RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01511
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20080904

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Human Recourses Specialist, medically separated for “shin pain  …” and “bilateral foot and ankle pain,” rated 20% and 0% respectively, with a combined disability rating of 20%.

CI CONTENTION:  Pain has worsened since her discharge; her ankles are swollen daily and she requires ankle braces.  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 - 20080521	VARD – NA	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Shin Pain Mild Bilateral…	5299-5262	20%	No VA Exam in Evidence	
Bilateral Foot and Ankle Pain	5299-5276	0%		
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  NA	

ANALYSIS SUMMARY:  

Shin Pain Mild Bilateral.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI reported bilateral shin pain since October 2004 which was aggravated by running and weight bearing.  A bone scan on 7 October 2005 showed a mild stress response in her shin bones.  She was evaluated in orthopedics on 18 November 2005 where her pain was disproportionate to her injury.  Despite treatment for shin splints, her pain persisted.  She reported that she wanted out of the US Army.  The treatment for stress injuries was discussed, but the CI reported that she just wanted to go home.  She was placed on a profile and started on a walk-to-run protocol.  The records then fell silent until 29 January 2008, 7 months prior to separation, when the CI was again seen in orthopedics.  She reported bilateral shin and ankle pain for 3 years which was worse with activity.  On examination, mid-shin tenderness was present, but the legs were otherwise unremarkable.  The gait and X-rays were normal.  A bone scan in January 2008 showed moderate stress changes in the shins, but not the knees.  

During the 27 February 2008 MEB examination the CI reported bilateral knee, ankle, and foot pain when standing over 1 hour.  The 65-inch tall CI was noted to weigh 179 pounds and was determined to be obese.  On examination, motion of the knees and ankles was full but painful.  The 27 April 2008 MEB NARSUM examination noted the CI was issued a P2 profile after the bone scan (2005) and that she had not sought further treatment until she went to the field when her unit prepared for deployment.  She reported pain with standing all day and with carrying heavy loads.  She reported pain with motion of the knees and ankle and pain to palpation of her shins bilaterally.  On examination, shin tenderness was noted.  The gait was stable.  Dorsiflexion (toes up) of the ankles was limited by pain to 13 degrees on the right and left.  Extension of the knees was normal (0 degrees), but limited to 136 degrees of flexion (normal 140).  No reason for the limitation in motion was recorded.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral shin pain at 10% each, incorporating the bilateral factor, coded 5299-5262 (analogous to tibial impairment).  It was determined that the CI was unfit due to the risk of progression with continued military duty.  No VA rating was in evidence.  

The panel considered the bone scan which showed stress changes of the shins; the X-rays were normal but tenderness was present.  Motion of the knees and ankles was painful and slightly limited.  The gait was normal.  However, there was no radiographic evidence of knee pathology (the panel did not find that knee X-rays had been done, suggesting that there was not significant impairment from the knees) and neither bone scan was recorded as showing increased uptake in the knees.  The bone scan did show increased uptake in the ankles which also showed limited and painful motion.  X-rays were normal though.  The 10% rating for each tibia (shin) is supported under the code 5262 for slight ankle disability, but this provided no advantage to the CI over the 20% rating adjudicated by the PEB.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded there was insufficient cause to recommend a change in the PEB adjudication for the bilateral shin condition.  

Bilateral Foot and Ankle Pain.  The PEB combined the bilateral foot and ankle pain conditions as a single unfitting condition coded analogously 5276 and rated 0%. This 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.  

According to the STR and the MEB NARSUM, the CI reported a 3-year history of anterior leg and ankle pain when seen in orthopedics on 29 January 2008.  Review of the medical records revealed no clinical evaluations or profiles for the ankle and foot pain prior to that encounter.  She reported bilateral anterior leg (shin) and ankle pain for 3 years which was worse with activity.  She also gave a history of multiple ankle injuries, but further details were not recorded and there is no record of these in the evidence available for review.  On examination, generalized tenderness was present.  Testing for laxity showed a 1+ anterior drawers test which was equal bilaterally (normal).  Dorsiflexion was 5 degrees and plantar flexion was 40 degrees.  Motor function was normal.  Bilateral flat feet were noted.  At the examination on 27 February 2008, she reported ongoing knee, ankle, and foot pain with prolonged standing.  Tenderness of the ankles was present, but the examination was otherwise normal.  Painful motion was reported, but tenderness while walking was not observed.  The MEB NARSUM examination recorded ankle pain after standing all day.  Her gait was stable.  Motion of the ankles was painful and dorsiflexion limited to 13 degrees.  Mild stress changes on a bone scan in January 2008 were noted for the ankles, feet, and toes.  X-rays of the ankles were normal though.  Joint laxity was not present.  The panel observed that the CI was not profiled for the ankles or feet until identified for an MEB for the shin splint condition.  No VA rating was in evidence.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral foot and ankle pain condition at 0%, coded 5299-5276 (flatfoot).  The PEB recorded that the CI had congenital flatfoot and that no other etiology for the ankle and foot pain had been found.  The painful and limited motion of the ankles has already been used to support the 10% ratings for each shin splint (above) and IAW VASRD §4.14 (avoidance of pyramiding) could not be used to support ratings for the bilateral foot and ankle pain.  The CI reported a history of ankle sprains, but these were not otherwise found in evidence and the ankles were stable on examination.  The CI apparently worked for years within the P2 profile issued for the shin splints without problems until the rigors of field training.  This is consistent with the mild impairment cited by the PEB for the flatfoot condition which supports a 0% rating.  No diagnosis for the foot pain was otherwise found.  The panel found no route to sever the conditions into separate unfitting conditions to provide a rating greater than the 0% adjudicated by the PEB.  Accordingly, there was no advantage to the CI and this is rendered moot.  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 foot and ankle condition.  

BOARD FINDINGS:  In the matter of the bilateral mid-shin pain condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the bilateral foot and ankle condition 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 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 20150620, w/atchs
Exhibit B.  Service Treatment Record

AR20170009361, XXXXXXXXXXXXXXXXXX 

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Dear XXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found your separation disability rating and your separation from the Army for disability with severance pay to be accurate.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed), and I accept its recommendation.  I regret to inform you that your application to the DoD PDBR is denied.  

	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.

Sincerely,					       
						      					
Enclosure