RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01875
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20030121

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E2, Trainee, medically separated for “left foot pain” and “bilateral knee pain,” rated at 0% each, with a combined 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 - 20021224	VARD - 20030426	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Foot Pain…	5099-5003	0%	Status Post Left Calcaneal Stress Fracture	5284	0%	20030319	
Bilateral Knee Pain	5022	0%	Status Post Right Knee Synovitis	5020	NSC		
			Left Knee Synovitis				
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Left Foot Pain.  According to service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s left foot condition began in July 2002 after performing the Army Physical Fitness Test (APFT) at which time she felt a pop in her ankle and noted some swelling.  X-rays dated 30 July 2002 of the left calcaneus (heel bone) were normal.  Physical therapy was instituted along with a heel cup and Indocin (indomethacin, a nonsteroidal anti-inflammatory drug (NSAID) prescribed by a podiatrist.  Despite physical therapy for 4 months the CI still had 5-6/10 pain (10 being the worst pain) in the posterior aspect of the foot around the heel region.  Radiographs dated 27 August 2002 of her calcanei (heel bones) showed a left calcaneus fracture through the posterior tuberosity of the calcaneus.  A bone scan dated 17 October 2002 showed a healing stress fracture of the left calcaneus with some stress reaction bilaterally in the remainder of the foot.  Heel wedges were provided and were changed to thinner wedges when the CI overcompensated, but pain persisted.  

During the 24 October 2002 MEB examination (recorded on DD Forms 2807-1 and 2808), 3 months prior to separation, the CI reported a calcaneus stress fracture since mid-July 2002.  Physical examination showed a normal arch and the examiner noted in the summary of defects and diagnoses “medical board for left calcaneal heel stress fracture still with pain.”  

On examination on 21 November 2002 the CI had slight bilateral supination in shoes/inserts, but supination was within normal limits in bare feet.  The active range of motion (ROM) and flexibility of both lower extremities was within normal limits with mild tenderness to palpation at the retrocalcaneal (Achilles tendon insertion) area and pain in the area on plantar flexion and full dorsiflexion.  There was a positive calcaneal squeeze on the left.  Transverse friction massage to the retrocalcaneal area along with gastrocnemius/soleus muscle stretches were recommended.  The examiner assessed the CI as having a persistent left calcaneal stress fracture and probable mild Achilles tendinitis/retrocalcaneal bursitis.  Orthopedic evaluation on 5 December 2002 noted the left calcaneal stress fracture was healing.  

The 5 December 2002 MEB NARSUM examination, 1 month prior to separation, noted complaints of persistent pain in the posterior aspect of the foot around the heel region.  Physical examination showed a reciprocal gait pattern without antalgia.  The CI had a mildly valgus hindfoot and a slightly low but an arch within normal limits, which was well maintained with toe-rising.  She was able to perform heel walk, toe walk, and tandem gait without any difficulty.  Ankle range of motion was 15 degrees (normal 20) dorsiflexion and 45 degrees (normal 45) of plantar flexion.  Stability testing of the ankle to subtalar stress testing was symmetrically intact about 10 degrees and anterior drawer testing showed no significant anterior translation in either ankle.  The CI had discomfort with compression of the left calcaneus and had intact pulses and sensation as well as normal motor function bilaterally in her lower extremities.  

