RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00162
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050501

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Light-weight Wheeled Mechanic, medically separated for “bilateral lower extremity stress reactions, involving knees, feet, tibia, feet” with a disability rating of 0%.  

CI CONTENTION:  The CI contended multiple conditions not within review and a worsening of migraines.  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 - 20050208	VARD - 20051114	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Lower Extremity Stress Reactions, Involving Knees, Tibia, Feet	5099 5022	0%	Residuals, Right Shin Splint and Stress Reaction Fracture	5099-5022	0%	20050803	
			Residuals, Right Shin Splint and Stress Reaction Fracture		0%		
Migraine Headaches	Not Unfitting	Migraine Headaches	8100	0%		
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Bilateral Lower Extremity Stress Reactions, Involving Knees, Tibia, Feet.  The PEB combined the Medical Evaluation Board (MEB) forwarded conditions of chronic bilateral shin splints, bilateral foot pain and bilateral knee pain conditions under a single disability rating, coded analogously to 5022 (periostitis) and rated 0%.  This 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’s initial charge in this case was therefore directed at determining if 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 chronic bilateral shin splints and bilateral knee pain were correlated with bilateral lower extremity stress reactions involving the knees and tibiae, but there was no evidence of stress reactions/fractures of either foot.  Therefore, the evidence for the chronic bilateral shin splints and bilateral knee pain conditions are discussed together and the bilateral foot pain conditions are discussed separately with attendant recommendations regarding separate unfitness, and separate rating if indicated.  

Chronic Bilateral Shin Splints and Bilateral Knee Pain.  The MEB narrative summary (NARSUM) was not in record.  According to the service treatment record (STR), the CI’s “bilateral lower extremity stress reactions, involving knees, feet, tibia, feet” condition began in 2000.  A bone scan showed a stress fracture of the tibia.  The CI was treated with profiles and a period of non-weight bearing and the condition was downgraded to shin splints.  The CI became pregnant during follow up of the right leg pain and after return from her pregnancy leave, the CI developed left leg pain.  A bone scan performed in June 2003 showed a stress fracture of the left tibia near the ankle.  The left leg stress fracture was treated with profiles and a walking cast.  A 23 March 2004 orthopedic clinic visit, 13 months before separation, noted complaints of bilateral leg pain since 2001 that alternated between legs.  There was some improvement with limited walking, but once back to full duty, the pain worsened.  The CI was in the process of a MEB to reclassify.  The physical examination noted bilateral pes planus.  Ankle dorsiflexion was 5 to 10 degrees (normal 20) and equal bilaterally.  There was tenderness of the inner aspect of the ankles bilaterally, left greater than right.  A bone scan was planned to rule out stress fracture and the CI was referred for new orthotics.  

The 30 April 2004 orthopedic visit recommended a P2 profile for bilateral shin splints.  A 21 June 2004 orthopedic visit, 11 months before separation, recommended a P3 profile and MEB due to bilateral leg pain aggravated by training.  The 27 January 2005 permanent profile listed “bilateral leg pain, foot pain, knee pain.”  The 9 August 2004 commander’s statement implicated the stress fractures of the right and left legs as impairing the CI’s successful performance of the duties of her MOS.  

During the 10 August 2004 MEB examination (recorded on DD Forms 2807 and 2808), 9 months prior to separation, the summary of defects and diagnoses included bilateral leg pain and left foot pain.  

At a 5 November 2004 physical therapy evaluation, 6 months before separation, the CI reported a right ankle sprain three weeks earlier while walking casually and re-injury approximately a week earlier that had improved significantly.  The CI reported that the ankle was sore in the morning, better by physical training time, and “ok” through the day.  The physical examination showed tenderness of the right ankle.  There was laxity of the right ankle and painful motion.  Right ankle ROM was DF 0 degrees and PF 20 degrees.  Left ankle ROM was 15 degrees and 40 degrees PF (normal 45).  There was full ROM of the knees.  The CI was able to squat fully with some pain in the right lateral ankle.  The assessment was a grade 1+/3 sprain of the ankle that was resolving.  

As noted above, the 1 November 2004 MEB NARSUM examination, 6 months before separation, was not in record.  

