RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01221
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20030124

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a National Guard E1, Trainee, medically separated for “bilateral stress reactions, lower extremities involving the knee, hips and feet” with a disability rating of 0%.  

CI CONTENTION:  “Pain and range of motion have worsened.”  “Review all conditions.”  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 - 20030103	VARD - 20041013	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Stress Reactions, Lower Extremities Involving the Knee, Hips and Feet	5099-5022	0%	Osteonecrosis, Left Hip	5013-5262	10%	20040727	
			Osteonecrosis, Right Hip	5013-5262	10%		
			Residuals, Stress Fracture, Left Tibial Plateau	5299-5262	0%		
			Residuals, Status Post Stress Fracture, Mid-Foot Bilateral Feet	5299-5284	NSC		
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Bilateral Stress Reactions, Lower Extremities Involving the Knee, Hips and Feet.  The Medical Evaluation Board (MEB) forwarded three conditions of bilateral hip pain, left medial tibial plateau stress fracture, and bilateral mid foot stress fractures to the PEB.  The PEB combined all the MEB conditions as a single unfitting condition coded analogously to 5022 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 evidence for the bilateral hip pain, left medial tibial plateau stress fracture knee, and bilateral mid foot stress fractures is presented below, with attendant recommendations regarding separate unfitness, and separate rating if indicated.  

According to the service treatment records (STR) and the MEB narrative summary (NARSUM), the CI’s bilateral stress reactions of the hips, left knee, and feet began in September 2002 during Basic Training.  Bone scan performed on 15 October 2002 showed increased uptake of the bilateral femoral heads, not characteristic of stress fractures, a stress fracture of the left medial tibial plateau (knee) and stress fractures of the base of the second and third metatarsals (feet) bilaterally.  Magnetic resonance imaging of the hips was “not entirely conclusive” but showed abnormal bone swelling and possible signs of early avascular necrosis or transient osteoporosis.  

The 25 November 2002 permanent profile, 2 months prior to separation, listed bilateral hip pain.  There was no commander’s statement in record.  

The 25 November 2002 MEB NARSUM examination, 2 months prior to separation, noted complaints of bilateral hip, knee and foot pain.  The CI reported that her hip pain had improved over time and was graded 2/10, with stiffness in the mornings that improved throughout the day. The CI reported that bilateral knee pain and foot pain were improving as well.  The physical examination showed full bilateral hip range of motion (ROM) with pain at the extremes of motion bilaterally.  Right and left knee ROM was 0 degrees extension (normal 0) and 135 degrees flexion (normal 140) with no tenderness to palpation (TTP).  No instability of the right knee was noted. There was full ROM of the bilateral ankle and feet with no TTP.  The MEB NARSUM examiner’s assessment was that the bilateral hips were minimally symptomatic but would require orthopedic follow-up after separation.  He noted the CI reported her hip symptoms had “markedly resolved since onset.”  The left knee was asymptomatic and the tibial stress fracture was expected to heal without incident, but return to training might cause a recurrent stress fracture.  The bilateral feet were also asymptomatic.  

At civilian orthopedic evaluations after separation in March through August 2003 (2 to 7 months after separation), the CI reported she was having increasing hip symptoms and intermittent hip symptoms with weight bearing activities were noted.  There was no mention of knee pain or foot pain.  The serial examinations noted “slight limp” and “without a significant limp.”  Avascular necrosis of the bilateral hips was diagnosed.  The CI was not taking any medications or pain medications for the hip conditions.  It was anticipated that the CI would eventually require arthroplasty (hip replacement), but she was being followed conservatively at the time because lesser surgical interventions were thought unlikely to be of benefit.  

