RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02557
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20080822

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Cryptologic Linguist, medically separated for “bilateral leg pain,” “left ankle pain,” “rated 20%, 0%, and “bipolar disorder, determined to have existed prior to service (EPTS) and was not rated,”  with a combined disability rating of 20%.  

CI CONTENTION:  The CI requests 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 - 20080812	VARD - 20090220	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Tibial Stress Reactions	5299-5262	20%	H/O Stress Fracture, R Knee	5299-5260	0%	20081209	
			H/O Stress Fracture L Knee	5299-5260	0%	20081209	
Stress Fracture of Left Talus	5299-5284	0%	H/O Stress Fracture, R Ankle	5262-5271	0%	20081209	
			H/O Stress Fracture L Ankle	5262-5271	0%	20081209	
Bipolar Disorder	9432	--%	Bipolar Disorder/Depression	9432-9434	NSC	20081217	
Bilateral Hand Numbness	Not Unfitting	Bilateral CTS	8516	NSC	20081209	
Bilateral Trigger Finder	Not Unfitting	Bilateral Tenosynovitis of the Fingers	5024	NSC	20081209	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Bilateral Tibial Stress Reaction.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI was first seen for knee and shin pain on 1 April 2008, 6 weeks after accession, reporting left knee and shin pain for 2 weeks.  Both knees were tender and the right leg showed swelling and tenderness.  X-rays of the right knee and leg were normal.  She was diagnosed with a stress fracture and given medications and duty limitations.  The panel noted that the CI had already been treated one month earlier for a left ankle sprain with medications, duty limitations, and crutches (discussed further below).  A bone scan on 9 April 2008 showed increased uptake of in both knees, left ankle, and left midfoot.  She was then placed on convalescent leave.  She returned to her home station and used a wheel chair for non-weight bearing ambulation.  On 22 April 2008, X-rays of both lower extremities were normal.  The next day in orthopedics, a vibratory test (with a low frequency tuning fork) was positive, consistent with bilateral shin stress fractures.  On 13 May 2008, she was seen in orthopedics prior to the end of her convalescent leave.  It was noted that she was not yet healed and the orthopedist recommended the use of a wheelchair/crutches for travel.  She reported to the emergency room on 16 May 2008, shortly after return to basic training.  She stated that she was required to follow her unit on crutches and was not being given her pain medications.  During the history, she disclosed a prior history of depression including admission for the MH condition a few months prior to her enlistment.  Due to the persistence of her symptoms and an inability to complete basic training, she was entered into the MEB process.  The mental health issue is discussed separately below.  She was issued a L3S3 profile on 21 May 2008.  X-rays of the lower legs were repeated on 27 May 2008 and remained normal.  

The MEB NARSUM examination was prepared in orthopedics and dated 2 June 2008, 2 months prior to separation.  It noted that the CI had been referred for an MEB due to the length of time needed for the stress fractures to fully heal.  On examination, the range of motion (ROM) of the knees was slightly reduced at 135 degrees of flexion (140 is normal), but symmetric.  Extension was normal.  The ROM of the ankles was normal for both dorsiflexion (toes up) and plantar flexion (toes down).  The knees were stable.  Neither shin was tender to palpation, but the left ankle was (medial malleolus, the lower end of the tibia [shin bone]).  The stress fractures were expected to slowly resolve over time.  The CI was re-evaluated by orthopedics on 17 July 2008 while an inpatient in the mental health ward.  She was noted to have a stiff gait.  There was no periosteal tenderness (no signs of shin splints).  It was advised that she discontinue use of the wheelchair.  

On 23 September 2008, X-rays of the lower legs were normal.  In orthopedics, she was noted to continue use of a wheelchair.  She reported improvement in her symptoms though.  On examination, she was noted to have minimal tenderness of the tibiae and feet.  The ROM was normal.  She was advised to begin walking, but to avoid high impact activities.  She was released without limitations otherwise.  A bone scan on 7 October 2008 showed diffuse uptake in both midfoot regions consistent with stress changes (but not stress fractures).  No uptake was noted over either shin.  In orthopedics on 15 October 2008, the examiner noted that this was the first he had seen her not in a wheelchair.  The tenderness over the tibiae and feet was reduced.  The ROM was normal.  She was released without limitations.  