At the 19 March 2003 VA Compensation and Pension (C&P) evaluation, 2 months after separation, the CI reported being diagnosed with a left calcaneal stress fracture, which began as ankle pain on 24 July 2002.  She had pain at rest and with standing and walking.  Physical examination showed a normal gait and no sign of abnormal weight bearing and she did not require a device to assist in ambulation.  There was tenderness upon palpation of the heel of the left foot.  There was no pes planus or evidence of deformities, but there was slight to moderate tenderness on the plantar surface of the left heel.  There was good alignment of the Achilles tendon on the left.  There was no claw foot, no signs of a dropped foot, or marked valgus deformity.  Dorsiflexion of the toes produced no pain and dorsiflexion of the ankle joint revealed no limitation.  Palpation of the metatarsal heads produced no tenderness.  The CI did have limited function for standing and walking and reported pain in the left heel.  The pain was worse with exertion and did create a limp with standing long periods of time or walking aggressively.  The CI did not have any corrective shoe wear.  The examiner’s diagnosis was status post stress fracture of the left heel, based on negative X-rays of the left foot on 18 March 2003, with residual tenderness and pain.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left foot pain condition 0%, coded 5099-5003 (arthritis, degenerative), citing no loss of ROM and no instability.  The VA rated the foot pain condition 0%, coded 5284 (other foot injuries), based on the C&P examination 2 months after separation, citing lack of evidence to support moderate symptoms associated with a foot injury.  Panel members noted that the CI had pain in retrocalcaneal area on plantar flexion and on full dorsiflexion of the left foot during a physical therapy examination on 21 November 2002, but at subsequent examinations she had a non-antalgic gait.  While a 10% rating using code 5099-5003 is not unreasonable based on the 21 November 2002 examination, there was no further painful motion demonstrated objectively thereafter; however, at the VA examination it was reported that “pain was worse with exertion and did create a limp with standing long periods of time or walking aggressively.”  However, the panel determined that the objective threshold for a 10% rating for painful motion was not achieved.  Since the CI had a calcaneal fracture, panel members considered use of code 5284; however, the fracture noted to have been healing prior to separation and X-rays of the left foot 2 months after separation were normal.  Therefore, the condition proximate to separation did not rise to a moderate level foot injury warranting a rating of 10%.  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 condition.  

Bilateral Knee Pain.  According to the STR and the MEB NARSUM, the CI’s bilateral knee pain condition began on or about 1 September 2002 without injury.  However, at that time the CI was undergoing physical therapy for a stress fracture of the left calcaneus.  The CI complained of 5-6/10 pain with “giving way” and “locking,” but no swelling.  On examination on 10 September 2002, the CI had active ROM of both knees, a negative patellar glide test (to determine instability) bilaterally, mild laxity on Lachman’s testing, and varus/valgus stress bilaterally with a firm end feel.  The diagnosis of PFPS (patellofemoral pain syndrome) was made.  Subsequent physical therapy examinations revealed positive patellar glide testing more so on the right than the left and a positive distal femoral squeeze on the right knee and negative on the left knee.  X-rays of the knees on 3 October 2002 were positive for a probable stress fracture of the right medial tibial table.  A bone scan on 12 October 2002 showed minimal uptake in the knees bilaterally.  On 22 October 2002 there was tenderness about the right medial tibial plateau.  At an orthopedic evaluation on 5 October 2002 the CI was noted to have bilateral knee pain with squatting.  A bone scan dated 17 October 2002 showed minimal stress reaction about both of her knees.  

During the 24 October 2002 MEB examination (recorded on DD Forms 2807-1 and 2808), 3 months prior to separation, the CI reported a MTF (medial tibial plateau) stress fracture in both knees with locking and stiffness bilaterally.  The examiner checked normal lower extremities (except feet) for the clinical evaluation.  The 5 December 2002 MEB NARSUM examination, 1 month prior to separation, noted complaints of a sensation of the CI’s knees giving-way, but no true locking, popping, or swelling.  Physical examination showed the CI was able to heel walk, toe walk, and tandem gait without any difficulty.  There was some mild tenderness to palpation over the medial femoral condyle, a little bit more in the right knee than the left knee.  She had no effusion in either knee, but did have a questionable palpable plica (a fold of synovial membrane) in the right knee.  However, she had no joint line tenderness.  The knees were intact to valgus and varus stress testing.  ROM was from about 3 degrees of hyperextension to 145 degrees of flexion.  She had a 1A Lachman test (no significant laxity) bilaterally and was intact to anterior and posterior drawer testing (to determine instability) bilaterally.  McMurray’s test (to determine a meniscal tear) bilaterally was negative and there was no palpable patellofemoral crepitus (grinding).  

