RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00982
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050320

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

CI CONTENTION:  The CI made no specific contention in their application.  The CI’s 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 - 20050207	VARD - 20050413	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Lower Extremity Pain Secondary to Periostitis	5022	0%	Periostitis, Left Lower Extremity (Claimed as Leg Pain Due to Stress Fractures)	5022	0%	20050208	
			Periostitis, Right Lower Extremity	5022	0%	20050208	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  The evidence for the bilateral LE pain conditions are presented below, with attendant recommendations regarding separate unfitness, and separate rating if indicated.  

Bilateral LE Pain Secondary to Periostitis.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s bilateral LE pain condition began in April 2004 due to physical training.  The CI reported left foot pain of the first metatarsal (MT) after falling in a hole a few weeks earlier.  An X-ray was normal and a bone scan showed a stress fracture (fx) of the left first MT.  There was increased uptake in the left proximal tibia consistent with a grade 1/4 stress fx.  There was also evidence of bilateral shin splints and stress changes of the knees and ankles.  The CI was placed on 30 days convalescent leave (CL).  Repeat X-rays of the left tibia and foot in June 2004 noted a still discernable stress reaction of the left tibia.  The CI was given 30 more days of CL.  When he returned he reported increased LE symptoms with increased activity.  He began physical therapy (PT) and was placed on profile.  At a PT evaluation on 16 August 2004, the CI reported 3/10 baseline pain and 7/10 with prolonged weight bearing.  The physical exam showed a normal gait without pain.  There was tenderness to palpation (TTP) of the left tibia and the left first MT.  The MEB forwarded “stress fracture of left tibia and first left metatarsal” and “bilateral shin splints” for PEB adjudication.  

The permanent profile 3 November 2004, 5 months prior to separation, listed left leg/foot pain due to stress fx.  The commander’s statement implicated the CI’s physical profile limitations as impairing his duty performance, but did not mention any specific medical conditions.  

At the MEB NARSUM examination also dated 3 November 2004, 5 months prior to separation, the CI reported pain of his legs with running, marching, or prolonged walking.  Physical exam showed a normal gait.  There was TTP of both shins, greater on the left than the right.  There was TTP of the left first MT.  There was full range of motion (ROM) of the feet, knees, and ankles.  The MEB NARSUM examiner determined that the CI was unable to continue with basic training due to the stress fxs of the left leg and foot.  

At the VA Compensation and Pension (C&P) examination in February 2005, performed 1 month before separation, the CI reported constant left leg and foot pain due to stress fxs aggravated by weight bearing activities with functional impairment of difficulty standing and walking for prolonged periods of time.  Physical exam showed normal gait and posture.  There were no signs of abnormal weight bearing of the feet.  The exams of the right and left lower legs were normal.  There was no tenderness or swelling of the left foot.  There was full ROM of both knees and ankles and there was no additional limitation of ROM with repetition.  Left tibia/fibula and left foot X-rays were normal.  

The panel directed attention to its rating recommendation based on the above evidence.  The VA rated the right and left LE each 0% coded straight 5022.  The PEB combined the bilateral lower extremity (LE) pain conditions as a single unfitting condition coded analogous to 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 panel’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 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.

The panel first considered if the both the right and left LE pain conditions having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The CI reported pain of only the left foot and leg, not the right LE at PT in July and August 2004.  The permanent profile listed only the stress fxs of the left LE.  The MEB NARSUM examiner determined the left LE pain impaired the CI’s ability to perform his duties and did not specifically mention the right LE.  The panel concluded from the evidence that the left LE pain condition was unfitting when considered separately, but not the right LE pain condition and therefore the right LE condition was not eligible for separate disability rating.  Next the panel considered if both the left tibial stress fx and the left MT stress fx remained separately unfitting when considered individually and concluded that both related to the same disability of LE pain with weight bearing activities and are not separable as to their fitness implications and cannot be given separate ratings IAW VASRD 4.14 (avoidance of pyramiding).  

The panel then considered its rating recommendation for the unfitting left LE condition at the time of separation.  

Although the CI reported pain with use of the left LE and the MEB NARSUM noted TTP of the left tibia and foot, by the time of the VA exam, 1 month before separation, the CI’s exam of the left LE, including the knee, leg, ankle and foot, was completely normal and X-rays no longer showed evidence of the stress fx or reactions.  The PEB rated the bilateral LE condition 0% and the panel reviewed to see if a higher rating than 0% was supported for the unfitting left LE pain.  There was no evidence of painful, limited motion of the knee or ankle for a 10% rating coded as 5099-5022.  There likewise was no limitation of motion which attained a minimum rating under the diagnostic codes for limitation of leg flexion or extension (5260, 5261) or ankle motion (5271).  There was no evidence of residual foot pain for 10% rating under metatarsalgia (5279), analogous to malunion of a MT fx (5283) or coded as other foot injury (5284).  The panel considered alternative VASRD knee, ankle, foot, and analogous codes, but all were less applicable and not advantageous to rating.  There was no therefore no higher than a 0% rating available with any applicable VASRD code.  After having unbundled the bilateral LE pain condition, the panel found there was no ratings benefit to the CI and therefore no change to the PEB adjudication is recommended.  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 left LE pain condition.   

PANEL FINDINGS:  In the matter of the bilateral lower extremity pain condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  There were 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 20150606, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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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,