RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00910
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20040326

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E2, Basic Trainee, medically separated for “multiple stress fractures ” with a disability rating of 0%.

CI CONTENTION:  Review of all conditions requested.  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 - 20040309	VARD - 20040623	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Multiple Stress Fractures 	5099-5003	0%	Right Hip Condition	5299-5255	NSC	20040510	
			Left Hip Condition	5299-5255			
			Symphysis Pubis	5299-5294			
			Left Knee Condition	5299-5257			
			Right Knee Condition	5299-5257			
			Left Navicular Bone Condition	5299-5257			
			Left Ankle Condition	5299-5284			
			Right Ankle Condition	5299-5284			
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:

Multiple Stress Fractures.  The PEB combined the right inferior pubic ramus, left pubic symphysis, left navicular stress fracture conditions and bilateral ankle and knee stress reaction conditions under a single disability rating, coded analogously to 5003 (degenerative arthritis) and rated 0%.  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’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.  For clerical simplicity the multiple stress fractures and reactions are presented together, with attendant recommendations regarding separate unfitness, and separate rating if indicated. 

According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s multiple stress fractures condition started in September 2003 during basic training.  The CI reported right hip pain and there was tenderness in the right groin.  Right hip X-rays performed in October 2003 were normal.  A bone scan performed later in October 2003, 5 months before separation, showed a stress fracture of the right inferior pubic ramus (IPR - right anterior pelvis) and a stress fracture of the left foot navicular bone (tarsal bone) and increased focal uptake involving the left knee, with lesser stress reactions noted of the ankles.  The CI was given 30 days convalescent leave.  At an 8 January 2004 physical therapy (PT) visit, 3 months before separation, the CI noted improvement in the right IPR fracture-related pain, but reported increased right knee pain and pain that radiated from the buttocks to the back of the right knee.  Radiographs of the pelvis showed the right IPR stress fracture was healing and noted an area of healing stress changes of the left aspect of the pubic symphysis (ligamentous joint between the left and right pubic rami) as well.  At a 27 January 2004 PT visit, 2 months before separation, the CI reported improvement in foot and ankle symptoms after cessation of pool therapy.  However, although the right hip symptoms had improved, they were aggravated by attempting to jog.  At the 18 February 2004 PT visit, 1 month before separation, the examiner noted he had consulted with an orthopedic specialist following the previous PT visit and an MEB was recommended.  The CI reported continued right hip pain, graded 2-3/10, aggravated by activity, and occasional right knee pain.  The physical examination noted no tenderness of the lumbosacral spine, right knee, tibia, nor pain of the femur or tibia.  The permanent profile listed right IPR stress fracture.  There was no commander’s statement in the record.  

During the 9 January 2004 MEB examination (recorded on DD Forms 2807-1 and 2808), 3 months prior to separation, the CI reported current a knee problem and pelvic stress fracture.  She checked yes to “have you ever had or do you now have” foot problems, but did not indicate any current ankle or foot symptoms.  

The 17 February 2004 MEB NARSUM examination, 1 month prior to separation, noted complaints of pain in the knee, back and hips.  Physical examination showed bilateral hip range of motion (ROM) in degrees of flexion 120 (normal 125), abduction 45 (normal), adduction 30 (normal 45) and external rotation 45 (normal).  There was tenderness of the right IPR and no tenderness anywhere else on the anterior pelvis.  There was no pain with log roll (hip pain) or heel tap and the CI was able to perform the straight leg raise bilaterally.  Bilateral knee ROM was extension 0 degrees (normal 0) and flexion 130 degrees (normal 140).  There was no evidence of instability of either knee.  There was no tenderness anywhere else on the bilateral lower extremities.  The NARSUM indicated the CI had minimal pain on examination, but pain was exacerbated by physical activity and she was at risk of recurrent stress fracture of the right IPR, as well as aggravation of the stress reactions of the left foot navicular bone, ankles and knees if she returned to basic training.  

