RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX 	CASE:  PD-2016-00169
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20051013

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Petroleum Supply Specialist, medically separated for “bilateral tibial stress reactions” 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 - 20050824	VARD – 20061024	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Tibial Stress Reactions	5022	0%	Bilateral Shin Splints	5099-5022	NSC	STR
No VA Exam	
Right Plantar Fasciitis	Not Unfitting	Bilateral Foot Condition	5099-5020	NSC		
Left Wrist Sprain	Not Unfitting	No VA Placement	
COMBINED RATING:  0%	COMBINED RATING:  NSC	

ANALYSIS SUMMARY:  

Bilateral Tibial Stress Reactions.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s “bilateral tibial stress reactions” condition began in November 2000 after inability to complete a group run.  Bone scan indicated stress fractures and the CI was on numerous profiles for lower leg pain receiving orthotics (shoe inserts) which did not help.  The CI fell and fractured her right distal fibula in May 2002, and had increasing bilateral leg pain with activity.  Following re-deployment in February 2005 the CI’s continued and worsening bilateral leg pain led to reevaluations.  X-ray on 22 March 2005 showed evidence of a healed right distal tibial fracture and was otherwise normal, and a bone scan on 28 March 2005 demonstrated bilateral shin splints and a right distal tibia Grade I stress fracture.  The MEB forwarded “bilateral shin pain, right tibial stress fractures” for PEB adjudication.  

At the 3 May 2005 primary care evaluation, 5 months prior to separation, the CI reported 3 weeks of increased shin and feet pain on awakening and falling that morning with swelling and decreased sensation in her feet.  Pain was in the Achilles area and the heel.  Physical exam showed the CI ambulated with an abnormal gait, had decreased range of motion (ROM) with flexion, tenderness to palpation on the plantar surface and edema in the mid foot.  The assessment rule out plantar fasciitis, and treatment was conservative treatment with a consult to podiatry.  

The MEB NARSUM examination on 24 June 2005, 4 months prior to separation, noted complaints of duty-limiting bilateral leg pain that increased with activities and standing.  Constant pain at rest was 3-4/10 that increased to 7-8/10 with activities of walking approximately ¼ mile or running less than 15 yards.  Daily medication (Naproxen) helped decrease the pain intensity.  The physician stated “after nearly 5 years of bilateral leg pain and multiple visits with primary care, physical therapy, podiatry, and orthopedics, (the CI) has had only increasing symptoms of her bilateral leg pain.”  Physical examination showed tenderness to palpation at the middle one-third of the medial aspect of bilateral legs and pain increased with placement of a 128 Hertz tuning fork.  There was no pain at the knee or ankle joints with full active ROM.  

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 combined the left and right tibial stress fracture conditions under a single disability rating, coded 5022 (periostitis) and rated 0%, citing without loss of motion of the contiguous joints.  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 VA rated the “bilateral shin splints” condition “not service connected” coded 5099-5022 (analogous to periostitis), based on no VA examination to show permanent residual or chronic disability.  

In this case, bilateral shin splints (tibial stress reactions) and right tibial stress fracture were considered to fail retention standards, were profiled, and were implicated by the NARSUM.  Bilateral shin splints were implicated by the commander’s statement.  The commander’s statement and other STR evidence did not provide any information which would permit the panel to discriminate the performance limitations attributable to either tibial stress reaction over the other.  Since undue speculation would be required to conclude that impairment from either tibial stress reaction would not have unacceptably interfered with the performance of military duties, members agreed that each tibial stress reaction was reasonably justified as separately unfitting.  

There was no limitation of ankle or knee motion on either side that supported a rating under the VASRD diagnostic codes for limitation of motion of the ankles or knees (5271, 5260, or 5261).  There was conflicting evidence of painful motion of one or both ankles for rating either tibial condition at 10% for painful ankle motion IAW VASRD §4.59 (painful motion).  The bone scan of the bilateral lower legs showed abnormal uptake of both tibias with bilateral shin splints and right tibia stress fracture, therefore the panel considered rating using 5262 (impairment of the tibia and fibula).  The CI experienced chronic residual bilateral leg pain with tenderness and significant activity restrictions.  The panel agreed the residual functional loss supported a 10% rating for each side for slight knee or ankle disability.  

After due deliberation, and considering all of the evidence, the panel recommends a disability rating of 10% for the right tibial stress reaction condition and 10 for the left tibial stress reaction condition, each coded 5022-5262.  

Contended PEB Conditions:  Right Plantar Fasciitis, Left Wrist Sprain.  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 or implicated in the commander’s statement or 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 bilateral tibial stress reactions condition, the panel unanimously recommends that each side be separately adjudicated as follows: an unfitting right tibial stress reaction condition coded 5022-5262 and rated 10%, and an unfitting left tibial stress reaction condition, coded 5022-5262 and rated 10%, both IAW VASRD §4.71a.  In the matter of the contended “right plantar fasciitis” and “left wrist sprain” conditions, 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 the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Bilateral Tibial Stress Reactions	Right	5022-5262	10%	
	Left	5022-5262	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160329, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170014094, 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