RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00661
BRANCH OF SERVICE:  Army	SEPARATION DATE:   20030922 

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E2, Trainee, medically separated for “chronic pain due to stress fracture, right heel” and “lower extremity stress fractures tibias, left femur diagnosed by bone scan without X-ray confirmation,” rated 0% and 0%, respectively, with a combined disability rating of 0%.

CI CONTENTION:  The CI made no specific contention.  His 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 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 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 - 20030801	VARD - 20031003	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Pain due to Stress Fracture Right Heel…	5099-5003	0%	Stress Fracture, Medial Tibial Plateaus, Right Lower Extremity	5099-5014	10%	STR	
Lower Extremity Stress Fractures Tibias, Left Femur…	5022	0%	Stress Fracture, Medial Tibial Plateaus, Left Lower Extremity	5099-5014	10%	STR	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Chronic Pain due to Stress Fracture Right Heel.  According to service treatment records (STRs) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s right heel pain condition began in February 2003.  By 18 February 2003, however, he denied heel pain, which a week earlier was swollen.  However, a bone scan on 25 February 2003 was suggestive of stress fractures or significant bone injuries of both heels, the right side more than the left.  On 27 March 2003 X-rays showed mild fuzzy calcification on the posterior of the right heel consistent with a stress fracture and on examination there was edema of the right heel and pain with a heel squeeze.  Treatment consisted of wearing tennis shoes and using crutches along with the issuance of a temporary profile.  With physical therapy and convalescent leave, healing was unremarkable, but once the CI ramped up to PT (physical training) at his own pace and tolerance,  his pain “returned immediately” and increased to a level of 6/10 (10 being the worst pain).  A bone scan on 19 May 2003 showed an increased uptake of the right heel.  X-rays of the right heel on 29 May 2003 showed some mild sclerosis consistent with a healing stress fracture.  On examination on 29 May 2003 there was no edema of the right heel, but there was pain with a heel squeeze.  The ROM of the ankle and the subtalar joint was normal without pain or crepitus.  
Despite treatment, the chronic pain due to stress fracture of the right heel 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 “multiple lower extremity stress fractures of knees and heels” for PEB adjudication.

At the MEB examination (recorded on DD Forms 2807-1 and 2808) dated 13 June 2003, 3 months prior to separation, the CI reported he had stress fractures since February 2003.  The examiner annotated normal for the lower extremities and feet on the clinical evaluation.  At the NARSUM examination dated 16 July 2003, 2 months prior to separation, the examiner noted the CI took no medications and had no edema, although he had some pain with a heel squeeze of the right heel.  He had a normal range of motion (ROM) of the ankle and subtalar joint without pain or crepitus.  The examiner noted the CI was healing well and no long-term complications were anticipated unless he returned to intense physical activity as was required by military training.

No VA Compensation and Pension (C&P) examination was available for review and the VA Rating Decision (VARD) dated 2 October 2003 was based on the STRs.  However, the chronic pain due to stress fracture right heel was not addressed or rated.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 0% rating under an analogous 5099-5003 code (Degenerative arthritis), citing chronic pain due to stress fracture, right heel, diagnosed by X-ray and rated as minimal/occasional IAW USAPDA pain policy.  The VA did not assign any rating as noted above.  Board members considered a 10% rating using code 5099-5003; however, there was no limitation of motion or “X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups.”  The 5273 code (Os calcis or astragalus, malunion of) was also considered; however there was no evidence of a moderate deformity at the time of separation.  Nevertheless, the CI did have a stress fracture, albeit it was in the process of healing at the time of separation.  Therefore, use of code 5284 (Foot injuries, other) was not unreasonable.  Board members then discussed whether a 10% rating for a moderate disability rather than a 0% rating for a mild disability was warranted.  In favor of a 10% rating was that at 4 months prior to separation there was mild sclerosis of the heel on X-ray suggestive of healing, but the record was silent about callus formation, which would suggest more advanced healing.  In favor of a 0% rating was the fact that healing was in progress prior to separation and the foot injury did not rise to a moderate level necessary for the 10% rating since there was an ongoing healing process proximate to separation not unlike the healing process that was in evidence until the CI ramped up his physical training.  Furthermore, 2 months prior to separation the NARSUM indicated the CI took no medication and had no edema and the ankle motion was normal without pain or crepitus.  Although the NARSUM examiner noted “no long-term complications were anticipated unless he would return to intense physical activity,” the statement was speculative and did not assist in determination of an appropriate rating in the absence of either VA or other evidence to indicate the stress fracture status 12 months after separation.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board majority concluded that there was insufficient cause to recommend a change in the PEB adjudication for the chronic pain due to stress fracture, right heel condition.  
Lower Extremity Stress Fractures Tibias, Left Femur.  According to service treatment records (STRs) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s lower extremity stress fractures condition began in February 2003 with bilateral knee pain after training.  On 24 February 2003, the CI had tenderness to palpation of the medial tibial plateau and the condition was assessed as either an overuse injury or a stress reaction/fracture.  Treatment consisted of Tylenol (acetaminophen, a pain reliever) and Oscal (calcium).  A bone scan demonstrated focal increased tracer uptake overlying the right medial tibial plateau suggestive of an early stress fracture and increased tracer uptake within the left proximal fibular tibial joint space suggesting a bone injury.  Treatment consisted of crutches, a profile, and Ultram (tramadol, an opioid-like medication).  In May 2003 the CI was tender at the left distal femur and both knees medially.  Bone scan results in May 2003 were reported as bilateral medial tibial plateau stress fractures and Tylenol #3 (a combination of codeine, a narcotic and acetaminophen) was prescribed.  Orthopedic examination in May 2003 revealed tenderness to palpation bilateral medial tibial plateaus.  The ROM of the knees was full and strength was 5/5.  There was no laxity and the CI was neurovascularly intact distally.  A bone scan of May 2003 showed more uptake noted in the right tibial plateau and some uptake in the left tibial plateau and distal femur.   Despite treatment, the chronic pain due to stress fracture of the right heel 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 “multiple lower extremity stress fractures of knees and heels” for PEB adjudication.

