RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01050
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20061205

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Basic Trainee, medically separated for “stress fractures, left femoral neck and right calcaneus,” with a disability rating of 10%.

CI CONTENTION:  The CI made no specific contention.  The CI’s 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 - 20061120	VARD - 20070510	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Stress Fractures, Left Femoral Neck and Right Calcaneus	5099-5003	10%	Residuals Of Left Femoral Neck Stress Fractures	5252-5015	10%	20070212	
			Residuals Of Right Calcaneus Strain	5284	0%		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Stress Fractures, Left Femoral Neck and Right Calcaneus.  According to service treatment records (STRs) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s stress fractures (left femoral neck (hip) and right calcaneus (heel)) condition began during basic training in April 2006 with right heel pain and in May 2006 with gradual onset of mild, daily left hip burning pain and tingling, which increased in severity with a cracking sensation after the CI tripped while wearing a rucksack.  An initial X-ray series of the left femur was normal on 11 May 2006 as was an X-ray series on 19 May 2006.  However, an X-ray series on 26 May 2006 demonstrated linear sclerosis (thickening) in the left femoral neck consistent with an early stress fracture.  A bone scan on 23 June 2006 revealed a stress fracture of the right calcaneus and left femoral neck, while an X-ray on 23 June 2006 demonstrated a healing phase of the compressive aspect of the left femoral neck stress fracture.  A note dated 30 June 2006 indicated the CI was a borderline candidate for surgery; however, healing without surgery was expected as long as the he stayed on crutches.  Physical therapy evaluation revealed an abnormal Trendelenburg gait (gluteus medius lurch due to weakness of the abductor muscles of the lower limb) and mild tenderness to pressure at the left hip flexor.  There was tenderness to palpation of the right calcaneus and pain with a squeeze.  An X-ray on 17 July 2006 demonstrated a left femoral neck stress fracture, which was slightly more prominent than seen in a prior study.  Physical therapy to improve hip strength and core stability with a goal to progress the CI off crutches continued.  X-rays of the left hip dated 23 August 2006 demonstrated findings consistent with a stable left femoral neck stress fracture with no significant interval change, while a bone scan on the same date demonstrated abnormal uptake in the left femoral neck, right posterior calcaneus, the medial tibial plateaus (not in the scope of review), and the base of the left great toe (also not in the scope of review).  Physical therapy range of motion (ROM) measurements of the left hip are in the chart below.   

Despite treatment, the stress fractures condition could not be adequately rehabilitated to meet the physical requirements of the CI’s basic military training and specialty and the CI was referred for an MEB.  The MEB forwarded “symptomatic, healing left femoral neck stress fracture” and “right calcaneal stress fracture” for PEB adjudication.  

At the MEB examination (recorded on DD Forms 2807-1 and 2808) dated 29 August 2006, 4 months prior to separation, the CI reported continued pain in the right heel and a fractured femoral neck that kept him from running, jumping, marching or carrying more than 10 pounds.  He also reported not much change in the condition over the prior 4 months.  The examiner noted in the summary of defects and diagnoses chronic ankle and foot pain with a stress fracture of the left femoral neck, but deferred examination to a consultant.  The MEB NARSUM examination on 6 September 2006, 3 months prior to separation, noted complaints of intermittent daily pain of a sharp quality in his left lateral hip and groin and heel pain worse with weight bearing.  Physical examination revealed the CI to be using crutches in no apparent distress.  His hips had a normal appearance and he was nontender to palpation over the left hip and groin.  Hip flexion strength was 4/5 as was extension strength.  Internal and external rotation strengths were 3/5 and abduction and abduction were 5/5.  He had a negative FABER test (to determine hip pathology) and a positive Ober test (to determine the tightness of the tensor fascia lata and iliotibial band).   An MEB Addendum dated 7 September 2006 noted the ROM of the feet was normal bilaterally and there was no pain with motion.  Strength was 5/5 and the heel was nontender to palpation. The feet were neurovascularly intact.  Since the CI was on crutches with toe-touch weight bearing on his left leg, he was unable to perform basic tasks.

