RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01129
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060829

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

CI CONTENTION:  The CI makes no contention.  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 - 20060816	VARD – 20070529	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Bilateral Lower Extremity Pains…	5099-5003	0%	Stress Fracture of the Left Femoral Head	5299-5255	0%	STR	
			Stress Fracture of the Left Proximal Tibia	5299-5262	0%		
			Left Mid-Foot Stress Fracture	5299-5284	0%		
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Chronic Bilateral Lower Extremity Pains.  The PEB combined multiple lower extremity conditions as a single unfitting condition coded analogously to 5003 (degenerative arthritis) and rated 0% with likely application of the US Army Physical Disability (USAPDA) Pain Policy.  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 also noted that “bundling,” the combining of two or more major joints, may be permissible under the VASRD 5003 rating requirements, and that this approach does not compromise the VASRD §4.7 directive to choose the higher of two valid ratings.  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.

According to service treatment records (STR) the CI developed left hip pain in March 2006.  Although initial X-rays were negative, a bone scan in March 2006 showed very early left hip stress injury, “borderline stress fractures” in the left midfoot and stress changes in the knees and right ankle.  Crutches were prescribed, with instructions to use them until her gait (which was antalgic due to left hip pain) returned to normal.

The Medical Evaluation Board (MEB) forwarded “left femoral neck stress fracture, left proximal tibia stress fracture, right anterior knee pain, left midfoot stress fracture and right ankle stress fracture” for PEB adjudication.  

Review of the STR found that the CI first presented for clinical attention on 13 March 2006 (approximately 6 months prior to separation) for left thigh pain that began that same day after running 1 mile.  The following day in physical therapy (PT) the CI was placed on a profile for a week.  By 16 March 2006, symptoms were described as left groin pain with some radiation down the inner thigh to the left knee.  Pain beyond the left knee was not present, and right lower extremity pain was not reported.  Due to clinical suspicion of a left hip stress fracture, a bone scan was ordered, and profile restrictions that prevented running, jumping or marching were imposed. 

The bone scan was performed on 17 March 2006, with results as noted above.  At a follow-up with PT on 21 March 2006, the CI reported left hip pain that was only present with walking.  No other lower extremity pain was mentioned.  Examination showed a painful gait favoring the left side.  The bone scan results were noted by the examiner, and the required use of crutches (“until gait is normal”) was added to the previous profile restrictions specifically for the left hip stress changes noted on the bone scan.

On 5 April 2006, the CI reported to PT that she had “minimal pain” at the left foot and some left knee pain.  Pain at the left hip was the primary complaint.  There was no report of any right sided symptoms.  Physical examination showed a painful gait favoring the left side.  There was painful motion of the left hip, pain in the anterior left knee during full extension, and tenderness of the left MTP area (forefoot).  The only diagnosis rendered was left hip sprain.  The CI was switched from crutches to a cane.

At PT follow-up on 26 April 2006 (4 months prior to separation) the CI’s chief complaint was left hip pain and low back pain.  There was no mention of pain in other areas.  The cane reportedly “helped significantly” and was being used on an as-needed basis.  Examination showed painful left hip motion and a gait that was “slowed” by left hip pain.  The examiner confirmed that there had been no running for 6 weeks, and rendered diagnoses only of left hip sprain and backache.  Marching at own pace and distance was now allowed, but running and jumping were still prohibited.

On 24 May 2005 (3 months prior to separation) the CI, reporting on her effort to resume running at own pace and distance, stated that she was only able to run 1/4 mile because of pain in the left hip, thigh and knee.  There was no mention of left foot or right lower extremity symptoms.  Examination showed left hip pain at the end of internal rotation.  Although gait was “slowed” there was no pain observed during ambulation.  The only diagnoses rendered were left hip sprain and backache.  Profile restrictions now specified no running, jumping or marching.

The MEB NARSUM examination on 29 June 2006, 2 months prior to separation, reported that during rehabilitation of the left hip “multiple other complaints including left anterior knee pain and right anterior knee pain as well as right ankle and left foot pain” occurred.  Physical examination showed painful left hip motion in all directions, although gait was described as non-antalgic.  Left hip flexion was 100 degrees (normal 125) and external rotation was 60 degrees.  Extension, adduction and abduction were not reported.  Some hip tenderness was present.  Examination of the left and right knees was “rather benign.”  There was no knee tenderness except at the medial aspect of the kneecaps.  There was tenderness of the left mid-foot.  Right ankle motion was non-painful, and tenderness was only present behind the lateral malleolus.  Right ankle dorsiflexion was 15 degrees (normal 20) and plantar flexion was 45 degrees (normal 45).  Recent X-rays reportedly showed findings consistent with stress reaction or stress fracture of the left tibia near the knee and healing stress fracture of the left hip.  The examiner’s assessment was left femoral neck stress fracture, left proximal tibia stress fracture, right anterior knee pain, left midfoot stress fracture, and right ankle stress reaction.