At the 3 August 2005 VA Compensation and Pension (C&P) evaluation, performed 3 months after separation, the CI reported left and right shin pain.  She did not report any joint symptoms or foot pain.  Physical exam showed no muscle weakness, atrophy, or spasm.  There was no joint swelling, effusion, tenderness, or laxity.  There were no residuals of fracture.  The feet and all extremities were reportedly normal.  Bilateral knee ROM was 0 degrees extension (normal 0) and 140 degrees flexion (normal 140) and bilateral ankle ROM was DF 20 degrees and PF 45 degrees.  There was no additional loss of ROM of the knees or ankles with repetition of motion.  A 30 March 2004 bone scan showed mild bilateral shin splints with reactive changes in the knees and ankles. Lower extremity strength, sensation and reflexes were normal.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the “bilateral lower extremity stress reactions, involving knees, feet, tibia, feet” condition 0%, coded 5099-5022 (analogous to periostitis), citing no loss of motion.  The VA rated the “residuals, right shin splint and stress reaction fracture” and “residuals, left shin splint and stress reaction fracture” conditions each 0% coded 5099-5022 (analogous to periostitis), based on the VA C&P examination 3 months after separation, citing lack of medical evidence demonstrating degenerative change with limitation objectively confirmed by findings of swelling, muscle spasm or satisfactory evidence of painful motion.  

The panel first considered if the bilateral knee pain having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The permanent profile listed bilateral leg pain and knee pain, but the commander’s statement specifically implicated bilateral stress fractures of the lower legs as impairing the CI’ duty performance.  During active duty the CI sought treatment for bilateral leg pain, with no reported knee symptoms or knee abnormalities noted on examinations.  A stress fracture of the right lower extremity was diagnosed remotely, with residual right shin splints, and in 2003 a bone scan of the left leg showed a stress fracture of the tibia near the ankle.  A bone scan in March 2004 showed bilateral shin splints and stress reactions of the knees and ankles.  There was no evaluation for knee pain or knee examinations in the STR.  One physical therapy (PT) visit for right ankle injury incidentally noted full ROM of both knees.  There was no performance based evidence that knee pain, unilateral or bilateral, functionally impaired the CI’s duty performance.  The panel members concluded that the preponderance of evidence showed the bilateral knee condition would not have caused the CI to be referred into the DES or to be found unfit when considered alone and accordingly cannot recommend a separate rating for it.  

The panel next considered if the chronic bilateral shin splints having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The permanent profile and commander’s statement both implicated bilateral leg pain.  The CI was evaluated and treated for bilateral lower leg stress fractures with repeated physical profiles.  The orthopedic visits in April and June recommended permanent physical profiles for bilateral shin splints/leg pain.  The MEB Form 2808 listed bilateral leg pain.  The panel concluded there was not a preponderance of evidence in the service records which overcame the panel’s presumption that the bundled chronic bilateral shin splints condition was reasonably considered separately unfitting.  The panel next considered if each of the bilateral shin splint conditions remained separately unfitting when considered individually.  The commander’s statement specifically mentioned both the right and left leg conditions and there was no other evidence in the STR which would permit the panel to discriminate the performance limitations attributable to either shin splint condition over the other.  Since undue speculation would be required to conclude that impairment from either leg would not have unacceptably interfered with MOS performance, members agreed that each shin splint condition was reasonably justified as separately unfitting and therefore eligible for individual rating.  The ratings for the right and left shin splints conditions are discussed together below.  

The PT examination in November 2004, 6 months before separation, was the most proximate examination to separation (prior to separation).  The CI had sustained a low grade right ankle sprain a few weeks earlier and was being treated by PT.  The examination at the time noted decreased right ankle ROM, normal ROM of the knees and left ankle ROM that was within normal.  No other abnormality of the left ankle or knees was documented and the right ankle sprain was noted to be resolving.  The VA examination, 3 months after separation, was the most proximate examination in record to the date of separation.  Examination of the knees, ankles, and legs was completely normal.  

There was no evidence of painful limited motion of either knee or ankle with imaging evidence of pathology for 10% rating under 5003 or the related 5022 code.  There was no evidence of painful motion of either knee or ankle supporting a 10% rating coded as 5299-5260 (limitation of leg flexion) or 5299-5271 (limitation of ankle motion), based on §4.59, §4.40 and §4.45.  There was likewise no limitation of motion which attained a minimum rating under the diagnostic codes for limitation of knee flexion or extension (5260, 5261) or limitation of ankle motion (5271).  A rating using the VASRD diagnostic code 5262 (impairment of the tibia, fibula and ankle) was considered, an analogous code for shin splints.  However, as noted above there was no objective knee or ankle disability documented to support greater than a 0% rating for either shin splint condition with this code.  There was therefore no higher rating than 0% available for either shin splints condition under any applicable VASRD code.  Since the panel had not arrived at a combined rating greater than that of the PEB combined adjudication, the fitness and rating, if applicable, of the bilateral foot pain condition was considered next.  