At the MEB examination the CI reported he had stress fractures since February 2003.  The examiner annotated normal for the lower extremities and feet on the clinical evaluation.  At the NARSUM examination dated 16 July 2003, 2 months prior to separation, the examiner noted the CI developed knee pain while he had been in the ramp-up process related to his heel.  The examiner noted the CI was healing well and no long-term complications were anticipated unless he would return to intense physical activity as is required with his military training.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 0% rating under the 5022 code (Periostitis), citing lower extremity stress fractures tibias, left femur diagnosed by bone scan without X-ray confirmation, without limitation of motion” IAW USAPDA pain policy.  The VA assigned a 10% rating using an analogous 5099-5014 code (Osteomalacia) based on the STRs, citing stress fracture, medial tibial plateaus, left lower extremity based on painful functional impairment of the left knee, and a 10% rating using an analogous 5099-5014 code based on the STRs, citing stress fracture, medial tibial plateaus, right lower extremity based on painful functional impairment of the right knee.  

The PEB combined the bilateral fractures of the tibias and left femur conditions as a single unfitting condition coded 5022 and rated 10% with application of the USAPDA pain policy.  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 femur conditions was presented together above.  In this case, multiple lower extremity stress fractures of the knees were profiled, were noted in the NARSUM as “multiple lower extremity stress fracture sites” and “stress reaction of the medial malleolus of left tibia” as well as implicated in the commander’s statement as “chronic knee and ankle problems.”  Members agreed that each lower extremity condition is separately unfitting and that identical coding and ratings are applicable.  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.  The CI had bone scan findings of bilateral knee involvement, while the PEB noted there was no supporting X-ray evidence.  Board members also considered code 5262 (Tibia and fibula, impairment of: Malunion of: With slight knee or ankle disability).  Orthopedic evaluation revealed bilateral tenderness at the tibial plateaus and distal left femur, 4 months prior to separation, and as a result he was unable to continue IET (initial entry training). While the CI did not have particularly detailed physical examinations or a VA C&P examination, 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, especially since the NARSUM examiner indicated no long term complications were anticipated.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the left tibia stress fracture and left femur conditions, coded 5262 and a disability rating of 10% for the right tibia stress fracture condition, coded 5262.

BOARD FINDINGS:  In the matter of the chronic pain due to stress fracture condition and IAW VASRD §4.71a, the Board majority recommends no change in the PEB adjudication.  The single voter for dissent recommended modification to 10%, but did not elect to submit a minority opinion.  In the matter of the left tibia stress fracture and left femur conditions, the Board unanimously recommends a disability rating of 10%, coded 5262 IAW VASRD §4.71a.  In the matter of the right tibia stress fracture 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	
Chronic Pain Due to Stress Fracture, Right Heel	5099-5003	0%	
Left Lower Extremity Stress Fractures Tibia and Femur	5262	10%	
Right Lower Extremity Stress Fracture Tibia	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, AR20170002437 (PD201500661)

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