RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00651
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20031230

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E2, Track Vehicle Repairer, medically separated for “bilateral lower extremity pain,” with a disability rating of 0%.

CI CONTENTION:  The CI requests consideration of all conditions.  The 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 – 20031022	VARD - 20040421	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Lower Extremity Pain	5022	0%	Status Post Stress Fracture, Right Tibia	5299-5262	10%	STR	
			Status Post Stress Fracture, Left Tibia	5299-5262	10%		
			Status Post Stress Reactions, Left Calcaneus (Foot) 	5299-5284	0%		
			Status Post Stress Reactions, Right Foot	5299-5284	0%		
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS: 20%	

ANALYSIS SUMMARY:  

Bilateral Lower Extremity Pain.  The PEB combined the right and left knee conditions under a single disability rating, coded 5022 (periostitis) and rated 0%.  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.  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.  

According to service treatment records (STRs) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s bilateral lower extremity pain condition, which initially presented as pain in both knees, began in May 2003 without specific injury or trauma, although he noticed “the pain after my 1st PT test.”  Despite Motrin (ibuprofen, a nonsteroidal anti-inflammatory drug (NSAID)), pain persisted and extended to both legs and feet.  A bone scan study on 18 June 2003 showed a stress fracture to the right medial tibial plateau and stress reactions in the left medial tibial plateau, left calcaneus, and right midfoot.  X-ray studies on 6 August 2003 indicated “probable progressively healing stress fracture, right medial tibial plateau and stress induced injury, medial plateau of the left proximal tibia.”  Orthopedic evaluation on 13 August 2003 revealed a full active range of motion (ROM) of the knee and ankles with tenderness to palpation along the right medial tibial plateau, tibial shafts and the feet dorsally.  There was no surgical indication, and conservative treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “bilateral lower extremity pain,” for PEB adjudication.  

At the MEB examination (DD Forms 2807-1 and 2808) dated 15 August 2003 and 28 August 2003 respectively the CI reported knee pain and foot pain in both legs due to running.  The examiner marked normal for the clinical evaluation of the lower extremities and feet.  At the narrative summary (NARSUM) examination on 21 August 2003, 4 months prior to separation, the CI reported knee pain down to his feet bilaterally and constant leg pain with swelling in his right knee.  The pain prevented him from running and negotiating stairs.  Physical therapy did not provide relief of the pain.  Physical examination revealed a full active ROM of the knees and ankles and tenderness to palpation along the right medial tibial plateau as well as tenderness to palpation along the tibial shafts bilaterally and the bilateral dorsal feet.  The CI had normal sensation and there was no effusion or swelling.  The examiner was silent regarding patellar grind or instability.  

The CI failed to report for the VA Compensation and Pension (C&P) examination on 9 March 2004; however, the VA rated the CI’s condition based on STRs (see below).  An MRI of the left knee 20 December 2004, 12 months post-separation, showed a joint effusion and degenerative changes in both menisci along with marrow edema suggestive of synovitis, while an MRI of the right knee also showed a joint effusion and degenerative changes in the menisci, but no gross evidence of an acute stress fracture.  

The Board directed attention to its rating recommendation based on the above evidence.  As mentioned, the PEB combined the right and left knee conditions under a single disability rating, coded 5022 (periostitis) and rated 0%.  The VA rated the right tibia, status post stress fracture 10% under code 5299-5262 citing tender to palpation on the right medial tibial plateau and tibial shaft and the left tibia, status post stress fracture 10% under code 5299-5262 citing tender to palpation along the left tibial shaft.  The Board concluded there was sufficient evidence of tibia impairment with slight knee or ankle disability to support a 10% rating for each knee IAW §4.40.  The diagnostic imaging studies on 6 August 2003, 4 months prior to separation, indicated a probably progressively healing stress fracture of the right medial tibial plateau and a stress induced injury of the medial plateau of the left proximal tibia which met the 10% criteria for tibia impairment with slight knee or ankle disability under code 5262.  In considering routes to a higher rating there was no limitation of motion to attain a minimum rating under the diagnostic codes for flexion (5260) or extension (5261).  The examinations proximate to separation did not demonstrate the presence of ligamentous instability or laxity (5257), and there was no history of dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258), or history of surgery to remove a meniscus (5259) to support a rating under the respective codes.  No additional functional limitation was evidenced by the examinations.  Therefore, there was no VASRD §4.71a route to a higher rating under any applicable code, and no grounds for additional rating based on the presence of instability.  Members agreed, therefore, that the right knee condition was reasonably justified as separately unfitting and met VASRD §4.71a criteria for a separate rating.  Likewise, the left knee condition was reasonably justified as separately unfitting and it met VASRD §4.71a criteria for a separate rating.  After due deliberation, and considering all of the evidence, the Board recommends a separately unfit determination with a disability rating of 10% coded 5262 for the right knee condition and a disability rating of 10% coded 5262 for the left knee condition.

BOARD FINDINGS:  In the matter of the right knee condition, the Board unanimously recommends a disability rating of 10%, coded 5262 IAW VASRD §4.71a.  In the matter of the left knee condition, the Board unanimously recommends a disability rating of 10%, coded 5262 IAW VASRD §4.71a.  There were no other conditions within the Board’s scope of review for consideration.  

The Board 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	
Right Knee Condition	5262	10%	
Left Knee Condition	5262	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150603, w/atchs
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 
XXXXXXXXXXXXXXXXXX, AR20170000442 (PD201500651)

1.  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, accept the Board’s recommendation to modify the individual’s disability rating to 20% without re-characterization of the individual’s separation.  This decision is final.  

2.  I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum.   

3.  I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures.

 BY ORDER OF THE SECRETARY OF THE ARMY:

CF: 
(  ) DoD PDBR
(  ) DVA