RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02039
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20041015

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Special Forces Candidate, medically separated for “chronic pain from multiple stress fractures of both lower extremities” with a rating of 10%.  

CI CONTENTION:  The CI contends that after 11 years his condition persists.  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 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 - 20040816	VARD - 20041101	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Pain from Multiple Stress Fractures of Both Lower Extremities	5099-5003	10%	Stress Fracture, Right Femur	5299-5255	0%	20040727	
			Right Knee Strain	5299-5257	0%	20040727	
			Left Knee Strain	5299-5257	0%	20040727	
			Right Ankle Strain	5299-5271	0%	20040727	
			Left Ankle Strain	5299-5273	0%	20040727	
			Right Foot Strain Status Post Stress Fracture of First Metatarsal	5299-5283	0%	20040727	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Chronic Pain from Multiple Stress Fractures of Both Lower Extremities.  The PEB combined the right femur, the right 1st metatarsal, bilateral knee and bilateral ankle stress fractures with residual pain conditions as a single unfitting condition coded 5099-5003 (analogously to degenerative arthritis) and rated 10%.  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.  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.  Due to all of these conditions presenting at the same time with no distinct injury and the generalized nature of the Medical Evaluation Board (MEB) narrative summary (NARSUM) the evidence will be presented in first, a global approach and then the evidence for the right femur, right 1st metatarsal, right knee, left knee, right ankle and left ankle conditions are presented separately, with attendant recommendations regarding separate unfitness, and separate rating if indicated.  

According to the service treatment record (STR) and the MEB NARSUM, the CI’s bilateral lower extremity stress fractures began in November 2003 during basic training after no specific injury or trauma.  There was no surgical indication and after several months of light duty, 2 months of convalescent leave, physical therapy, and medications the CI’s lower extremity chronic pain condition could not be rehabilitated to allow for unrestricted duty and completion of basic training.  A 21 January 2004 nuclear medicine bone scan, 9 months prior to separation, showed a grade I stress fracture in the mid-shaft of the right femur, severe stress changes in the base of the right 1st metatarsal, severe stress changes about both knee joints and both ankle joints (right greater than left).  

The 24 May 2004 MEB NARSUM, 5 months prior to separation, noted complaints of pain in both lower extremities with any running, prolonged walking, going up and down stairs, squatting or heavy lifting.  Physical examination showed tenderness on deep palpation over the fight femur in the mid portion.  Tenderness along both joint lines of the knees, tenderness on compression of the patellae bilaterally.  He was very tender on palpation of the ankle joints with the right being worse than the left.  There was also tenderness on palpation along the sole of the right foot and distal half of the first metatarsal.  There were no range of motion measurements listed.  

Right Femur.  At the 27 July 2004 VA Compensation and Pension (C&P) evaluation, performed 3 months before separation, the CI reported right thigh pain that was worse with training.  The pain occurred constantly.  Physical examination showed a normal stance and gait, right hip range of motion (ROM) flexion to 125 degrees (normal), extension 30 degrees (normal 20), adduction 25 degrees (normal 45), abduction 45 degrees (normal), external rotation 60 degrees (normal 45) and the ROM was not additionally limited by pain, fatigue, weakness, lack of endurance, or incoordination.  A right femur X-Ray performed in conjunction with the C&P evaluation was read as normal.  

The panel directed attention to its rating recommendation based on the above evidence.  The panel first considered if the right femur stress fracture, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The majority of the visits to various clinics for pain were found to be for each of the various conditions with the right thigh/leg mentioned equally with the others.  In addition, all conditions were implicated in the permanent profile as well as the commander’s impact statement.  Panel members agreed that the preponderance of the evidence indicates the right femur stress fracture was separately unfitting for continued service.  The PEB rated the bundled bilateral lower extremity pain condition 10%, coded 5099-5003 (analogous to degenerative arthritis), citing slight/frequent pain.  The VA rated the right femur stress fracture condition 0% coded 5299-5255 (analogous to femur, impairment of)), based on the C&P examination 3 months before separation, citing no functional impairment at the hip or knee that could be attributed to a current fracture.  

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.  There was no evidence of painful motion (VASRD §4.59) to support a minimum rating using any of the above codes.  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 femur stress fracture condition as bundled with the overall bilateral lower extremity stress fracture condition.  

Right 1st Metatarsal.  At the 27 July 2004 C&P evaluation, performed 3 months before separation, the CI reported that at rest he had no pain, weakness, stiffness, swelling or fatigue.  While standing or walking he did not have any pain, weakness, stiffness, swelling, or fatigue.  Physical examination showed a tenderness of the right foot (no specifics of where were recorded) and no limitation of standing and walking.  A right foot X-Ray performed in conjunction with the C&P evaluation was read as normal.  