At the 27 July 2004 VA Compensation and Pension (C&P) examination, 18 months after separation, the CI reported chronic bilateral hip pain with decreased ROM and pain.  She reported she could not sit cross legged.  She reported daily left knee pain aggravated by activities but no foot pain.  The physical exam showed a slight limp that improved after several steps.  There was no TTP of the hips.  Right hip ROM of flexion of 110 degrees (normal 125), extension 10 degrees (normal 20) abduction 30 degrees (normal 45)adduction 20 degrees (normal 45) and external rotation 40 degrees (normal 45).  Left hip ROM was the same as the right except for 40 degrees of abduction.  There was pain and slight crepitus with ROM of both hips.  There was an increase in pain and decreased ROM of 10 percent with repetitive motion.
Left knee ROM was 0 degrees extension and 130 degrees flexion.  Right knee ROM was 0 degrees extension and 130 degrees flexion.  There was tenderness of the left knee joint line.  There was painful motion with repetitive motion without decreased ROM.  There was no evidence of instability of either knee.  The bilateral foot exams were normal except for mild right bunion.  Bilateral leg strength was normal and the CI was able to heel and toe walk.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral lower extremity conditions 0%, coded 5099-5022 (analogous to periostitis), citing “rated as periostitis without loss of motion of the contiguous joints.”  The VA rated the right hip condition 10% coded 5013-5262 (osteoporosis-tibia/fibula impairment), based on the C&P examination 18 months after separation, citing: “discomfort with motion.”  The VA also rated the left hip condition 10% coded 5013-5262, citing: “discomfort with motion.”  The VA rated the left tibia 0% coded 5299-5262 (analogous to impairment of the tibia and fibula).  The VA did not service-connect the bilateral foot condition (coded 5299-5284).  

The panel first considered if the bilateral hip condition, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The bilateral hip pain was permanently profiled and the NARSUM determined the CI fell below retention standards due to the hip conditions.  The panel concluded that there was not a preponderance of evidence of the service records that overcame the presumption that the bilateral hip condition was reasonably considered separately unfitting.  Additionally, there was no distinction in the record regarding the fitness implications of the right and left hips and therefore each hip condition was reasonably considered separately unfitting and eligible for disability rating.  

The rating criteria for both hips were nearly identical and therefore the rating of the hips is considered together.  There was no limitation of motion which supported a rating under the diagnostic codes for limitation of thigh flexion or extension, thigh impairment (5251, 5252).  However, there was evidence of painful motion with functional loss supporting a 10% rating coded analogously to 5022 (periostitis) or coded analogously to 5252 (limitation of thigh flexion), based on §4.59, §4.40 and §4.45.  The panel reviewed to see if a higher evaluation was supported under any other applicable VASRD code.  The examinations proximate to separation did demonstrate the presence of femur impairment (5255) proximate to separation that would warrant a 10% rating for each hip due to “slight” hip disability.  The panel agreed, however, that the 5255 threshold for a higher rating (moderate hip disability) was not met based on the evidence at the MEB NARSUM examination, civilian orthopedic evaluations shortly after separation, and the VA examination of slight limp, if any.  There was no evidence of hip ankyloses or a flail hip joint (5250, 5254) for a rating under the respective codes.  There was therefore no route to a rating higher than 10% for each hip under any applicable VASRD §4.71a code.  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 right hip condition and 10% for the left hip condition, both coded 5099-5022.  

The panel next considered if the left knee condition, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The left knee condition was not permanently profiled.  The MEB NARSUM examiner indicated that the left tibial plateau stress fracture was asymptomatic at the time of the NARSUM.  However, resumption of basic training might cause a recurrence.  There was no performance based evidence that the left knee condition would have caused the CI to be referred into the DES or be found unfit when considered alone and accordingly the panel cannot recommend a separate rating for it.  

The panel finally considered if the bilateral mid-foot stress fractures condition, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The bilateral mid-foot stress fractures condition was not permanently profiled.  The MEB NARSUM examiner indicated that the bilateral feet were asymptomatic at the time of the NARSUM.  There was no performance based evidence that the right foot, left foot or bilateral mid-foot stress fractures would have caused the CI to be referred into the DES or be found unfit at separation when considered alone and accordingly separate rating cannot be recommended.  

BOARD FINDINGS:  In the matter of the “bilateral stress reactions, lower extremities involving the knee, hips and feet” condition, the panel unanimously recommends a disability rating as follows: an unfitting right hip condition and an unfitting left hip condition, each rated 10%, both coded 5099-5022, IAW VASRD §4.71a; a not unfitting left knee condition and a not unfitting bilateral foot condition.  There are 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	
Right Hip Pain	5099-5003	10%	
Left Hip Pain	5099-5003	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150612, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170007914, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXX
XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

	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