RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02453
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070129

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a National Guard E1, Medical Specialist, medically separated for “chronic left lower leg pain secondary to tibial stress fracture” 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 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 - 20070111	VARD – N/A	
Condition	Code	Rating	Condition	Code	Rating	
Left Lower Leg Pain ... Tibial Stress Fracture	5099-5003	0%	No VA Examination in Evidence	
Adjustment Disorder	Not Unfitting		
Bilateral Plantar Fasciitis			
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  N/A	

ANALYSIS SUMMARY:  

Left Tibial Stress Fractures.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI suffered an atraumatic onset of left lower leg pain in February 2006 (12 months before separation) during basic training.  She was diagnosed with tibial stress fractures (left medial plateau and shaft), which were shown to be healing in a follow-up X-ray (5 months before separation), and for which there was no surgical indication. 

Clinical STR entries documented normal to non-specifically decreased range of motion (ROM) of the ankle and foot, with some entries noting painful motion and others specifying the opposite; and, no entries indicated any severe ROM limitation.  Earlier entries documented an antalgic gait that was resolved in all later entries.  There were entries, without contrary evidence, that documented the absence of other ratable features of the ankle, knee, or foot.  Improvement was noted after conservative treatment (a trial of non-weight bearing and convalescent leave), but this was insufficient to allow a timely resumption of training; and, the CI was referred for an MEB.  

The 7 December 2006 NARSUM examination, 2 months before separation, documented “significantly improved” pain rated “minimal and occasional” that permitted alternate events for physical fitness testing; but, that precluded resumption of rigorous training and general soldiering requirements.  The physical examination recorded a normal gait, tenderness over the mid-tibia, intact neurovascular findings, and “knee and ankle joint ... without effusion, edema or pain.”  There was no directed comment regarding ROM in the NARSUM or in the MEB’s DD Form 2808 physical examination.  

There was no VA claim, examination, or clinical notes on file; and, there was no other post-separation evidence in this case.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB’s 0% rating under code 5099-5003 (analogous to degenerative arthritis) referenced the U. S. Army Physical Disability Agency pain policy.  The only codes available under VASRD §4.71a that are applicable to this case are 5003 (or the more clinically specific 5022 [periostitis] that defaults to criteria of 5003); or, analogous application of code 5262 (tibia and fibula, impairment of) which confers ratings for contiguous knee or ankle disability: 10% for “slight,” 20% for “moderate,” and 30% for “severe.”  

Members deliberated whether there was satisfactory evidence of painful motion in support of the minimum 10% rating (VASRD §4.59) under code 5022, and concluded that the evidence was equivocal (intermittent in STR clinical entries and not directly assessed in the NARSUM).  Member consensus was, however, that reasonable doubt was fairly conceded in favor of application of §4.59 to support the minimum compensable rating under any chosen code.  Furthermore, members consensus was that the “slight” 10% criterion for rating under 5299-5262 was supported by the residual disability still present at separation (per the NARSUM functional evidence); again with deference to reasonable doubt and to VASRD §4.7 (higher of two evaluations).  All members agreed that the “moderate” criterion of 5262 was not supported by the functional evidence at separation; and, that there was no ROM limitation or other ratable criterion in evidence to support a rating higher than 10% under any other code.  

After due deliberation, considering all of the evidence and conceding VASRD §4.3 (reasonable doubt), the panel’s consensus recommendation is a 10% rating for the left tibial stress fractures under code 5299-5262.  

Contended PEB Conditions:  Adjustment Disorder and Bilateral Plantar Fasciitis.  The CI developed depression and anxiety in association with her orthopedic problems and the demands of military service.  She was diagnosed with adjustment disorder (incidentally not a service ratable condition IAW DoDI 1332.38 [E5.1.3.9.4]) and treated with medication.  The MEB psychiatric consultant concurred with that diagnosis, documented a favorable course and normal mental status examination, and signed an S1 profile.  

The origin of the MEB’s DA Form 3947 entry for bilateral plantar fasciitis was unclear.  It appeared as an incidental diagnosis in some STR entries, although conversely other examiners recorded the absence of plantar fasciitis.  There were no STR entries that indicated the condition was clinically active, and it was not referenced in the NARSUM.  

The panel’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  None of the conditions were profiled, implicated in the commander’s statement nor judged to fail retention standards.  There was no performance-based evidence from the record that any of the conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded that there was insufficient cause to recommend a change in the PEB fitness determination for any of the contended conditions and so no additional disability ratings are recommended.   

BOARD FINDINGS:  In the matter of the left tibial stress fractures, the panel by a majority vote recommends a disability rating of 10%, coded 5299-5262 IAW VASRD §4.71a.  The single voter for dissent recommends no change and does not elect to submit a minority opinion.  In the matter of the contended adjustment disorder and bilateral plantar fasciitis, the panel unanimously recommends no change from the PEB determinations as not unfitting.  There are 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 his prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Multiple Stress Fractures, Left Tibia	5299-5262	10% 	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20151014, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170012928, 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