RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00452
BRANCH OF SERVICE:  AIR FORCE 	SEPARATION DATE:  20030613

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 “stress fractures, both femurs…” with a disability rating of 10%.  

CI CONTENTION:  Her back and the other conditions continue to worsen and affect daily acitvities.  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 after separation.  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 - 20030606	VARD - 20040316	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Stress Fractures, both Femurs, associated with Stress Fracture, Right Proximal Tibia	5021-5299-
5003	10%	Bilateral Stress Fractures, Femurs	5299-5255	NSC	20030825	
			Small Stress Fracture Right Side Upper Tibial Bone	5262	0%	20030825	
Low Back Pain	Category II 	Early Degenerative Changes of the Posterior Elements at the L4-L5 and L5-S1	5242-5003	10%	20030825	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Bilateral Femoral Stress Fractures associated with Right Proximal Tibia Stress Fracture.  The PEB combined the right and left femur as well as the right tibial conditions under a single service disability rating, dual-coded 5021-5299-5003, rated 10%.  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 also noted that “bundling,” the combining of two or more major joints, may be permissible under the VASRD 5003 rating requirements, and 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 right and left extremities conditions are presented together with attendant recommendations regarding separate unfitness, and separate rating if indicated.  

According to the service treatment record (STR) and Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s bilateral leg pain began during initial entry training in November 2002 without specific trauma.  A 2002 bone scan showed bilateral femur Grade I stress fractures and borderline stress fracture of the right proximal tibia.  There was no surgical indication.  

The 27 May 2003 MEB NARSUM examination, 2 weeks prior to separation, noted complaints of lower leg pain.  The examiner noted the CI had a normal physical examination and that a review of the physical form at military entrance processing “was unremarkable, revealing no significant medical findings or disqualifying defects.”  

At the 25 August 2003 VA Compensation and Pension (C&P) evaluation, 2 months after separation, the CI reported she had intermittent leg pain that radiated to the lower back in the posterior thigh area.  She did not require any ambulatory aid. Physical examination revealed absence of painful motion in the lower extremity joints, and no limitation of motion due to pain, fatigue, weakness or lack of endurance following repetitive use.  Hip range of motion (ROM) testing recorded 125 degrees flexion (normal), 30 degrees extension (normal 20), 25 degrees adduction (normal 45), 45 degrees abduction (normal), 60 degrees external rotation (normal 45), and 40 degrees internal rotation (normal 45).  ROM of the knees recorded flexion to 140 degrees (normal) and extension of 0 degrees (normal).   Bone scan showed a small stress fracture on the right side upper tibial bone and no other findings (i.e., bilateral femur stress fractures were not identified on this repeat scan).

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral femoral stress fractures associated with right proximal tibia stress fracture 10%, dual-coded 5021-5299-5003 (myositis and analogous to arthritis, degenerative (hypertrophic or osteoarthritis)).  The VA rated the tibial stress fracture 0%, coded 5262 (tibia and fibula, impairment of), based on the C&P examination 2 months after separation, citing “absence of malunion of the tibia and fibula with slight knee or ankle disability.”  The VA did not service connect the bilateral femoral stress fractures, citing no permanent residual or chronic disability.  

The panel first considered if the either femoral stress fracture or the right tibial stress fracture, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  In this case, the both lower extremities were considered to fail retention standards and were implicated by the NARSUM as well as in the majority of the available clinic notes.  The MEB NARSUM and other STR evidence did not provide any information which would permit the panel to discriminate the performance limitations attributable to either lower extremity over the other. Since undue speculation would be required to conclude that impairment from either would not have unacceptably interfered with duty performance, members agreed that each lower extremity stress fracture was reasonably justified as separately unfitting.  

Turning to rating, the panel noted there was no limitation of motion in either knee which attained a minimum rating under the diagnostic codes for limitation of flexion or extension (5260, 5261).  There likewise was no evidence of painful motion with functional loss supporting a minimum rating in either leg (based on §4.59, §4.40 and §4.45).  There was no history or evidence of dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258), or history of surgery to remove a meniscus (5259) to support a rating under that  those codes.  There was no fracture, nonunion or malunion of the femur or tibia to support consideration under the respective codes for knee impairment related to long bone conditions (5255, 5262).  The panel concluded there was no evidence to support a rating higher than that adjudicated by the PEB.  

Therefore, after due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends no re-characterization of the PEB adjudication for the bilateral femoral stress fractures associated with right proximal tibia stress fracture condition.  

Contended PEB Condition:  Low Back Pain.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended condition was not unfitting.  The PEB adjudicated the low back pain as an Air Force Category II condition (can be unfitting but is not currently compensable or ratable).  Although there were two short-term temporary profiles, there was no evidence in the STR that the contended condition caused a long-term disability and it was not judged to fail retention standards.  There was no performance-based evidence from the record that the contended condition significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded there was insufficient cause to recommend a change in the PEB fitness determination for the contended condition and so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the bilateral femoral stress fractures and right proximal tibia stress fracture condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the contended low back pain condition, the panel unanimously agrees it cannot recommend it for additional disability rating.  There are no other conditions within the panel’s scope of review for consideration.  The panel, therefore, recommends 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 20120610, with attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

SAF/MRB
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD  20762

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2016-00452.

After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was appropriate.  The Board recommended no re-characterization or modification of your separation.

I carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding and their conclusion that re-characterization of your separation is not warranted.  I accept their recommendation that your application be denied.

Sincerely,

Attachment:
Record of Proceedings