The panel directed attention to its rating recommendation based on the above evidence.  The panel then considered if the right 1st metatarsal stress fracture, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The majority of the visits to various clinics for pain were found to be for each of the various conditions with the right foot mentioned equally with the others.  In addition, all conditions were implicated in the permanent profile as well as the commander’s impact statement.  Panel members agreed that the preponderance of the evidence indicates the right 1st metatarsal stress fracture was unfitting for continued service.  The PEB rated the bundled bilateral lower extremity pain condition 10%, coded 5099-5003 (analogous to degenerative arthritis), citing slight/frequent pain.  The VA rated the right 1st metatarsal stress fracture condition 0% coded 5299-5283 (analogous to tarsal, or metatarsal bones, malunion of, or nonunion of), based on the C&P examination 3 months before separation, citing no current X-Ray evidence of nonunion or malunion of the prior fracture and there was only mild ongoing symptoms of disability.  

There was no evidence of foot atrophy, disturbed circulation or weakness to justify rating using code 5277 (weak foot, bilateral).  There was no evidence of fracture with malunion or nonunion of the first metatarsal to rate under code 5283.  There was insufficient evidence of a moderate or more severe foot injury to rate using code 5284 to provide a rating higher than the 10% adjudicated by the PEB.  The panel agree that there was evidence of metatarsalgia (pain on or around the metatarsal bones) to validate a 10% rating using code 5279 (metatarsalgia, anterior (Morton’s disease), unilateral or bilateral) but that it provided no rating advantage to the CI.  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 1st metatarsal stress fracture condition as bundled with the overall bilateral lower extremity stress fracture condition.  

Right Knee.  At the 27 July 2004 VA Compensation and Pension (C&P) evaluation, performed 3 months before separation, the CI reported constant and recurrent knee pain that prevented the CI from performing activities like running and road marching.  Physical examination showed flexion to 140 degrees (normal), extension 0 degrees (normal), ROM was not additionally limited by pain, fatigue, weakness, lack of endurance or incoordination.  A right knee X-Ray performed in conjunction with the C&P evaluation was read as normal.  

The panel directed attention to its rating recommendation based on the above evidence.  The panel first considered if the right knee stress fracture, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The majority of the visits to various clinics for pain were found to be for each of the various conditions with the right knee mentioned equally with the others.  In addition, all conditions were implicated in the permanent profile as well as the commander’s impact statement.  Panel members agreed that the preponderance of the evidence indicates the right knee stress fracture was unfitting for continued service.  The PEB rated the bundled bilateral lower extremity pain condition 10%, coded 5099-5003 (analogous to degenerative arthritis), citing slight/frequent pain.  The VA rated the right knee strain condition 0% coded 5299-5257 (knee, other impairment of), based on the C&P examination 3 months before separation, citing current anterior knee tenderness without evidence of instability, fracture, joint disease or significant limitation of function.  

There was no limitation of motion which attained a minimum rating under the diagnostic codes for limitation of flexion or extension (5260, 5261).  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.  There was no fracture, nonunion, or malunion of the femur or tibia to support consideration under the respective codes for knee impairment related to long bone conditions (5255, 5262).  No additional functional limitation was evidenced by the examinations.  There was no evidence of painful motion with functional loss supporting a minimum 10% rating (based on §4.59, §4.40 and §4.45).  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 knee stress fracture condition as bundled with the overall bilateral lower extremity stress fracture condition.  

Left Knee.  At the 27 July 2004 C&P evaluation, 3 months before separation, the CI reported constant and recurrent knee pain that prevented the CI from running and road marching.  Physical examination showed flexion to 140 degrees (normal), extension 0 degrees (normal), ROM was not additionally limited by pain, fatigue, weakness, lack of endurance or incoordination.  A left knee X-Ray performed in conjunction with the C&P evaluation was read as normal.  

The panel directed attention to its rating recommendation based on the above evidence.  The panel then considered if the left knee stress fracture, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The majority of the visits to various clinics for pain were found to be for each of the various conditions with the left knee mentioned equally with the others.  In addition, all conditions were implicated in the permanent profile as well as the commander’s impact statement.  Panel members agreed that the preponderance of the evidence indicates the left knee stress fracture was unfitting for continued service.  The PEB rated the bundled bilateral lower extremity pain condition 10%, coded 5099-5003 (analogous to degenerative arthritis), citing slight/frequent pain.  The VA rated the left knee strain condition 0% coded 5299-5257 (knee, other impairment of), based on the C&P examination 3 months before separation, citing current anterior knee tenderness without evidence of instability, fracture, joint disease or significant limitation of function.  