At the VA Compensation and Pension (C&P) evaluation performed on 9 December 2008, 4 months after separation, the CI reported that her symptoms were improved and that she could bear her weight for up to 45 minutes at a time.  On examination, she could flex her knees to 125 degrees with normal extension.  The knees were stable.  The ankles showed normal plantar flexion; dorsiflexion was reduced to 15 degrees from the normal 20 degrees.  There was no change with repetition.  X-rays, not in evidence, were noted on the VA rating decision dated 20 February 2009 to be normal with “no significant bony or joint abnormality.”  No comment was made on tenderness.  The examiner noted that there was a history of bilateral stress fractures of the knees, but did not record an active problem.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral tibial stress reactions at 10% each coded 5299-5262 (analogous to slight impairment of the tibia and fibula.  The VA assigned a non-compensable (0%) rating coded 5299-5260 (limitation of flexion) for the knees.  A bone scan over 4 months prior to separation showed diffuse uptake consistent with stress changes in both knees and the left foot.  When repeated 6 weeks after separation, the scan showed some uptake over the left mid foot, but none over the lower legs (shins).  X-rays in April, May, September, and December were consistently normal without evidence of stress fractures.  The evidence shows that the condition was essentially resolved around the time of separation or shortly thereafter.  No route to a higher rating was found.  The panel noted that a rating of no higher than 10% for both lower legs was supported by the code 5022 (periostitis), which better described the clinical findings at separation.  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 tibial stress reaction condition.  

Stress Fracture of the Left Talus Diagnosis.  As noted above, the CI initially presented with left ankle pain 2 weeks after accession, and 1 month before seeking medical attention for the shin splint condition, following a sprain.  She endorsed pain with walking and running and was observed to limp.  The ankle was tender, but stable to examination and the ROM was intact.  Swelling and/or discoloration were not present.  As noted, the bone scan on 9 April 2008 showed uptake of the distal tibia, an ankle bone (talus) and a bone of the midfoot (2nd metatarsal).  These findings were not present on an X-ray accomplished on 23 April 2008.  She was placed on convalescent leave for this and for the unfitting bilateral tibial stress reactions.  

The MEB NARSUM examination, noted continued tenderness in the areas of the left foot as shown on the previous bone scan.  The ROM of the ankle was normal.  An orthopedic follow up appointment on 17 July 2008 noted that the CI had normal ROM and that there was no tenderness present.  Painful motion was not recorded and was specifically noted to be absent with ambulation.  X-rays on 23 September 2008 showed subtle changes of the right foot, but no pathology for the left foot.  Another orthopedic follow up on 23 September 2008, 1 month after separation, documented normal range of motion and no swelling.  Tenderness of both feet was noted.  She was advised to begin walking, but to avoid high impact activities.  A repeat bone scan on 7 October 2008 showed mild, diffuse uptake of the midfoot bilaterally.  It was consistent with mild stress changes.  The final orthopedic evaluation in evidence was dated 15 October 2008, 2 months after separation.  The ROM was normal, swelling was absent, and tenderness was not documented.  Painful motion was not documented on any of these examinations.  

The VA C&P evaluation recorded continued pain with activity.  Plantar flexion was normal.  Dorsiflexion was reduced to 15 degrees bilaterally.  The examiner noted “some local discomfort” with motion.  Neither swelling nor tenderness were documented.  X-rays were normal as addressed above.  The examiner recorded a history of bilateral stress fractures (not supported by the record), but did not document current pathology.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated left talus stress fracture at 0%, coded 5299-5284 (other foot injuries at less than a moderate level of impairment), noting pain with motion.  The VA rated the history of stress fracture left ankle condition 0% coded 5262-5271 (impairment of the tibia/fibula - limited motion of the ankle) noting that the limitation in motion did not rise to the moderate level.  The panel considered the evidence.  It noted that the CI was clearly improving the final months of her service and continued to improve after separation.  Most examinations documented full ROM without documenting painful motion.  The totality of evidence did not support a 10% rating for either limited or painful motion at separation.  The panel observed that even if this was recommended, the bilateral tibial stress reaction condition only supported a 10% rating for a combined disability rating of 20%.  This rating determination provided no 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 left talus stress fracture condition.  

