RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00898
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20080103

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E1, trainee, medically separated for “stress reactions of both knees and left heel”, with a disability rating of 10%.

CI CONTENTION:  The CI contended for both of his unfitting 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 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 - 20071204	VARD - 20080428	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Stress Reactions of Both Knees and Left Heel	5022	10%	Stress Fracture Right Knee	5299-5261	0%	STRs	
			Stress Fracture Left Knee	5299-5261	0%	STRs	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

ANALYSIS SUMMARY:  Service treatment records (STRs) were not available in evidence before the Board, and could not be located after repeated requests.  Furthermore, the CI did not attend a scheduled VA Compensation and Pension (C&P) examination.  However, the Medical Evaluation Board (MEB) Narrative Summary (NARSUM) was available as was the PEB Proceedings document. Further attempts at obtaining the missing documents would likely be unsuccessful and introduce additional delay in processing the case.  It was judged by the members of the Board that the missing evidence would not materially alter the Board’s recommendations.

Stress Reactions of Both Knees and Left Heel.  According to the MEB NARSUM dated 23 October 2007, approximately 2 months prior to separation, the CI’s bilateral knee pain and left heel pain condition began in late July 2007, during the first week of basic training when there was an increase in strenuous activities and weight bearing.  The CI reported no prior knee or heel problems prior to enlistment.  X-rays were normal; however, a bone scan showed significant increased uptake in the bilateral medial [tibial] plateaus as well as bilateral calcanei (heels).  Treatment consisted of occasional ibuprofen, a nonsteroidal anti-inflammatory drug (NSAID), a series of profiles, and restricted duty including PTRP (Physical Training and Rehabilitation Program) for almost 11 weeks.  Although the CI began to be pain free in the right knee during normal ambulation, once he began to run, the pain returned.  On physical examination the CI had a mild antalgic gait.  There was no effusion of either knee.  He had a full range of motion (ROM) with only minimal discomfort, but had significant tenderness to palpation over the medial (tibial) plateaus.  He was nontender about the shins, but there was left heel tenderness without evidence of swelling.  There was no ankle involvement bilaterally.  The examiner noted that because of functional limitations and pain associated with his condition, the CI could not perform his duties; his condition was not improving; and he received maximal medical care and no further treatment was warranted.  At the MEB examination (recorded on DD Forms 2807-1 and 2808) dated 31 October 2007, 2 months prior to separation, the CI reported stress “fractors” (sic) in knees and left foot.   The examiner noted tenderness to palpation to the anterior medial tibias.    

The CI did not appear for a scheduled VA Compensation and Pension (C&P) examination and the VA rated the CI based on STRs.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under the 5022 code (Periostitis), citing the USAPDA Issue & Guidance Memo #8 with a rating based on two or more major joints with positive imaging.  The VA assigned a 0% rating for the stress fracture right knee and a 0% rating for the stress fracture left knee using an analogous 5299-5261 code (Leg limitation of extension) for each knee based on STRs, citing a noncompensable evaluation is assigned whenever extension of the leg is limited to 5 degrees.  

Board Approach to PEB Consolidated Rating. The PEB combined the stress reactions of both knees and left heel conditions as a single unfitting condition coded 5022, which is rated under the analogous code 5003 (Arthritis, degenerative (hypertrophic or osteoarthritis), and rated 10%. 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’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 stress reactions of both knees and left heel conditions was presented together above.  In this case, the bilateral knee and left heel stress reactions conditions were noted in the profile, and the bilateral knee condition, but not the left heel condition was implicated in the commander’s statement.  Members agreed that each knee condition is separately unfitting as was the heel.  Board members discussed rating options and the majority felt that based on imaging findings code 5099-5003, which permits “With X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups” was applicable.    Alternatively, separate coding and ratings were discussed based on the bone scan findings of significant uptake at the tibial plateaus.  Analogous code 5299-5262 (Tibia and fibula, impairment of:  Malunion of: With slight knee or ankle or disability) offers a 10% rating option for each knee.  However, a higher rating is not applicable in the absence of moderate or marked knee disability, knee ankylosis (code 5256), knee impairment (code 5257), cartilage, semilunar, dislocated (code 5258), limitation of flexion (code 5260), or limitation of extension (code 5261).  The discussion was then directed to the left heel stress reaction. Using code 5284 (Foot injuries, other) a rating option exists; however, a 10% rating requires a moderate disability, which was not in evidence.  Therefore, a 0% rating is not unreasonable.  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 stress reactions of both knees and left heel condition.   