Bilateral Foot Pain.  According to the STR, the CI’s bilateral foot pain condition began in 2002.  The CI was evaluated by podiatry and provided orthotics for arch pain and shin splints.  Various orthotic adjustments were tried for the foot pain.  At the 23 March 2004 orthopedic clinic visit, 13 months before separation, physical examination showed bilateral pes planus.  At a 24 March 2004 podiatry visit, 13 months before separation, the CI reported left foot pain and the physical examination noted tenderness to palpation of the left plantar fascia.  Foot X-rays were normal and plantar fasciitis was diagnosed.  At the 21 May 2004 podiatry visit, the CI reported continued left heel pain despite orthotics.  She was given an injection and night splints.  At the 28 September 2004 podiatry visit, the CI noted continued left heel pain with no improvement with orthotics, but temporary improvement with heel injection.  The examination was “unchanged.”  

During the 10 August 2004 MEB examination (recorded on DD Forms 2807 and 2808), 9 months prior to separation, the physical examination showed normal foot arches.  The summary of defects and diagnoses included bilateral leg pain and left foot pain.  A 30 March 2004 bone scan showed mild bilateral shin splints and stress reactive changes in the knees and ankles.  

The 5 October 2004 MEB podiatry consult, 7 months before separation, summarized the podiatry visits through September 2004 reviewed above.  The podiatrist indicated the CI had intractable foot and leg pain that was incompatible with her duties.  

The 1 November 2004 MEB NARSUM examination, 6 months before separation, was not in record.  

At the 3 August 2005 VA Compensation and Pension (C&P) evaluation, performed 3 months after separation, the CI reported no foot problems.  The physical examination showed no abnormalities of the feet.  Ankle ROM was normal bilaterally, with no additional loss of ROM with repetition.  The VA examiner did not address any reported symptoms or of the feet, or make any diagnosis of either foot.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the “bilateral lower extremity stress reactions, involving knees, feet, tibia, feet” condition 0% as noted above.  The original VA Rating Decision did not address a claim for any condition of either foot or both feet.  
The panel first considered if the bilateral foot pain having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The permanent profile listed bilateral foot pain, but the commander’s statement specifically implicated only the bilateral stress fractures of the lower legs as impairing the CI’s duty performance.  However, the MEB podiatry consult, which was dictated 2 months after the commander’s statement, indicated the CI fell below retention standards due to the left foot heel spur syndrome.  The CI sought treatment for bilateral arch pain, but the last podiatry note in record that related to the bilateral feet was 9 May 2003, 2 years before separation.  Podiatry notes from March 2004 to separation, 13 months before separation, addressed only left foot pain.  The panel concluded there was not a preponderance of evidence in the service records which overcame the panel’s presumption that the bundled left foot pain condition was reasonably considered separately unfitting; however, there was a preponderance of evidence that the right foot would not have caused the CI to be referred into the DES or to be found unfit when considered alone and accordingly cannot recommend a separate rating for it.  The panel then considered its rating recommendation for the unfitting left foot condition at the time of separation.  

Although the CI was treated for chronic left foot pain during active duty, the most proximate examination in record before separation which noted any abnormality of the left foot was the September 2004 podiatry visit, 7 months before separation.  The Service orthopedic specialist noted bilateral pes planus.  However, the MEB DD 2808 examination noted normal arches and the VA examination 3 months after separation, noted no foot abnormality and the CI reported no symptoms of the feet.  There was conflicting evidence of pes planus, however, there was no evidence of pain on manipulation or use of the feet to support a 10% rating for “moderate” acquired flatfoot (5276).  There was no evidence claw foot, hallux valgus (5276, 5278, 5280), metatarsalgia (5279), or tarsal or metatarsal nonunion or malunion (5283) for consideration of a rating under these codes.  The panel considered if a higher rating than 0% was supported coded as other foot injury (5284) IAW VASRD 4.71a (musculoskeletal conditions), or coded analogously to 5310 IAW VASRD 4.73 (muscle injuries), an analogous code for PF, but the panel concluded that the CI’s foot pain could not be characterized as “moderate” for a 10% rating under either of these codes, based on the available evidence proximate to separation.  The panel concluded from the VA evidence that the CI’s left foot pain improved shortly after military separation, consistent with the improvement anticipated when the CI was no longer subject to the physical rigors of the military life.  There was therefore no higher rating than 0% for the left foot pain condition with any alternative VASRD code at separation.  

After having unbundled the PEB’s combined adjudication of the knees, tibiae, and feet, the panel found there were no ratings benefit to the CI.  Therefore, no change to the PEB’s combined rating is recommended.  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 lower extremity stress reactions, involving knees, feet, tibia, feet” condition.  

Contended PEB Condition:  Migraine Headaches.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended condition was not unfitting.  The migraine headache condition was not profiled or implicated in the commander’s statement or judged to fail retention standards.  There was no performance-based evidence from the record that the condition 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 the migraine headache condition and so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the “bilateral lower extremity stress reactions, involving knees, feet, tibia, feet” condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the contended “migraine headaches” condition, the panel unanimously recommends no change from the PEB determination as not unfitting.  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 20160325, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170014089, 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