There was no limitation of motion which attained a minimum rating under the diagnostic codes for limitation of flexion or extension (5260, 5261).  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.  There was no fracture, non-union, or malunion of the femur or tibia to support consideration under the respective codes for knee impairment related to long bone conditions (5255, 5262).  No additional functional limitation was evidenced by the examinations.  There was no evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45).  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 knee stress fracture condition as bundled with the overall bilateral lower extremity stress fracture condition.  

Right Ankle.  At the 27 July 2004 C&P evaluation, 3 months before separation, the CI reported constant and recurrent ankle pain that prevented the CI from running and road marching.  Physical examination showed a normal gait and stance, dorsiflexion to 20 degrees (normal), plantar flexion 45 degrees (normal), ROM was not additionally limited by pain, fatigue, weakness, lack of endurance or incoordination.  Plain film X-Rays of the right ankle performed in conjunction with the C&P evaluation were read as normal.  

The panel directed attention to its rating recommendation based on the above evidence.  The panel next considered if the right ankle stress fracture, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The majority of the visits to various clinics for pain were found to be for each of the various conditions with the right thigh/leg mentioned equally with the others.  In addition, all conditions were implicated in the permanent profile as well as the commander’s impact statement.  Panel members agreed that the preponderance of the evidence indicates the right femur stress fracture was unfitting for continued service.  The PEB rated the bundled bilateral lower extremity pain condition 10%, coded 5099-5003 (analogous to degenerative arthritis), citing slight/frequent pain.  The VA rated the right ankle strain condition 0% coded 5299-5271 (analogous to ankle, limited motion of), based on the VA C&P examination 3 months before separation, citing intermittent pain with impact and significant weight bearing activities.  

There was no X-ray evidence of arthritis to rate using VASRD code 5003 (arthritis, degenerative).  There was no limitation of motion of the ankle joint to support a rating under diagnostic code 5271 (limitation of motion) or 5024 (tenosynovitis) and none of the examinations in evidence noted the presence of painful joint motion to support a minimum rating IAW VASRD §4.59.  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 ankle stress fracture condition as bundled with the overall bilateral lower extremity stress fracture condition.  

Left Ankle.  At the 27 July 2004 C&P evaluation, 3 months before separation, the CI reported constant and recurrent ankle pain that prevented the CI from running and road marching.  Physical examination showed a normal gait and stance, dorsiflexion to 20 degrees (normal), plantar flexion 45 degrees (normal), ROM was not additionally limited by pain, fatigue, weakness, lack of endurance or incoordination.  Plain film X-Rays of the left ankle performed in conjunction with the C&P evaluation were read as normal.  

The panel directed attention to its rating recommendation based on the above evidence.  The panel then considered if the left ankle stress fracture, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The majority of the visits to various clinics for pain were found to be for each of the various conditions with the left ankle mentioned equally with the others.  In addition, all conditions were implicated in the permanent profile as well as the commander’s impact statement.  Panel members agreed that the preponderance of the evidence indicates the left ankle stress fracture was unfitting for continued service.  The PEB rated the bundled bilateral lower extremity pain condition 10%, coded 5099-5003 (analogous to degenerative arthritis), citing slight/frequent pain.  The VA rated the left ankle strain condition 0% coded 5299-5273 (analogous to os calcis or astragalus (talus), malunion of), based on the VA C&P examination 3 months before separation, citing intermittent pain with impact and significant weight bearing activities.  

There was no X-ray evidence of arthritis to rate using VASRD code 5003 (arthritis, degenerative).  There was no limitation of motion of the ankle joint to support a rating under diagnostic code 5271 (limitation of motion) or 5024 (tenosynovitis) and none of the examinations in evidence noted the presence of painful joint motion to support a minimum rating IAW VASRD §4.59.  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 ankle stress fracture condition as bundled with the overall bilateral lower extremity stress fracture condition.  

BOARD FINDINGS:  In the matter of the chronic pain from multiple stress fractures of both lower extremities condition, the panel majority recommends no change in the PEB adjudication.  The single voter for dissent recommends separate unfitness determinations and a list of separate disability ratings for each condition which would provide no rating advantage to the CI and elected not to submit a minority opinion.  There are 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 20150722, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170010027, 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,