At the 12 February 2007 VA Compensation and Pension (C&P) evaluation, performed 2 months after separation, the CI reported the left femoral neck hip pain as burning, aching, and sharp with a severity of 1/10 (10 being the worst pain) and he was able to function without medication.   The right calcaneus pain was described as crushing, aching, and oppressing at a level of 1/10.  The CI was unable to stand for long periods of time and could not run without pain after running.  On examination the CI’s posture and gait were within normal limits as was his left femur.  There were no signs of edema, effusion, weakness, tenderness, redness, heat, abnormal movement, subluxation or guarding of movement.   The ROM on external rotation and internal rotation were each limited by 5 degrees on repetition.  Examination of the right foot revealed no tenderness, weakness, edema, atrophy or disturbed circulation.  The CI did not have any limitation with standing and walking.  He required gel inserts, but the pain was not relieved by corrective shoe wear.  X-rays of the left femur and right heel were negative on 12 February 2007.  

The range of motion (ROM) examinations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.  

Left Hip (Thigh) ROM
(Degrees)	PT ~4 Mo. Pre-Sep
	VA C&P ~2 Mo. Post-Sep
	
Flexion (125 Normal)	 114,113,113*	125	
Extension (20)	19,18,18*	30	
External Rotation (45)	45,47,47	45 	
Abduction (0-45)	40,38,40*	50*	
Adduction (45)	17,20,18*	30*	
Comment	*Painful motion 	Posture and gait WNL; *painful motion with joint limitation of 5 degrees on repetition; no signs of edema/effusion/ weakness/TTP/abnormal movement/subluxation or guarding	
§4.71a Rating	PEB 10%	VA 10%	

Right Ankle ROM
(Degrees)	MEB ~3 Mo. Pre-Sep
	VA C&P 2 Mo. Post-Sep 	
Dorsiflexion (20 Normal)	Normal	20	
Plantar Flexion (45)		45	
Comment	No pain on motion; heel non-TTP; neurovascularly intact	Normal gait/posture; no tenderness, weakness, edema, atrophy or disturbed circulation 	
§4.71a Rating	-- 	VA 0%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating for the stress fractures, left femoral neck and right calcaneus under an analogous code 5099-5003 (Arthritis, degenerative), citing likely application of the US Army Physical Disability Agency pain policy and rated for pain-slight, frequent.  The VA assigned a 10% rating for residuals of left femoral neck stress fractures under an analogous code 5252-5015 (Thigh, limitation of flexion-Bones, new growths of, benign).  The VA also assigned a 0% rating for residuals of right calcaneus strain condition under the 5284 code (Foot injuries, other) based on the VA C&P examination 2 months after separation, citing painful and limited range of motion. 

The PEB combined the stress fractures, left femoral neck and right calcaneus conditions as a single unfitting condition analogously coded 5099-5003 and rated 10% with application of the USAPDA pain policy and AR 635-40 B24.f.  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 fractures, left femoral neck and right calcaneus conditions was presented together above.  In this case, a slow healing left femoral neck stress fracture was mentioned explicitly in the profile and both the hip and heel conditions were implicated in the NARSUM; however, there was no commander’s statement available to review. Nevertheless, members agreed that each stress fracture condition is separately unfitting and that an individual code and rating is applicable for each condition.  In the absence of hip ankylosis (code 5250), compensable limitation of motion of the thigh (codes 5251, 5252), thigh impairment (code 5253), flail hip (code 5254) or femur impairment with nonunion, false joint, or malunion with moderate hip disability (codes 5255 and 5299-5255), there was no route to a higher rating than 10%, which could be achieved with either use of either analogous code 5099-5003 or 5299-5255 (slight disability) proximate to separation based on noncompensable ROMs with painful motion.  The right calcaneus stress fracture appeared to have healed based on X-ray evidence 2 months post-separation.  Therefore, use of code 5284 offers only a 0% rating since the stress fracture of the right heel did not appear to rise to the moderate level at the time of separation.  Furthermore, the CI had a normal gait 2 months post-separation, albeit he used gel inserts in his shoes and had reported difficulty standing for a long period of time, although he was able to run despite pain after running.  Therefore, use of the 5284 code with a 0% rating offers no advantage to the CI.  Additionally, use of code 5273 (Os calcis or astragalus, malunion) likewise does not offer a rating above 0% in the absence of a moderate deformity, which was not present on examinations prior to or post-separation.  Therefore, the 10% rating assigned by the PEB is deemed to have been appropriate in the absence of occasional incapacitating exacerbations, if the rating were to be based on X-ray evidence, although the calcaneus is not a joint.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the stress fractures, left femoral neck and right heel condition.  

BOARD FINDINGS:  In the matter of the stress fractures, left femoral neck and right heel condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  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 20150609, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170005670, XXXXXXXXXXXXXXXXXX

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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,