BOARD FINDINGS:  In the matter of the stress reactions of both knees and left heel condition and IAW VASRD §4.71a, the Board majority recommends no change in the PEB adjudication.  The single voter for dissent submitted the appended minority opinion.  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 20150531, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

	

Minority Opinion.  The problem with determining a rating in this case was the absence of individual clinic visit documents, and reliance to determine a rating was based solely on the NARSUM, which by definition is a narrative summary.  Furthermore, there was no VA C&P examination and/or follow-up visits to provide details necessary to achieve a rating IAW VASRD §4.3, which states “When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant.”   The majority’s presumption that the stress reactions were temporary and not permanent indicators of disability is speculative and not supported by the medical evidence.  However, in the medical literature an article entitled “The long-term follow-up of soldiers with stress fractures” indicated that “After a minimum of 1 year after basic training five clinical patterns were observed: (1) uneventful recovery (47%); (2) protracted recovery (13.6%); (3) symptoms consistent with recurrent stress fractures in new sites (19.6%); (4) intermittent nonstress fracture bone pain (16.7%); and (5) chronic stress fractures (3%).” Furthermore, “the incidence of recurrent stress fractures was 10.6%.”  
(https://www.ncbi.nlm.nih.gov/pubmed/?term=The+long+term+followup+of+soldiers+with+stress+fractures Accessed on 19 December 2016)  

Furthermore, an article entitled “Bone stress injuries causing exercise-induced knee pain” noted “The most common anatomical location for a bone stress injury was the medial tibial plateau (31%), which was also the most typical location for a more advanced injury. After the commencement of military service, a bone stress injury in the medial tibial plateau caused knee pain earlier than did a bone stress injury elsewhere in the knee (P = .014).”  
(https://www.ncbi.nlm.nih.gov/pubmed/?term=Bone+stress+injuries+causing+exercise-induced+knee+pain Accessed on 19 December 2016)

Thus, separate ratings for each knee and heel are unquestionably warranted since the bone scan, which was approximately 4 months prior to separation, showed significant increased uptake in the bilateral medial [tibial] plateaus as well as bilateral calcanei (heels) and there was no evidence that there was any resolution either prior to or after separation.

Therefore, the minority voter suggests the ROP be modified as follows:

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 right knee stress reaction condition, coded 5299-5262, a disability rating of 10% for the left knee stress reaction condition, coded 5299-5262, and a disability rating of 0% for the left heel stress reaction condition coded 5284.  In the matter of the right knee stress reaction condition, the Board recommends a disability rating of 10%, coded 5299-5262 IAW VASRD §4.71a.  In the matter of the left knee stress reaction condition, the Board recommends a disability rating of 10%, coded 5299-5262 IAW VASRD §4.71a.  In the matter of the left heel stress reaction condition, the Board recommends a disability rating of 0%, coded 5284 IAW VASRD §4.71a.  

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 Stress Reaction	5299-5262	10%	
Left Knee Stress Reaction	5299-5262	10%	
Left Heel Stress Reaction	5284	0%	
COMBINED	20%	

AR20170011783, XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

	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 record of proceedings, majority recommendation, and minority opinion (copy enclosed).  I reject the Board’s majority recommendation and accept the Board’s minority opinion that your disability rating should be modified to 20% but not to the degree that would justify changing your separation for disability with severance pay to a permanent retirement with disability.  

	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.  

	A copy of this decision has also been provided to the Department of Veterans Affairs.

Sincerely,						

Enclosure