RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01670
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20050622

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E1, Trainee, medically separated from for “right tibial stress fracture” and “chronic left hip pain,” each rated at 0%, with a combined rating of 0%.

CI CONTENTION:  The CI’s conditions continue to worsen.  The 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 - 20050504	VARD - 20050908	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Tibial Stress Fracture	5022	0%	Residuals, Right Tibial Stress Fracture	5299-5262	NSC	20050809	
Chronic Left Hip Pain	5099-5003	0%	Left Hip Bursitis	5252	NSC	20050809	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:

Right Tibial Stress Fracture.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s right tibia condition began in May 2004 during basic training without apparent trauma.  A bone scan on 13 May 2004 was positive for stress fractures in both heels, both ankles, and the right tibia.  After 14 weeks of rest and physical therapy she was able to complete basic training but her right lower leg pain recurred.  A follow-up bone scan on 10 November 2004 again showed a right tibial stress fracture with the other abnormal areas noted on the previous scan resolved.  There was no surgical indication.  After further rest and physical therapy, treatment did not result in improvement sufficient to allow unrestricted duty.  At the physical therapy appointment for the MEB NARSUM 14 March 2005, 3 months prior to separation, the CI complained of 6-7/10 pain in her left hip with no complaint of pain in her right leg.  

The 1 April 2005 MEB NARSUM examination, 3 months prior to separation, noted complaints of constant pain in her right lower leg that sometimes caused difficulty sleeping.  Pain was made worse by being cold and with activity, the pain typically worsened throughout the day.  The CI reported that she did not often take pain medications, the only pain medication she took was ibuprofen and the last time she took ibuprofen was two weeks prior to the examination.  Physical examination showed tenderness along the tibia on the right lower leg.  Range of motion (ROM) measurements for the right knee were 0 degrees extension (normal) and 120 degrees flexion (140 normal).  The right ankle ROM was 20 degrees dorsiflexion (normal) and 45 degrees plantar flexion (normal).  

At a 3 May 2005 primary care clinic appointment, 2 months prior to separation, the CI requested a refill of pain medication that she occasionally took for hip pain.  There was no mention of shin pain at that visit.  At 5 separate chiropractic clinic visits in May and June of 2005, in the last month prior to separation, the CI consistently complained of low back and left hip pain with no complaint of right tibial pain.  

At the 09 August 2005 VA Compensation and Pension (C&P) evaluation, performed 2 months after separation, the CI reported occasional tenderness about the anterior aspect of the right lower leg with prolonged standing and walking and occasional slight swelling about the lower leg.  Physical examination showed a normal gait.  The CI indicated the area where the tenderness occurs with prolonged standing but no obvious deformity or complaint were noted on the examination.  Plain film X-Rays of the distal tibia done in conjunction with the C&P examination were normal with no evidence of fracture.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right tibial stress fracture condition 0%, coded 5022 (periostitis), citing full range of motion.  The VA did not service connect the right tibia stress fracture condition based on the STR and the C&P examination 2 months after separation, citing no permanent residual or chronic disability.  

There was no evidence of nonunion or malunion with knee or ankle disability to rate using VASRD code 5262 (tibia and fibula, impairment of).  There was no ratable decrease in ROM of the right ankle to rate using VASRD codes 5270 (ankle, ankylosis of) or 5271 (ankle, limited motion of) or the right knee using codes 5256 (knee, ankylosis of), 5260 (leg, limitation of flexion of) or 5261 (leg, limitation of extension of).  There was no evidence of painful movement of either joint surrounding the right tibia to justify rating via VASRD §4.59, painful motion.  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 right tibia stress fracture condition.

Left Hip Pain.  According to the STR and the MEB NARSUM, the CI’s left hip pain condition began in the October 2004 after passing an APFT.  The CI was treated with rest, physical therapy, chiropractic care as well as anti-inflammatory medications.  There was no surgical indication.  Conservative treatment did not result in improvement sufficient to allow unrestricted duty.  

Plain film X-Rays of the left hip performed 22 October 2004 showed no evidence of fracture or other abnormality.  A bone scan completed 10 November 2004 showed no areas of abnormal uptake in either hip.  The 1 April 2005 MEB NARSUM examination, 3 months prior to separation, noted complaints of left hip pain of 6-7/10 intensity.  Physical examination showed an antalgic gait on the left side with the left hip ROM of 100 degrees flexion (125 normal), 10 degrees extension (20 normal), 20 degrees external rotation (45 normal), 20 degrees adduction (45 normal), 25 degrees abduction (45 normal).  Flexion, extension, and internal rotation caused pain with movement.  At the 09 August 2005 C&P evaluation, performed 2 months after separation, the CI reported occasional soreness about the lateral aspect of the left hip.  Physical examination showed a normal gait.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic left hip pain condition 0%, analogously coded 5033-5003 (arthritis, degenerative), citing full range of motion.  The VA did not service connect the left hip pain condition citing no permanent residual or chronic disability based on the STR and the C&P examination 2 months after separation.  The findings supplied from the X-rays completed 22 October 2004 did not show evidence of arthritis to support a rating using code 5003 (arthritis, degenerative).  The panel agreed that there was insufficient limitation of range of motion to provide a minimum rating using VASRD codes 5251 (thigh, limitation of extension of), 5252 (thigh, limitation of flexion of) or 5253 (thigh, impairment of).  In addition, there was no indication of a flail joint of the hip to support an 80% rating using code 5254, ankylosing of the hip to support a 60% rating using code 5250 or malunion of a femur fracture to support a 10% or higher rating using code 5255.  The panel did find that there was sufficient evidence of painful motion (VASRD §4.59) to support a minimum 10% rating using code 5252.  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 left hip pain condition, coded 5252.  

BOARD FINDINGS:  In the matter of the right tibia stress fracture condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the left hip pain condition, the panel unanimously recommends a disability rating of 10%, coded 5252 IAW VASRD §4.71a.  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 Tibial Stress Fracture	5022	0%	
Chronic Left Hip Pain	5252	10%	
COMBINED	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150625, with attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170008711, XXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:  

	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