The permanent physical profile on 29 June 2006 identified “Pain bilateral lower extremity” as the medical condition, and allowed walking and swimming at own pace and distance.  At the MEB examination (recorded on DD Forms 2807-1 and 2808) dated 5 July 2006 (2 months prior to separation), the CI wrote that left lower extremity symptoms were the cause of “Impaired use of arms, legs, hands or feet” and “Knee trouble.”  There was no mention of right lower extremity symptoms.  On the Report of Medical Assessment (same day) the CI also wrote that “left leg and knee” stress fractures were the cause of impairment.  There was no mention of right lower extremity or left foot difficulties.

Examination by PT on 10 July 2006 observed no evident pain or difficulty when transferring from supine to sitting to standing positions.  The CI was able to fully squat with buttocks to floor without evidence of pain, but did display difficulty in arising from that position due to left hip pain.  The CI was able to “fully flex knees to chest” without an observable pain reaction.  Left hip flexion was 125 degrees, extension 15 degrees (normal 20), abduction 45 degrees (normal 45), adduction 45 degrees (normal 45) and external rotation 45 degrees (normal 45).  Both knees displayed 0 degrees of extension (normal 0) and 135 degrees of flexion (normal 140).  Ankle range of motion was considered full and equal bilaterally.  At 2 separate emergency room visits for problems unrelated to the lower extremities on 18 August and 24 August 2006 (1-2 weeks prior to separation) the CI denied pain or musculoskeletal complaints.  There was no VA examination in evidence proximate to separation.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB’s combined 0% rating rested on application of the USAPDA pain policy as above; but, this rating did not comport with VASRD §4.71a which confers a 10% rating under 5003 for the involvement of “two or more major joints” without specifying a need for additional criteria.  The VA assigned 0% ratings for the left femoral neck stress fracture, the left midfoot stress fracture and the left proximal tibia stress fracture based on the STR.  Service-connection was denied for the right ankle and right knee.  The VA’s rating decisions were based on the absence of proof of ongoing disability due to a missed examination.  The panel first considered whether the left femoral neck stress fracture (hip) condition, when considered separately, was unfitting for continued military service.  The left hip was the CI’s chief complaint during the five months it was present prior to separation and was the primary focus of almost all STR entries.  It required constant therapeutic attention and profiling restrictions from the time of its onset.  Panel members agreed the evidence reasonably justified that the functional limitations from the left hip condition contributed to the CI’s inability to perform her military duties and, accordingly, a separate disability rating is recommended.  Regarding a rating recommendation, panel members noted that there was no limitation of hip motion that supported a rating higher than 0% under the respective codes (5251, 5252, or 5253).  However, there was sufficient evidence of painful motion to warrant a 10% rating IAW VASRD §4.59 (painful motion).  A rating was also considered under an analogous 5255 code (femur, impairment of, malunion).  It was agreed that “slight” disability was an accurate descriptor of the condition, therefore a 10% rating was also warranted via this pathway.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the left femoral neck stress fracture condition, coded 5099-5003.

Next, the panel turned its attention to the left proximal tibia stress fracture, right anterior knee pain, left midfoot stress fracture and right ankle stress reaction conditions.  As previously elaborated, the panel must first consider whether these conditions remained separately unfitting, having been de-coupled from a combined PEB adjudication.  In analyzing the intrinsic impairment for appropriately coding and rating these conditions, the panel is left with a questionable basis for arguing that any of them were independently unfitting.  Although all of them were mentioned by the NARSUM examiner, the STR reflected either no or minimal complaints referable to any of them, and there is no evidence that they imposed any significant impact on performance.  The PT providers overlooking and managing her care never rendered a diagnosis related to the lower extremities, other than the left hip.  There were specified profiling restrictions for the left hip and the lumbar spine, but no such restrictions were ever imposed for these other conditions.  Finally, unless a stress fracture progresses to a complete fracture (which did not occur in this case) the natural course of bony stress injury is complete healing.  The Service's responsibility was not to see such conditions through to their maximal resolution when it was clear that continued service was not possible.  However, panel members deliberated that the final emergency room visits just prior to separation, at which time the CI reportedly was experiencing no further pain and denied any musculoskeletal complaints, constituted sufficient evidence that such bone healing occurred.  It should also be noted that there is insufficient evidence in support of a rating higher than 0% for any of the aforementioned conditions, even if any were conceded as unfitting.  After due deliberation, members agreed the evidence does not support a conclusion that the functional impairment from left proximal tibia stress fracture, right anterior knee pain, left midfoot stress fracture or right ankle stress reaction conditions was integral to the CI’s inability to perform her MOS, and accordingly cannot recommend a separate rating for any of them.

BOARD FINDINGS:  In the matter of the left femoral neck stress fracture condition, the panel unanimously recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a.  In the matter of the right ankle, left foot, and left and right knee conditions, the panel unanimously agrees that it cannot recommend any for additional disability rating.  There were no other conditions within the panel’s scope of review for consideration.  The panel 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	
Left Femoral Neck Stress Fracture	5099-5003	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150608, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170007387, 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