RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02014
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20051124

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Cannon Crewmember, medically separated for “chronic bilateral tibial pain” with a disability rating of 0%.

CI CONTENTION:  “Review all conditions.”  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 panel 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 determinations 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 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 - 20050802	VARD - 20060314	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Bilateral Tibial Pain	5099-5003	0%	Left Tibial Stress Fracture	5262	0%	STR	
			Right Tibial Stress Fracture	5262	0%	STR	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Chronic Bilateral Tibial Pain.  The PEB combined the right and left tibia conditions as a single unfitting condition coded analogously to 5003 (arthritis, degenerative) and rated 0%.  The 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 or implied adjudication that each condition was separately unfitting.  The panel also noted that “bundling,” the combining of two or more major joints may be permissible under the VASRD 5003 rating requirements, and that this approach does not compromise the VASRD §4.7 directive to choose the higher of two valid ratings.  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.  The evidence for the right and left tibia conditions are presented together, with attendant recommendations regarding separate unfitness and rating in the rating discussion.  

According to service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI injured his right lower extremity in a bad parachute landing during airborne jump school in November 2003.  The 11 December 2003 right tibia/fibula radiographic (X-rays) studies showed an early tibia stress fracture (repetitive stress induced fracture).  A 13 April 2004 nuclear medicine bone scan showed a healing right mid-tibial shaft stress fracture and a left tibial stress reaction (precursor lesion to stress fracture).  A 16 March 2005 bone scan showed an improved right tibial stress fracture and a mild left tibial stress reaction.  

The 22 April 2005 orthopedic surgery consultation for the MEB recounted the history and interventions.  “He says the right leg pain slowly became bilateral leg pain and bilateral foot pain.”  The CI reported no leg pain at rest but complained of 6-8/10 pain with running.  Symptoms were exacerbated by walking, running (> 100 yards), jumping, and load bearing.  The bilateral lower extremity examination revealed patellofemoral joint crepitation (grating sensation or sound), soft muscle compartments, and no deformity, effusion (fluid collection), or ligamentous laxity.  Bilateral knee and ankle range of motion (ROM) was full.  Muscle strength and tone were excellent.  The diagnosis listed bilateral tibia stress reactions.  

At the 7 June 2005 MEB NARSUM, 6 months before separation, the CI complained of chronic bilateral tibial pain with prolonged standing, prolonged walking, and running.  “He has been on temporary profile since his first injury in November 2003 for nearly all of the past 1 ½ years.”  He failed to improve with conservative management with included activity modification, Ace wraps, heel cups, and medication.  The bilateral knees revealed no swelling or ligamentous laxity.  Pain-free bilateral knee ROM was full with “mild crunching” on extension and flexion.  The bilateral tibiae revealed no erythema (redness), ecchymosis (bruising), edema (excess tissue fluid swelling), or tenderness.  The bilateral ankles and feet revealed no edema, tenderness, or pain with all movements.  The diagnosis listed bilateral tibial stress reactions.  There was no VA Compensation and Pension examination in evidence proximate to separation.

The panel directed attention to its rating recommendation based on the above evidence.  As previously elaborated, the panel must first consider whether each tibia condition remains separately unfitting, having been de-coupled from a combined PEB adjudication.  The PEB assigned a 0% rating for the bilateral tibiae under an analogous 5003 code (arthritis, degenerative) citing chronic bilateral tibial pain, bilateral tibial stress reactions by X-rays and bone scans, not using any medications, no pain in the feet, ankles, lower legs, or knees by physical examination, and rated for pain in accordance with Physical Disability Agency pain policy.  

The VA assigned a 0% rating for the right, and a 0% rating for the left, tibia under the 5262 code (tibia and fibula, impairment of) based on the Service medical records and documenting that the CI failed to show for his scheduled C&P examination.  The VA cited right and left stress fractures, stress fractures by bone scans, and assigned non-compensable evaluations in the absence of malunion of the tibiae and fibulae with slight knee or ankle disability.  

There was no knee ankylosis (5256), knee recurrent subluxation/lateral instability (5257), dislocated meniscus (5258), symptomatic removed meniscus (5259), tibia and fibula nonunion/malunion (5262), genu recurvatum (5263),  ankle ankylosis (5270), subastragalar or tarsal joint ankylosis (5272), os calcis or astragalus malunion (5273) or excision of the astragalus (5274) for consideration under the respective codes.  There was no compensable limitation of knee flexion (5260), knee extension (5261), or ankle motion (5271) for consideration under the respective codes.  

The panel agreed a 10% rating was not supported based on VASRD §4.40 (functional loss) or §4.59 (painful motion).  The panel concluded that the evidence did not provide sufficient grounds for recommending separate disability ratings in this case, and that the combined rating of 0%, coded 5099-5003, was a good analogy to both the pathology and disability.  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 tibia condition.  

BOARD FINDINGS:  In the matter of the chronic bilateral tibial pain condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  There were no other conditions within the panel’s scope of review for consideration.  The panel, therefore, recommends that 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 20150718, w/attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170009985, XXXXXXXXXXXXXXXXXX 

XXXXXXXXXXXXXXXXXX

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,