RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01178
BRANCH OF SERVICE:  Navy 	SEPARATION DATE:  20020222

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Seaman Recruit, medically separated for “bilateral femoral stress fractures, left greater than right,” 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 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 - 20020107	VARD – N/A	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Femoral Stress Fractures, Left Greater than Right	5255-5003	10%	No VA examination in Evidence	
Bilateral Shin Splints	Category III		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  N/A	

ANALYSIS SUMMARY

Bilateral Femoral Stress Fractures, Left Greater than Right Diagnosis.  The PEB combined the left and right femoral stress fracture conditions as a single unfitting condition coded 5255-5003 (femur, impairment with arthritis, degenerative), citing rated for radiographically proven stress fractures of 2 or more major joints with normal 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 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 the service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s bilateral femoral stress fractures began in May 2001 with complaints of primarily left thigh pain with no acute trauma.  Initial bone scan in June 2001 showed bilateral shin splints with uptake in the mid-shaft of the femurs, left greater than right.  She was treated with limited duty and Os-Cal, a calcium supplement. 

At the 1 November 2001 MEB NARSUM examination, 3 months prior to separation, noted complaints of pain in the left thigh had not improved since treatment began.  The CI had difficulty climbing stairs and carrying any loads heavier than several books.  Physical examination showed “full range of motion of the hip and knee.”  The left femur was non tender with no palpable lesions or masses.  Neuro vascular was intact.  On 23 October 2001, repeat bone scan showed resolution of the bilateral shin splints, healing of the left distal third femoral shaft stress fracture, and healing of the right femoral stress reaction.  CI was placed on a profile that prevented running, heavy lifting, prolonged walking, standing and other activities.  The non-medical assessment noted the CI was away from assigned duties on average 3 hours per week, was working outside of her specialty because of the medical condition, and had last passed boot camp in November 2000.  

At the November 2001 MEB examination (recorded on DD Forms 2807-1 and 2808), 3 months prior to separation, the CI reported left thigh pain.  Examination showed the left femur was tender to palpation with no palpable lesions or masses.  There was full range of motion of the hip and the knee.  Bone scan showed interval healing of the left distal third femoral shaft stress fracture with decreased uptake and healing of the right femoral stress induced reaction, and resolution of the bilateral shin splints.  She reported difficulty climbing stairs and carrying more than several books in a backpack.  There was no VA Compensation and Pension (C&P) evaluation in evidence proximate to separation. 

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral femoral stress fractures 10%, coded 5255-5003 (femur impairment of-with arthritis, degenerative (hypertrophic or osteoarthritis).  The PEB assigned a Category III condition to the bilateral shin splints, noting they were not separately unfitting and did not contribute to the unfitting condition.   

Neuroimaging noted bilateral shin splints with increased uptake in the mid-shaft of both femurs, left greater than right.  The CI complained of recurring pain in the left thigh.  Treatment records and neuroimaging only referenced the left femoral mid shaft stress fracture.  Repeat bone scan showed: interval healing of the left distal third femoral shaft stress fracture with decreased uptake, healing of the right femoral stress reaction, and resolution of the bilateral shin splints.  Left thigh pain had not improved and continued to restrict activity.  The panel concluded the right stress fracture was healing and unfitting but the left femoral stress fracture showed interval healing with continued pain in the left thigh that impaired function.  

Ideal coding would be for a 10% left femoral stress fracture and a 0% right femoral stress reaction; however, this would be no higher than the 10% awarded by the PEB.  There was therefore no VASRD §4.71a route to a rating higher than the 10% adjudicated by the PEB under any applicable code.  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 bilateral femoral stress fractures.  

BOARD FINDINGS:  In the matter of the bilateral femoral stress fractures and IAW VASRD §4.71a, the panel unanimously 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 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, with attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR DIRECTOR, SECRETARY OF THE NAVY COUNCIL OF REVIEW
               BOARDS 

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS
 
Ref:   (a) DoDI 6040.44
       (b) CORB ltr dtd 10 May 17

      In accordance with reference (a), I have reviewed the cases forwarded by reference (b), and approve the recommendations of the PDBR that the following individual’s records not be corrected to reflect a change in either characterization of separation or in the disability rating previously assigned by the Department of the Navy’s Physical Evaluation Board:

		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN

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