RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02524
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20020502

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Basic Trainee, medically separated for “patellofemoral pain syndrome, bilateral, as well as bilateral lower extremity stress fractures,” with a disability rating of 0%.  

CI CONTENTION:  The CI made no specific contention.  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 - 20020411	VARD - 20020511	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Patellofemoral Pain Syndrome as well as Bilateral Lower Extremity Stress Fractures	5099-5003	0%	Left Patellofemoral Syndrome with Lower Extremity Stress
Fractures	5299-5014	10%	STR	
			Right Patellofemoral Syndrome with Lower Extremity Stress
Fractures	5299-5014	10%		
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Bilateral Patellofemoral Pain Syndrome, as well as Bilateral Lower Extremity Stress Fractures.  The PEB combined the bilateral patellofemoral pain syndrome and lower extremity stress fractures conditions as a single unfitting condition coded 5003 and rated 0% with application of the USAPDA pain policy AR 635-40 B24.f. 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 conditions are presented below, with attendant recommendations regarding separate unfitness, and separate rating if indicated.  

According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s bilateral knee and shin conditions began in February 2002 during basic training without specific trauma. The CI presented to an acute care facility on 14 November 2001 and complained of recurrent bilateral shin pain for two weeks.  The examiner noted bilateral mid and lower shins tenderness to palpation.  The CI was observed to ambulate with an antalgic gait.  Radiographs performed showed periosteal reaction to the shaft area of the right tibia consistent with stress fractures of the right tibia.  On 22 January 2002, the CI complained of recurring left lower leg pain.  The CI stated that he was treated for stress fractures to the left lower leg.  Radiographic findings supported stress fracture to the left tibia-fibula area.  At a primary care appointment on 28 January 2002, the CI complained of pain with running, jumping and marching that started sometime in November.  The CI reported that the area had swelling at the end of the day.  Physical examination showed the right mid and distal shins were moderately tender to palpation.  The CI was observed to walk with an antalgic gait.  

At an orthopedic appointment on 5 February 2002, the CI complained right and left lower extremity pain and swelling.  The CI stated that he had pain with walking and was not able to run.  The examiner noted the lower extremities were edematous (swelling).  There was full active range of motion of the knees.  The examiner noted the bone scan findings showed increased uptake over bilateral shins and the right knee articulation.  The examiner opined the CI had multiple stress fractures.  At an orthopedic examination on 22 March 2002, the CI complained of pain lower legs and knees.  The CI reported the pain was associated with ascending and descending stairs and squatting or kneeling.  The CI also complained of pain and swelling behind the knees and lower shins.  Physical examination showed tenderness to palpation over both shins, inside of the right knee, and inner side of the patella.  The examiner opined bilateral lower extremity stress fractures.  The 3 April 2002MEB NARSUM examination, 1 month prior to separation, noted complaints of bilateral lower extremity pain.  The CI stated that the pain was “located on the medial aspect of the knee as well as the left lower extremity.”  Physical examination showed positive medial patella (facet) tenderness and positive pain with patella compression.  There was tenderness to palpation over the medial lower right knee and bilateral shins.  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 bilateral knee and shin conditions 0%, coded 5003 (Arthritis, degenerative (hypertrophic or osteoarthritis)), citing “slight occasional pain” IAW the US Army Physical Disability Agency (USAPDA) pain policy.  The VA rated the left and right lower leg patellofemoral syndrome and stress fractures conditions 10% respectively, coded 5014 (Osteomalacia.), based on the service treatment records (STR), citing “functional impairment as well as painful motion of a major joint.”  

The panel first considered if the patellofemoral syndrome and stress fractures conditions, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The lower legs and knees were profiled, implicated in the commander’s statement, and considered to fail retention standards. The panel determined that the available evidence did not support the conclusion that performance limitations were attributable to one knee or lower leg over the other without undue speculation.  Members agreed that based on the clinical evidence and fitness performance criteria each lower leg and knee was reasonably justified as separately unfitting.

As noted above, there were no functional impairment or fitness distinctions between the right and left knees and lower legs.  There was no limitation of the knee or painful motion of the knees for separate VASRD ratings.  The panel noted that a single 5003 rating of 10% for the bilateral diagnoses was IAW VASRD §4.71a.  Members agreed that the evidence did not meet criteria for separate right and left knee or lower leg ratings. There was radiographic evidence and an absence of limitation of motion for a single 10% rating under 5003.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a 10% rating, coded 5099-5003 for the bilateral patellofemoral pain syndrome and bilateral lower extremity stress fractures conditions.  

BOARD FINDINGS:  In the matter of the bilateral patellofemoral pain syndrome and bilateral lower extremity stress fractures, the panel unanimously recommends a disability rating of 10% coded 5099-5003 IAW VASRD §4.71a.  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	
Bilateral Patellofemoral Pain Syndrome and Bilateral Lower Extremity Stress Fractures	5003	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20151104, with attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170013311, 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