RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01051
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050802

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 “chronic bilateral lower extremity pain,” with a disability rating of 0%.

CI CONTENTION:  “Review all 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 - 20050718	VA	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Bilateral Lower Extremity Pain (Feet/Talus, Plantar Fasciitis, Hips, Knees)	5022	0%	No VA Disability Claim Filed	
Shin Splints, Resolved	Not Unfitting		
Stress Fracture of the Proximal Right Tibia, Resolved	Not Unfitting		
Heel Cord Tightness, Bilaterally	Not Unfitting		
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  NA	

ANALYSIS SUMMARY:

Chronic Bilateral Lower Extremity Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s lower extremity conditions began in August 2004 during basic training without any inciting injury.  Initial symptoms were left hip pain with increased activity.  Her left knee and left foot began hurting with activity with occasional right knee pain as well.  Bone scan in December 2004 showed findings consistent with stress reactions in the right proximal tibia and stress reaction of the left ankle and left foot, and X-rays showed minor stress reaction of the left hip.  All pain was relieved with rest and increased with “return to a more normal military level of activity.”  The CI was unable to walk fast enough to pass the modified Army Physical Fitness Test.  The MEB forwarded “unresolved stress reactions/stress fractures of the left talus and left mid-foot,” “plantar fasciitis, mild, left foot,” “probable left hip stress reaction versus occult,” “patellofemoral pain syndrome,” and “ankle laxity” for PEB adjudication.

The MEB Orthopedic NARSUM examination on 23 May 2005, 2 months prior to separation, noted complaints of inability to pass the physical fitness test with symptoms of pain and fatigability in the left knee, ankle, and foot.  At walking activity for two miles with morning training on her light duty profile she has symptoms up to the level of 5 or 6/10 and limping, despite a long period of treatment.”  She had accomplished a two-mile walk the morning of the examination.  X-rays of both hips and pelvis, right and left knees, left leg, left ankle, and left foot were normal.  Repeat bone scan was reported as normal.  X-rays of the ankles showed slight widening of the tibiotarsal joint space at the lateral aspect of the left foot as compared to the right with increased right foot displacement.  The orthopedic specialist reviewed the study and stated he did not feel that the finding (0.4mm difference) indicated gross clinical instability.  Left ankle MRI was normal.  Physical examination showed a mild limp on the left side.  Hip examination showed tenderness on deep palpation only.  There was no clicking or popping and “excellent range of motion (ROM)” bilaterally (extension was greater than 5 degrees, flexion was greater than 45 degrees, abduction was greater than 10 degrees, and rotation over 15 degrees for both hips).  Knee examination showed minimal patellofemoral crepitus with no tenderness.  ROM was 0-136 degrees (normal 0-140) on the left, and minimum hyperextension-139 degrees on the right.  There was no laxity or instability.  There was no lower leg tenderness and compartments were soft.  Heel cords are mildly tight, left greater than right, but dynamically, the heel cords were less tight than manual testing revealed.  The left ankle had significant tenderness, mild crepitus, and minimal soft tissue swelling around the tibiotalar joint.  There was no ankle instability.  Ankle ROM with a bent knee was; left ankle dorsiflexion 10 degrees (normal 20) and plantar flexion 48 degrees (normal 45), with right ankle dorsiflexion 15 degrees and plantar flexion 45 degrees).  Ankle dorsiflexion decreased with a straight knee to 0 degrees on the left and 5 degrees on the right.  The feet showed equal motion with no instability, and there was mild (1-2/10) tenderness over the tops of the mid foot surface, with no tenderness elsewhere on the feet.  There was no lower extremity muscle atrophy, vascular changes or edema.  Toe-walk was good and heel-walk was fair.  There was no VA Compensation and Pension examination performed proximate to separation.

The PEB combined the MEB diagnoses of “unresolved stress reactions/stress fractures of the left talus and left mid-foot,” “plantar fasciitis, mild, left foot,” “probable left hip stress reaction versus occult,” “patellofemoral pain syndrome,” and “ankle laxity” conditions as a single unfitting condition of “chronic bilateral lower extremity pain left worse than right” coded 5022 (periostitis) and rated 0% citing rated for normal -rays and full range of motion.  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 Board’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 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.  

There was no objective evidence of painful motion of any lower extremity joint.  The only clinically diagnosed disability condition with disability findings at separation was the left ankle/foot with unresolved stress reaction/stress fracture of the left talus and mid-foot; and it was considered reasonably unfitting and ratable.  The other MEB conditions showed no clinically significant symptoms or aspects of disability and were not considered reasonably unfitting or ratable at separation.
The left ankle had decreased ROM of 10 degrees of dorsiflexion (normal 20) that decreased to 0 degree on knee extension, significant tenderness, mild crepitus, minimal soft tissue swelling, abnormal imaging, and the CI had a mild limp on the left.  Although there was no objective evidence of painful motion IAW VASRD §4.59, the Board concluded there was sufficient evidence of functional loss (§4.40, §4.45) and limitation of motion of the ankle to support a 10% rating analogous to the VASRD diagnostic code for limitation of motion (5271) for moderate loss of motion.  The Board considered alternative VASRD ankle and analogous codes, but all were less applicable and not advantageous to rating.  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 chronic bilateral lower extremity pain (left ankle/foot) condition, analogously coded 5022-5271.

Contended PEB Conditions:  Resolved Shin Splints, Resolved Stress Fractures/Reactions of the Proximal Right Tibia, and Bilateral Heel Cord Tightness.  The Board’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  Although most conditions would be covered by the CI’s profile and general duty restriction implicated by the commander’s statement, none of the conditions were judged to fail retention standards.  All conditions were considered under the “chronic lower extremity pain” condition above, and all conditions were considered resolved, and not clinically significant at the MEB NARSUM examination.  After due deliberation, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for any of the contended conditions and so no additional disability ratings are recommended.

BOARD FINDINGS:  In the matter of the chronic bilateral lower extremity pain condition, the Board unanimously recommends a disability rating of 10% for the left ankle/foot, coded 5022-5271 IAW VASRD §4.71a.  In the matter of the contended resolved shin splints, resolved stress fractures/reactions of the proximal right tibia, and bilateral heel cord tightness conditions, the Board unanimously recommends no change from the PEB determinations as not unfitting.  There were no other conditions within the Board’s scope of review for consideration.  

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	
Chronic Bilateral Lower Extremity Pain
(Left Ankle/Foot) 	5022-5271	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150611, w/atchs
Exhibit B.  Service Treatment Record

AR20170005671, XXXXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found that your disability rating should be modified but not to the degree that would justify changing your separation for disability with severance pay to a permanent retirement with disability.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed) and I accept its recommendation.  This will not result in any change to your separation document or the amount of severance pay.  A copy of this decision will be filed with your Physical Evaluation Board records.  I regret that the facts of the case did not provide you with the outcome you may have desired.
  
	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