RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01498
BRANCH OF SERVICE:  navy 	SEPARATION DATE:  20030512

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E1, Seaman Recruit, medically separated for “left first cuneiform stress fracture” and “right posterior medial femoral condyle stress fracture,” with a disability rating of 10%.

CI CONTENTION:  “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 - 20030416	VARD - 20031125	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left First Cuneiform Stress Fracture and Right Posterior Medial Femoral Condyle Stress Fracture  	5022-5003	10%	Residuals, Stress Fracture, Left Foot, Left Fifth Cuneiform	5283	0%	20030728	
			Residuals, Stress Fracture, Right Posterior Medial Femoral Condyle, in the Area of the Right Knee	5255	0%	20030728	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:

Left Foot and Right Knee Stress Fractures.  The PEB combined the left first cuneiform (foot) stress fracture and the right posterior medial femoral condyle (knee) stress fracture conditions as a single unfitting condition coded 5022-5003 (periostitis-degenerative arthritis) and rated 10%.  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 evidence for the left first cuneiform stress fracture and the right posterior medial femoral condyle stress fracture conditions are presented below, with attendant recommendations regarding separate unfitness, and separate rating if indicated.  

According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s left foot and right knee stress fractures began in March 2003 after marching during initial entry training.  A bone scan in March 2003 showed stress fractures of the left mid foot and right knee.  

The commander’s statement dated 28 March 2003 indicated that physical limitations due to multiple stress fractures impaired the CI’s ability to perform the duties of her military specialty.  The MEB NARSUM examination noted only tenderness to palpation (TTP) of both the left foot and right knee in the area of the stress fractures and concluded that the CI fell below retention standards due to the left foot and right knee fractures.   

The panel first considered if the left foot and right knee stress fractures, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  Both conditions were implicated in the commander’s statement and determined to fall below retention standards.  The panel concluded that there was not a preponderance of evidence to overcome the panel’s presumption that each condition was reasonably considered separately unfitting and eligible for separate rating.  

The 27 March 2003 MEB NARSUM examination, 2 months prior to separation, noted complaints of left foot pain.  Physical examination showed focal tenderness of the left foot in the area of the stress fracture.  There was no swelling and there was normal strength and sensation.  The MEB NARSUM examiner indicated that it may take months to a year before the CI could resume full military training.  CI was deemed unlikely to be able to complete basic training in a reasonable time period due to the stress fracture.  

During the 4 April 2003, MEB examination (recorded on DD Forms 2807-1 and 2808), 1 month prior to separation, the physical examination showed TTP of the left foot and tenderness with walking.  

At the 28 July 2003 VA Compensation and Pension (C&P) evaluation, 2 months after separation, the history of the left foot stress fracture was noted.  Physical examination showed a normal posture and gait.  There was tenderness of the left great toe (not adjacent to the stress fracture) and ankle range of motion was normal.  Feet X-rays were normal.  The VA examiner indicated there was “some functional impairment” which should gradually improve.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left foot and right knee stress fractures 10%, coded 5022-5003 (periostitis-arthritis, degenerative).  The VA rated the left foot stress fracture condition 0%, coded 5283 (tarsal, or metatarsal bones, malunion or nonunion), based on the C&P examination 2 months after separation.  There was no limitation of motion of the ankle joint to support a rating under diagnostic code 5271 (limitation of motion) and the MEB and VA examinations did not note the presence of painful joint motion for a 10% rating under 5271 or 5022.  The CI’s gait was normal and therefore the panel concluded that a 10% rating was not warranted under the 5284 code for “moderate, other foot injury.”  There was therefore no higher rating than 0% available with any applicable VASRD code.  As noted above the panel may not recommend a lower combined rating than that of the PEB.  However, lower ratings may be recommended for individual conditions.  The panel therefore turned its attention to the right knee stress fracture before concluding deliberations.  

The 27 March 2003 MEB NARSUM examination, 2 months prior to separation, noted complaints of right knee pain.  The physical examination showed TTP of the right knee and was otherwise the same as the physical exam as recorded under the left foot stress fracture. 

During the April 2003, MEB examination (recorded on DD Forms 2807-1 and 2808) 1 month prior to separation, physical examination showed right knee pain with flexion, extension and weight bearing.  

At the 28 July 2003 VA Compensation and Pension (C&P) evaluation, 2 months after separation, the physical examination showed a normal posture and gait.  Right knee ROM was normal with TTP and crepitation noted.  Right knee X-rays were normal.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left foot and right knee stress fractures 10%, coded 5022-5003.  The VA rated the right knee stress fracture 0%, coded 5255 (impairment of the femur).  There was no limitation of motion which supported a rating under the diagnostic codes for limitation of flexion or extension (5260, 5261).  However, there was evidence of painful motion at the MEB examination to support a 10% rating coded under 5003 or 5260 (based on §4.59).  A 10% rating and no higher could be supported under 5255, which provided no rating benefit over the rating recommendation under 5003.  The examinations proximate to separation did not demonstrate the presence of ligamentous instability or laxity (5257), and there was no history of dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258), or history of surgery to remove a meniscus (5259) to support a rating under the respective codes.  There was therefore no VASRD §4.71a route to a rating higher than 10% under any applicable VASRD code.  After having unbundled the left foot and right knee stress fracture conditions, and recommended both as unfitting at separation, the panel determined there was no benefit to the CI and recommends no change to the 10% combined rating.  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 left foot and right knee conditions.    

BOARD FINDINGS:  In the matter of the left first cuneiform stress fracture and the right posterior medial femoral condyle stress fracture 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 modification or re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150615, w/atchs
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: PHYSICIU. DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDAT IONS Ref:	(a) DoDI 6040.44
In accordance with reference (a), I have reviewed the cases listed below 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 ., XXX XX 6924, former USN
-	XXXXXXXXXXXXXXXXXX, XXX XX 9590, former USMC	
                                             XXXXXXXXXXXXXXXXXX, XXX XX 3497, former USN