RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00707
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060201

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Trainee, medically separated for “bilateral shin pain…” with a disability rating of 0%.

CI CONTENTION:  The CI requested a review of all conditions.  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 - 20060118	VARD - 20060708	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Shin Pain…	5099-5003	0%	Bilateral Medial Tibial Plateau Fatigue Fractures and Bilateral Distal Medial Metaphyseal Fatigue Fractures	5262	0%	STR	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Bilateral Shin Pain.  The PEB combined the bilateral shin pain conditions under a single disability rating, coded analogously to 5003 and rated 0% with application of the US Army Physical Disability Agency pain policy and AR 635-40 B24.f.  This 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 panel 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 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.  

According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s bilateral shin pain began in June 2005 during the first week of basic training without specific injury or trauma.  Radiographs in July 2005 demonstrated stress reaction. Results of a bone scan at this time were consistent with “stress reaction proximal and distal tibiae medially.”  Her condition was treated conservatively with some improvement.  The MEB forwarded “bilateral medial tibial plateau fatigue fracture and bilateral distal medial tibial metaphyseal fatigue fractures” for PEB adjudication.  
	
At the time of the 12 December 2005 NARSUM, 2 months prior to separation, the CI noted persistent lower extremity pain in both legs with an intensity of 3-5/10.  She reported pain approximately 80% of her waking hours which she noted was much improved compared to before.  She was not taking medications and did not have any pain at night or difficulty sleeping.  She denied any loss of sensation.  Her profile restricted running; however, unlimited walking, biking, or swimming was not restricted.  Physical examination of bilateral lower extremities showed the knees and ankles with full range of motion (ROM), no effusion, and there was tenderness in the bilateral medial plateaus.  There was no tenderness along the rest of the tibia and down at the ankle.  She had normal motor strength and neurological function.  Painful motion was not documented.  The examiner noted radiographs conducted on the day of the NARSUM “compared to July looks normal.”

At the physical therapy (PT) ROM examination conducted on 16 December 2005, left knee ROM following repetitive movement was flexion 135 degrees (normal 140) and extension 0 degrees (normal 0).   The right knee ROM following repetitive movement was flexion 130 degrees and extension 0 degrees.   The left ankle ROM following repetitive movement was dorsiflexion 10 degrees (normal 20) and plantar flexion of 41 degrees (normal 45).   The right ankle ROM following repetitive movement was dorsiflexion 10 degrees and plantar flexion 43 degrees.   The examiner wrote, “All motions on left are limited by pain.”

There was no VA examination in evidence within the 12-month allowable window for adjudication.

The panel directed attention to its rating recommendation based on the above evidence.  As noted above, the PEB rated the bilateral condition as a single unfitting condition at 0%, coded analogously to 5003 (arthritis, degenerative, hypertrophic or osteo) citing the USAPDA pain policy.  The VA rated the bilateral medial tibial plateau fatigue fractures and bilateral distal medial metaphyseal fatigue fractures 0%, coded 5262 (tibia and fibula, impairment of) based on the STR, citing absence of malunion of the tibia and fibula with slight knee or ankle disability.  

The panel first considered if the individual the shin conditions, having been de-coupled from the combined PEB adjudication, were reasonably justified as separately unfitting as established above. The STR was silent in regards to one extremity being more symptomatic than the other.  The commander’s statement, 3 weeks prior to separation, stated the CI performed to standard, but her condition was not likely to improve enough to allow for continued military service.  There was no indication that one leg was worse than the other.  Her profile restricted noted a bilateral condition and restricted running but did not indicate that one extremity was worse than the other.  Panel members agreed, each extremity was separately unfitting and then proceeded to the rating of the left lower extremity.  Bone scans in 2005 demonstrated left and right leg stress fractures. X-rays taken 7 weeks before separation showed healing fatigue fractures, both extremities.  The record demonstrated that the CI reported she had pain with running and had a profile that restricted running of any kind.  The record documented no episodes of swelling, giving way, or loss of function.  Left extremity ROM recordings were normal at the NARSUM and during physical therapy examinations in September and November 2005; however, the December ROM showed a decrease in dorsiflexion bilateral extremities.  Pain on motion was not documented at the NARSUM, nor at the September or November examinations, but was noted in the December PT examination of the left extremity.  The panel noted that out of nine separate ROMs recorded in the STR, the December ROM was the only examination that documented decreased ROM.  The panel agreed that the record sufficiently documented pain; however, the preponderance of evidence did not support a compensable rating under any ROM code.  The panel unanimously agreed that the left extremity condition did not rise to a level of compensability under §4.59 or §4.40.  The panel was unable to find any additional codes for consideration.  

The panel then considered the right extremity and concluded that although there was documented shin pain, there was no decrease in ROM, painful motion or swelling, and no radiographic evidence of right leg pathology.  The right extremity was not compensable under any of the ROM codes, and the condition did not meet the requirement for compensation under §4.59 or §4.40. Given that separate ratings of 0% for the left and right shins would be of no benefit to the member, 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 shin pain condition.  

BOARD FINDINGS:  In the matter of the bilateral shin pain condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  There are no other conditions within the panel’s scope of review for consideration.   The panel, 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

AR20170006555, 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