RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00306
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20020518

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E2, Trainee, medically separated for “right leg pain,” 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 - 20020402	VARD - 20021120	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Leg Pain	5099-5003	0%	Residual of Right Tibial Stress Fracture	5099-5010	10%	20021008	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Right Leg Pain.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI began experiencing right shin and lateral ankle pain in October and December 2001 during and shortly after basic training.  Despite initial radiographic evaluation of the ankle and foot (X-rays, bone scan) in December 2001 that documented a ‘bone island’ and no evidence of fracture, bony changes, or arthritis, the diagnosis of “possible stress fracture” was made.  

During the 16 January 2002 MEB examination (recorded on Standard Forms 88 and 93), 4 months prior to separation, the physical examination noted pain with pressure of the mid-tibial shaft.  The 14 February 2002 MEB NARSUM examination, 3 months prior to separation, noted complaints of pain in the anteromedial distal tibia.  Physical examination showed ambulation with a limp, use of a cane, and guarding with tenderness of the anterior tibia.  The examiner referenced undated radiographs which were repeated and reportedly showed “remodeling type of change in the anterior tibia.”  At a 22 March 2002 primary care visit, 2 months prior to separation, the CI reported right ankle pain.  Physical examination showed no evidence of swelling or laxity.  

At the 8 October 2002 VA Compensation and Pension (C&P) evaluation, performed 5 months after separation, the CI reported pain on average every other day which was aggravated by long standing, running and walking and that he lost a job recently because of inability to stand for long periods.  Physical examination showed a normal gait with no deformity or tenderness.  There was normal toe and heel walk, hop, squat, and no evidence of pain with weight bearing.  Radiographs of the lower extremity (tibia and fibula X-rays) documented no acute bony process or soft tissue swelling.  The bone island was again identified.  

The panel directed attention to the rating recommendation based on the above evidence.  The PEB rated the right leg condition 0%, coded 5099-5003 (degenerative arthritis).  The VA rated the residuals of a right tibial stress fracture 10% coded 5099-5010 (arthritis due to trauma), based on the VA C&P examination 5 months after separation, citing pain and aggravation of standing, running or walking.  There was no documentation of painful motion nor evidence of limitation of flexion to 30 degrees (5260) or limitation of extension to 15 (5261) nor limitations in ankle motion (5262, 5271) for a higher rating.  There was no evidence of recurrent subluxation or lateral instability (5257) and no evidence of tibia or fibula impairment (5262) with “moderate” knee disability for a higher rating.  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 right leg condition.  

BOARD FINDINGS:  In the matter of the right leg condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  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 20160523, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170015260, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

	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