RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01722
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20040111

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E2, Automated Logistics Specialist, medically separated for “pain in the right lower extremity with a bone scan noting multiple areas of stress fractures,” with a disability rating of 0%.  

CI CONTENTION:  “Review all conditions.”  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 - 20031125	VARD -  NA	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Lower Extremity Stress Fractures	5099-5003	0%	No VA Examination in Evidence	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  NA	

ANALYSIS SUMMARY:  

Right Lower Extremity Stress Fractures.  As noted above, the PEB combined the multiple right lower extremity stress fracture conditions under a single Service disability rating, coded 5003.  Although VASRD §4.71a permits combined ratings of two or more joints under 5003, it allows separate ratings for separately compensable joints.  The panel’s initial charge in this case was therefore directed at determining if the PEB’s combined adjudication 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.  To that end, the evidence for the multiple right lower extremity stress fracture conditions are presented; with attendant recommendations regarding separate unfitness, and separate rating if indicated.  

According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s right lower extremity condition began during basic training in June 2003 without a reported injury or trauma.  Radiographic imaging (bone scan) in July 2003 documented stress fractures of the pelvis and right lower extremity.  

At the 13 August 2003 MEB examination (recorded on DD Forms 2807 and 2808), 5 months prior to separation, the CI reported feeling weak from the stress fractures.  Physical examination showed full range of motion (ROM) of the hip, knee, leg, and ankle with decreased (2/5) strength.  The 8 September 2003 MEB NARSUM examination, 4 months prior to separation, noted complaints of pain throughout the right lower extremity, and increased at the hip, with pain during prolonged walking, standing, jogging, running, bending, lifting, or twisting.  Physical examination showed a “moderately improved” gait without use of a cane.  There was tenderness at the anterior hip, full ROM of the hips, knees, and ankles, with pain on hip adduction and pain of the right foot with hopping.  A 5 November 2003 profile listed “multiple stress fractures, right pubic ramus (hip), right tibia (leg), right ankle/foot (navicular)” and prohibited marching, running, and running, including the physical fitness test.  At a 7 November 2003 physical therapy (PT) evaluation, ROM measurements documented hip flexion of 110 degrees (125 normal); hip extension of 15 degrees (20 normal); external rotation of 26 degrees (45 normal); adduction of 15 degrees (45 normal); abduction of 35 degrees (normal 45); all with pain.  Right knee ROM showed flexion of 140 degrees (normal) and extension of 0 degrees (normal).  Right ankle ROM showed dorsiflexion to 12 degrees (normal 20 degrees) and plantar flexion of 45 degrees (normal).  There was no documentation of pain with knee and ankle ROM.  There was no VA Compensation and Pension examination in evidence proximate to separation.

The panel directed attention to the rating recommendation based on the above evidence.  The PEB rated 0% for the right lower extremity stress fractures, analogously coded 5099-5003 (arthritis, degenerative), citing application of the US Army Physical Disability Agency (USAPDA) pain policy.  The panel first considered the fitness implications for the right hip.  In this case, the right hip condition was profiled, considered to fail retention standards, and implicated by the NARSUM and in the commander’s statement.  Panel members agreed therefore that the hip joint is separately unfitting and that a separate disability rating is applicable.  

Right Pubic Ramus (Pelvic and Hip) Stress Fractures.  Application of VASRD §4.59 (painful motion), §4.40 (functional loss), §4.45 (the joints) was supported by documentation (painful and limited hip motion, with radiographic evidence of stress fracture) to support a 10% rating coded as 5299-5252 (thigh, limitation of flexion).  There was no evidence of nonunion of the femur, with or without loose motion; no documentation of weight bearing preserved with aid of brace; and no evidence of a false joint in support of a higher than 10% rating.  There was no evidence of malunion of the femur that resulted in a moderate or marked degree of hip or knee disability in support of a higher rating.  There was no evidence of ankylosis (5250), abduction limited to 10 degrees (5253), or flexion limited to 30 degrees (5252) for a higher rating under those codes.  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 pubic ramus stress fracture condition, analogously coded 5299-5252.  

Right Tibial and Ankle Stress Fractures.  The panel next considered the fitness implications for the lower extremity stress fractures.  In this case, the lower extremity stress fractures were profiled, considered to fail retention standards, and implicated by the NARSUM.  However, the panel could not find evidence in the commander’s statement or elsewhere in the STR that indicated that the tibial or ankle stress fractures interfered with the performance of duties, nor were any physical findings documented by the MEB or VA examiners which would logically be associated with significant disability.  Therefore, the panel concluded that the preponderance of evidence showed that the tibial and the ankle stress fractures would not reasonably have caused the CI to be referred into the DES or be found unfit due to either condition.  After due deliberation, and considering all of the evidence, the panel concluded that there was insufficient cause to recommend a change in the PEB adjudication for the bundled tibial and ankle stress fracture conditions.  

BOARD FINDINGS:  In the matter of the right pubic ramus stress fracture condition, the panel unanimously recommends a disability rating of 10%, coded 5299-5252 IAW VASRD §4.71a.  In the matter of the right tibial and ankle stress fracture conditions, the panel unanimously agrees that it cannot recommend additional disability ratings.  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	
Right Pubic Ramus (Pelvis and Hip) Stress Fractures	5299-5252	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150630, w/atchs
Exhibit B.  Service Treatment Record

AR20170008860, 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