X-rays of the right and left knees were negative on 18 March 2003.  At the C&P evaluation the CI reported “pain that does not go away” below her kneecaps.  Physical examination showed the general appearance of the knees was within normal limits bilaterally.  ROM for flexion was 0-140 degrees bilaterally and extension was 0 degrees bilaterally. There was no pain, fatigue, weakness, lack of endurance or incoordination or any ankylosis of the knees.  Drawer and McMurray’s tests were within normal limits bilaterally.  The VA determined the bilateral knee pain condition was not service-connected.

The ROM examinations in evidence which the panel weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral knee pain 0%, coded 5022 (periostitis), citing rated as periostitis without loss of joint motion.  The VA determined the bilateral knee pain condition was not service-connected, coded 5022 (periostitis), based on the C&P examination citing a normal examination with no evidence of painful or limitation of motion.  

The PEB combined the bilateral knee pain conditions as a single unfitting condition coded 5022 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 bilateral knee pain conditions was presented together above.  In this case, knee pain was not listed in profile, but the bilateral knee pain was implicated in the NARSUM as probable synovitis.  No commander’s statement was available since the CI was a trainee.  Members agreed that each knee condition is separately unfitting and that identical coding is applicable, but ratings may vary according to the degree of disability.  The CI had findings on a bone scan of stress reactions about each knee, although an antecedent X-ray raised the possibility of a stress fracture of the right medial tibial plateau.  

There was no evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45).  There likewise was no limitation of motion which attained a minimum rating under the diagnostic codes for limitation of flexion or extension (5260, 5261).  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.  

While there were bilateral stress reactions about the knees to support consideration under the respective codes for knee impairment related to long bone conditions (5255, 5262), by the time of the VA examination X-rays of both knees were negative and the CI had full ROM bilaterally without any pain suggestive that the residual knee tenderness or pain was less than slight thereby precluding a 10% rating for either knee, albeit the right knee was the more tender of the two knees.  The panel majority noted that no functional limitations were evidenced by the examinations proximate to separation.  Therefore, the panel majority concluded there was not sufficient evidence to support a rating higher than the 0% adjudicated by the PEB.  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 knee pain condition.  

In the matter of the left foot condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the bilateral knee pain condition and IAW VASRD §4.71a, the panel majority recommends no change in the PEB adjudication.  The single voter for dissent submitted the appended minority opinion.  There were no other conditions within the panel’s scope of review for consideration.  The panel, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150701, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

Minority Opinion.  The minority voter notes that at the time of prior to separation there was no radiographic evidence of healing of the stress fractures of either knee.  Furthermore, there was some mild tenderness to palpation over the medial femoral condyle, a little bit more in the right knee than the left knee at the NARSUM examination, which is not inconsistent with the bone scan findings.  Admittedly, X-rays of the knees bilaterally were reported as negative on 18 March 2003, 2 months after separation; however, the subtlety of stress changes or stress fractures are better visualized on a bone scan rather than X-ray and even with the X-rays there should have been residual changes noted  (https://www.ncbi.nlm.nih.gov/books/NBK174863/#APP2.4ET1).  Therefore, use of code 5099-5003 for a 10% rating is not unreasonable since the CI did have bone scan of findings suggestive of a stress reaction bilaterally, which is congruent with the code 5003 requirement of “X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups;” however, there were no incapacitating episodes to warrant a higher rating.  

Therefore, the minority voter recommends the adjudication be modified as follows:

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 bilateral knee pain condition, coded 5099-5003.  

In the matter of the bilateral knee pain condition, the panel recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a.  

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	
Left Foot Pain	5099-5003	0%	
Bilateral Knee Pain	5099-5003	10%	
COMBINED	10%	

AR20170009231, 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,