Bipolar Disorder Diagnosis. The record shows that the CI was first seen in the military health care system for symptoms of anxiety and depression on 14 December 2006, 15 months prior to accession.  She was subsequently placed on medications and given an initial diagnosis of a generalized anxiety disorder (GAD).  She showed some improvement with medications and the diagnosis of depression was added at the next clinical visit on 30 January 2007.  On 10 February 2007, she was treated at and released from the emergency room when her deployed husband became concerned of suicidal ideation (she denied) and contacted his chain of command.  On 22 February 2007, she reported that she had discontinued her anti-depressant medication (Zoloft) as she believed that her symptoms were worsening.  She was then changed to a different medication.  This proved beneficial and she did better for several months.  She also discontinued the second medication (Paxil).  On both the history prescreen dated 13 November 2007 and the accession DD 2897 dated 16 November 2007, the CI denied any mental health treatment.  She next came to mental health treatment on 16 May 2008 shortly after returning to basic training from convalescent leave.  She reported pain from the multiple orthopedic issues and endorsed symptoms of depression.  She also reported an admission for depression in October 2007 (there are no records for inpatient treatment at this time, but she was seen once as an outpatient).  The CI was discharged to home with follow up in mental health the next morning.  She was then admitted for inpatient treatment in Life Skills.  It is not clear from the record if she was admitted for the orthopedic problems (she was using a wheelchair) or the mental health issues or both.  On 7 July 2008 it was noted that she had been diagnosed with Bipolar II Disorder (both depression and manic like episodes).  

The MEB NARSUM examination was dated 21 July 2008, 1 month prior to separation.  It noted that the CI had been treated for one year as a military dependent in 2007 and had done well except for one admission in October 2007 for self-mutilating behavior.  She had joined the US Army in order to leave her husband and support her son.  It was noted that her first contact with mental health was in 2002 while attending college, when she was flagged for “bipolar tendencies” on a screening history to be a surrogate mother.  The CI provided a history both periods of increased energy and poor judgement as well as periods of decreased energy and depression.  She took Wellbutrin for one year in 2005 and did well.  This was thought to be a period of hypomania.  Her DoD medical records (she was a dependent prior to enlistment) were reviewed and also thought to be consistent with the history provided by the CI.  On examination, she had poor eye contact and a mildly slow psychomotor state.  She endorsed auditory and visual hallucinations thought to be more consistent with high anxiety than a primary thought disorder.  Intermittent suicidal ideation was noted.  She was admitted at the time of the examination.  She was responding “fully” to current therapeutic interventions.  She was thought to be partially capable of civilian employment and issued an S3.  She was diagnosed with a Bipolar Disorder with an approximate date of onset in 2002.  Service aggravation was not present.  Her prognosis was fair as is typical for this condition.    

At the VA mental health C&P evaluation performed 9 December 2008, 4 months after separation, the CI reported continued depressive symptoms, but denied suicidal ideation.  She denied any history of mental illness prior to accession.  She was functioning as a homemaker and handled the family finances.  On examination, she was depressed with a blunted affect.  She felt helpless.  The remainder of the mental status examination was normal.  She was diagnosed with a major depressive disorder, severe and recurrent.  This was based solely on her history.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB determined that the Bipolar Disorder existed prior to service (EPTS), and was not divulged at accession.  No rating was assigned, but the code 9432 (Bipolar Disorder) was used.  The VA also determined, based on the VA C&P examination and service treatment records, that the Bipolar Disorder was EPTS.  Service connection was denied but the VA coded the condition 9432-9434 (Bipolar Disorder – Major Depressive Disorder).  The record clearly shows treatment for a mental health condition prior to service.  This included medications and at least one admission.  Her diagnosis dated back to 2002.  Bipolar disorder is a disease which waxes and wanes, but has periods of high function.  The fact that she initially succeeded in training (other than the orthopedic issues) is consistent with the normal variability of this diagnosis.  The evidence suggests that she actually was doing better on active duty than she had in the year prior to accession and supported the EPTS adjudication made by both the PEB and the VA.  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 Bipolar Disorder condition.  

Contended PEB Conditions:  Bilateral Hand Numbness and Bilateral Trigger Finger.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  Neither of the conditions was profiled nor implicated in the commander’s statement.  Both were judged to meet retention standards.  There was no performance-based evidence from the record that either 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 either of the contended conditions and so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the bilateral tibial stress reaction condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the stress fracture of the left talus condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the Bipolar Disorder condition, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the contended bilateral hand numbness and bilateral trigger finger conditions, the panel unanimously recommends no change from the PEB determinations as not unfitting.  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 20151122, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170013320, XXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX

	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,					      
						      					
Enclosure