At the 10 May 2004 VA Compensation and Pension (C&P) evaluation, 2 months after separation, the CI reported poor sleep due to right hip pain, especially if she turned on her right side.  She reported flare-ups twice per week, aggravated by standing more than one hour, sitting on a hard chair, or driving.  The CI indicated the pain was in the right pelvis.  Physical examination showed a normal gait.  The CI identified the area of pain as the right iliac crest.  Right hip ROM in degrees was flexion 120, abduction 30, extension 30 (normal 20) and left hip ROM was flexion 110, adduction 52, and extension 30.  All hip ROM was the same or greater after repetitive motion, except for left hip adduction which was decreased to 40 degrees (normal 45) with repetitive motion.  

Regarding knee and ankle pain the CI reported that she was not aware of any problem until she was told of the findings of the bone scan, which was performed for right hip pain.  She denied any current problems with the knees or ankles.  There was full ROM of both knees, with no additional loss of ROM with repetitive motion.  There was no swelling or joint line tenderness of either knee.  There was no evidence of instability or meniscal pathology.  There was full ROM of both ankles, with no additional loss of ROM with repetitive motion.  There was no ankle tenderness.  Lower extremity strength and reflexes were normal.   The examiner indicated the left navicular bone was encompassed in the examination of the ankles.  

The panel first considered if each of the stress fracture and stress reaction conditions noted above, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  Only the right IPR stress fracture was profiled.  There was no commander’s statement in record since the CI was in basic training.  The bone scan was ordered due to right pelvic tenderness and pain and the CI was placed on convalescent leave due to the right IPR stress fracture.  The CI was referred for an MEB for the right IPR stress fracture which was healing but remained symptomatic.  At the time the CI was referred for an MEB, she had reported the left ankle/foot pain was improved and the right knee pain was occasional.  There was no evidence in record that the CI had a duty-limiting disability due to pathology of the right knee; and the knee pain may have been referred pain related to the right IPR stress fracture, as evidenced by the production of knee pain with maneuvers to elicit pain from the hip noted at a PT visit.  By the February 2004 PT visit, 1 month before separation, the CI had reported improvement to the left ankle and foot pain and that right knee pain was occasional, but the right pelvic/hip pain was constant and aggravated by activity.  

The panel concluded there was not a preponderance of evidence in the STR which overcame the panel’s presumption that the right IPR stress fracture condition was reasonably considered separately unfitting.  However, the panel members concluded that the preponderance of evidence showed the left pubic symphysis stress changes (noted on X-rays) or left navicular stress fracture, stress reactions of the left knee, and bilateral ankles (noted on bone scan) would not have caused the CI to be referred into the DES or to be found unfit.  There was no imaging evidence of a stress fracture/reaction of the right knee in record.  The panel therefore recommends that only the right IPR stress fracture was eligible for service rating.  The panel then deliberated a rating for the unfitting right IPR stress fracture condition at the time of separation.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated multiple stress fractures 0%, coded 5099-5003 (degenerative arthritis) as noted above.  The VA rated the right IPR stress fracture 0%, coded 5236 (sacroiliac weakness and injury) and did not service connect the right or left hip, knee, ankle, pubic symphysis stress fracture, or the left navicular bone conditions based on the C&P examination 2 months after separation, citing no permanent residual or chronic disability subject to service connection.  

At the MEB NARSUM and VA examinations there was no evidence of painful motion of the right hip for 10% rating coded analogously to 5003 (or related 5022 [periostitis]) or to 5260 (limited thigh flexion), based on §4.59, §4.40 and §4.45.  There was no limitation of motion which supported a higher rating under the diagnostic codes for limitation of thigh flexion or extension, or thigh impairment (5251, 5252, and 5253).  There was no evidence of hip ankyloses, flail hip joint, or femur impairment (5250, 5254, 5255) for a rating under these codes.  There was therefore no rating higher than 0% for the right IPR stress fracture condition under any applicable VASRD §4.71a code.  After having unbundled the multiple stress fractures condition, the panel majority found there was no ratings benefit to the CI and therefore no change to the PEB’s combined adjudication is recommended.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel majority concluded there was insufficient cause to recommend a change in the PEB adjudication for the multiple stress fractures condition.  

BOARD FINDINGS:  In the matter of the multiple stress fractures condition and IAW VASRD §4.71a, the panel majority 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 there be no modification or re-characterization of the CI’s disability and separation determination.

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150529, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170010038, 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