 15 degrees (normal 20 degrees) with plantar flexion normal at 45 degrees.  He could squat, toe, heel, and hop without evidence of pain and he ambulated normally.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating for bilateral stress reactions of the tibias and left medial malleolus under an analogous 5099-5003 code (Degenerative arthritis), citing pain moderate and frequent IAW the US Army Physical Disability Agency (USAPDA) pain policy and noted the CI used Tylenol 3 (codeine, a narcotic and acetaminophen, a pain reliever) for pain.  The VA denied service-connection for stress fractures, bilateral pretibial areas, citing no permanent residuals or chronic disabilities were shown by STRs or demonstrated on the VA C&P examination.  

Board Approach to PEB Consolidated Rating. The PEB combined the bilateral stress reactions of the tibias and left medial malleolus conditions as a single unfitting condition coded 5099-5003 for moderate and frequent pain and rated 10% with application of the USAPDA pain policy and AR 635-40 B-24.f.  The approach by the PEB commonly 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 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 bilateral stress reactions of the tibias and the left medial malleolus conditions was presented together above.  In this case, the bilateral leg/ankle stress reactions were profiled, were noted in the NARSUM as “bilateral stress reactions of tibia” and “stress reaction of the medial malleolus of left tibia” as well as implicated in the commander’s statement as “stress fractures in both legs.”  Members agreed that each lower leg condition is separately unfitting and that identical coding and ratings are applicable.  However, IAW VASRD code 5003, in the absence of limitation of motion, a 10% rating requires “X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups,” but in the absence of “occasional incapacitating exacerbations” a 20% rating cannot be assigned.  

Board members also considered analogous code 5262 (Tibia and fibula, impairment of: malunion of: with slight knee or ankle disability).  At NARSUM examination, 5 months prior to separation the CI had bilateral tenderness on the medial aspect of both tibia as well as the medial malleolus; however, he was able to run a physical fitness test 3 months earlier, while at the VA, 2 months after separation and more proximate to separation, the examination was normal.  Nevertheless, the CI had a history of bilateral tibial pain for almost 3 years prior to separation, therefore, while he had a normal examination at the VA, it is not unreasonable to presume that he still had slight involvement of the tibia bilaterally at the time of separation sufficient to warrant a 10% rating for each leg; however that is speculative and a rating in the absence of credible medical evidence is not warranted.  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 bilateral stress reactions of the tibias and left medial malleolus conditions.  

BOARD FINDINGS:  In the matter of the bilateral stress reactions of the tibias and left medial malleolus 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 20150602, w/attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB						

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXXXXXX, AR20170000280 (PD201500607)

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