RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01329
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050318

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E2, Patriot Launching Station Enhanced Operator/Maintainer, medically separated for “chronic lower extremity pain secondary to stress fractures,” with a disability rating of 0%.  

CI CONTENTION:  “Medical issue still remains.”  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 - 20050303	VARD - 20050616	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Lower Extremity Pain Secondary to Stress Fractures	5099-5003	0%	Residuals, Left Lateral Femoral Condyle Stress Fracture	5255	0%	STR	
			Residuals, Right Femur Stress Fracture	5255	0%		
			Residuals, Right Second Metatarsal Stress Fracture	5283	0%		
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Chronic Lower Extremity Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s (bilateral) lower extremity pain condition began in June 2004 during basic training.  Bone scan dated 15 November 2004 showed a right distal femur metaphyseal stress fracture, a left lateral femoral condyle stress fracture and a right second metatarsal (foot) stress fracture.  The CI was treated for multiple lower extremity pain and stress fractures with crutches, profile restrictions, rest/convalescent leave, and did not improve.  At the Physical Therapy evaluation dated 7 January 2005 (2 months prior to separation), the CI complained of continued right and left lower extremity pain.  Examination showed a normal gait with full range of motion (ROM) of both knees and ankles with increased left knee pain during squatting and functional testing.  The evaluator considered the prognosis poor and recommended an MEB.  The MEB forwarded “right distal femoral, left lateral condyle and right second metatarsal stress fracture” for PEB adjudication.  

The MEB NARSUM examination on 4 February 2005, 1 month prior to separation, noted complaints of right thigh, left lower leg, and right foot pain.  Physical examination showed a normal gait.  There was mild tenderness of the distal right femur, left lateral condyle and distal (right) second metatarsal.  There was no swelling of the right thigh, knees, or right foot.  Knee ROMs were normal with no instability or ligamentous laxity.  Strength, reflexes, and sensation were normal in the lower extremities.  Diagnostic imaging was abnormal as noted above.  There was no VA Compensation and Pension evaluation proximate to separation in evidence.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB combined the right distal femoral stress fracture, left lateral condyle stress fracture, and right second metatarsal stress fractures conditions as a single unfitting condition coded analogously to 5003 (degenerative arthritis) and rated 0%, citing X-ray evidence and positive bone scan “without significant loss of joint function.”  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.  The VA rated the left lateral femoral condyle stress fracture condition 0%, coded 5255 (impairment of femur); rated the right femur stress fracture 0%, coded 5255; and rated the right second metatarsal stress fracture 0%, coded 5283 (tarsal, or metatarsal bones, malunion of or nonunion of); citing MEB evidence and absence of any VA examination.  

The profile listed right distal femur, left lateral condyle and right metatarsal stress fracture with limitations in running, marching and jumping.  The MEB listed the combined three conditions as not meeting retention standards, and most treatment notes likewise noted pain in both lower extremities.  There was no commander’s statement in evidence.  There was not a preponderance of evidence to indicate that any of the three conditions was not separately unfitting.  

The panel considered that only the left knee had objective evidence of painful motion proximate to separation (PT evaluation), although the NARSUM was silent on the presence (or absence) of pain on motion.  Both knees (distal femur and condyle) and the right foot had diagnostic imaging abnormalities consistent with degeneration; however, the single metatarsal is not considered a major joint or collection of minor joints for VA rating purposes.  

The panel considered the probative value of the examinations for a possible separate left knee 10% rating with the right knee and foot retaining a 0% rating, or a combined single 10% rating analogous to 5003 based on rating for “2 or more major joints” without significant ROM limitations or painful motion IAW VASRD §4.71a.  There were no documented incapacitating exacerbations for the higher 20% rating under 5003 criteria.  

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 chronic lower extremity pain condition, coded 5099-5003.  

BOARD FINDINGS:  In the matter of the chronic lower extremity pain condition, the panel unanimously recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a.  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	
Chronic Lower Extremity Pain Secondary to Stress Fractures	5099-5003	10%	

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

AR20170007556, XXXXXXXXXXXXXXXXXX

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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