RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01812
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20040914

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Health Care Specialist Trainee, medically separated for “chronic pain, due to stress fractures of left inferior pubic ramus and bilateral tibias,” with a disability rating of 0%.

CI CONTENTION:  The CI has contended “neuropathy due to pinched nerves.  Numbness and tingling in arms, hands, and fingers.”  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 – 20040817	VARD – N/A	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Pain, Due to Stress Fractures of Left Inferior Pubic Ramus and Bilateral Tibias	5022	0%	No VA Examination in Evidence	
Bilateral Upper Extremity Paresthesias	Not Unfitting		
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  N/A	

ANALYSIS SUMMARY:  

Chronic Pain Due to Stress Fractures of Left Inferior Pubic Ramus and Bilateral Tibias.  According to service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s chronic pain due to stress fractures condition began in during basic training in March 2004.  A whole body bone scan dated 16 April 2004, ordered for left groin pain and bilateral shin pain for 1 month, demonstrated a stress fracture in the left inferior pubic ramus, a Grade II stress fracture in the left mid tibia, and Grade I stress fractures at the mid tibia bilaterally.  There were also bilateral quad splints (uptake in both femur cortices) and diffuse uptake in the knees, ankles, and feet consistent with stress changes.  Despite treatment, the chronic pain due to stress fractures condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military training and specialty and the CI was referred for MEB.  The MEB forwarded “stress fracture of the left inferior pubic rami, pain is minimal and intermittent” and stress fracture of bilateral tibia, pain is minimal and intermittent” for PEB adjudication.

The commander’s statement dated 11 June 2004 indicated the CI was unable to perform the duties of her MOS due to stress fractures, which caused pain in her lower extremities when she ran, marched, and jumped.  During the 28 and 30 July 2004 MEB examination (recorded on DD Forms 2807-1 and 2808), 6 weeks prior to separation, the CI reported four stress fractures in the lower extremities since April 2004.  The 30 July 2004 MEB NARSUM examination, 6 weeks prior to separation, noted complaints of intermittent pain without medication requirement.  Pain recurred when she attempted to run.  Physical examination revealed a full range of motion (ROM) in both hips, knees, and ankles.  Both tibia were non-tender as was the left pubic ramus.  The examiner noted the CI had multiple stress fractures which required prolonged profiling that prevented her from completing the required Army physical fitness testing for graduation.  Her symptoms resolved to a large extent, but she remained unable to increase her activity to a level required for graduation.  A permanent L3 profile was issued for the left pubic stress fracture and the bilateral tibia stress fractures on 4 August 2004 with restrictions of running and moving with a fighting load.  There was no VA examination in evidence proximate to separation.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic pain due to stress fractures of left inferior pubic ramus and bilateral tibias condition 0%, coded 5022 (periostitis), citing diagnosed by bone scan, without X-ray confirmation and without limitation of motion.  The PEB combined the stress fractures of the left inferior pubic ramus and bilateral tibia conditions as a single unfitting condition coded 5022 for minimal and intermittent disability and rated 0%.  The approach by the PEB commonly reflected its judgment that the constellation of conditions was unfitting, and there was no need for separate fitness adjudications or implied adjudication that each condition was separately unfitting.  The panel’s initial charge in this case was 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 stress fractures of the left inferior pubic ramus and bilateral tibia conditions was presented together above.  In this case, each of the stress fractures was profiled, and the stress fractures were implicated by the NARSUM and the commander’s statement.  Members agreed that each stress fracture condition is separately unfitting.  While the tibia are not joints nor is the left inferior ramus, nevertheless, analogous code 5099-5003 (arthritis, degenerative) is applicable since in the absence of limitation of motion, a 10 rating is warranted “with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups,” albeit the CI had bone scan findings rather than X-ray evidence, but had painful motion while running.  However, by the time of separation there were no reported incapacitating exacerbations to justify a 20% rating.  Members also considered use of analogous code 5262 (tibia and fibula, impairment) for each of the tibia stress fractures; however, there was no evidence of any nonunion with loose motion requiring a brace or malunion with any knee or ankle disability to warrant a rating of 10% or higher for either tibia.  Furthermore, there was no applicable code to rate the left inferior pubic ramus in the absence of any hip or thigh limitation of motion (codes 5251 and 5252), impairment (code 5253) or femur impairment (code 5255).  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 pain due to stress fractures of left inferior pubic ramus and bilateral tibias condition, coded 5099-5003.  

Contended PEB Condition: Bilateral Upper Extremity Paresthesias, Intermittent.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended condition was not unfitting.  The contended condition was not profiled, implicated in the commander’s statement or judged to fail retention standards.  The CI reported on DD Form 2807-1 that she had “numbness in hands mostly at night, also during day, occurs at least once a day and lasts longer than 1 minute.”  The examiner noted “upper extremity paresthesias in a stocking/glove distribution” with “no limitations,” and she could “still use them.”  There was no performance-based evidence from the record that the condition significantly interfered with satisfactory duty performance at separation. The CI wrote on her DD Form 294 submission that she “had minor hand numbness,” while she served.  She submitted extensive remote chiropractic notes from 2014 and 2015, more than 10 years post-separation, which have no probative value.  After due deliberation, the panel concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the contended condition; and so, no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the chronic pain due to stress fractures of left inferior pubic ramus and bilateral tibias condition, the panel unanimously recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a.  In the matter of the contended bilateral upper extremity paresthesias, intermittent condition, the panel unanimously recommends no change from the PEB determination as not unfitting.  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 Pain Due To Stress Fractures Of Left Inferior Pubic Ramus And Bilateral Tibias Condition	5099-5003	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150706, w/atchs
Exhibit B.  Service Treatment Record

AR20170009330, 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