RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00541
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20030826

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an E2, Calvary Scout, medically separated for “bilateral stress fractures in the knees and feet with bilateral shin pain” with a disability rating of 0%.

CI CONTENTION:  Current conditions support a higher rating.  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 - 20030714	VARD - 20030911	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Stress Fractures in the Knees and Feet with Bilateral Shin Pain	5099-5003	0%	Tibial Plateau Stress Fracture of Left Knee	5099-5014	10%	20090123	
			Tibial Plateau Stress Fracture of Right Knee	5099-5014	10%	20090123	
			Stress Fracture Left Cuboid of the Foot	5099-5014	0%	20090123	
			Stress Fracture Right Cuboid of the Foot	5099-5014	0%	20090123	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:

Bilateral Fractures in the Knees and Feet with Bilateral Shin Pain.  The PEB combined the bilateral stress fractures in the knees and feet with bilateral shin pain conditions as a single unfitting condition coded analogously to 5003 and rated 0% with application of the US Army Physical Disability Agency (USAPDA) pain policy and AR 635-40 B24.f.  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 that 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 bilateral stress fractures in the knees and feet with bilateral shin pain conditions is presented together as the conditions were together evaluated at the same appointments.  Separate recommendations regarding unfitness and ratings are made as indicated.

According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI was first evaluated for right knee and bilateral ankle pain on 19 March 2003.  He was found to have a skin infection which was treated, but the pain persisted and a subsequent bone scan (report  not in evidence) revealed severe stress fractures within the bilateral medial tibial plateaus (knees), as well as bilateral cuboids (mid-foot bones).  He was placed on convalescent leave and treated with medications, limited duty, and partial weight bearing (crutches).  

During a 3 May 2003 physical therapy (PT) visit, the CI had a normal gait, heel-to-toe walk, and could squat without symptoms but a referral to orthopedics noted attempts to “ramp-up and return to training” had been unsuccessful. At a 4 June 2003 orthopedics visit, physical examination revealed swelling and pain on the medial aspect of the knee (side not specified) with diffuse pain in the tibias and ankles and occasional tingling in both lower extremities.  There was also tenderness over the medial tibial plateau and diffuse tenderness over the tibial shafts (shins).  The feet were not addressed.  Full range of motion was noted, presumably of the knees and ankles, but not specified.

At the 6 June 2003 MEB NARSUM examination, 2 months before separation, the same provider from orthopedics (2 days earlier), noted a 3-month history of bilateral ankle, shin, and knee pain and that the CI was using crutches.  The examination mirrored the orthopedic evaluation, but also documented non-tender feet.  During the 19 June 2003 MEB examination (recorded on DD Forms 2807-1 and 2808), 2 months prior to separation, the CI was on crutches and reported bilateral knee and ankle pain and using crutches when the pain “kicks up more.”  Examination showed bilateral tenderness over the knees but no comment was made on the shins, implying they were no longer tender.  The feet and ankles were checked “normal.”  There was no VA examination proximate to separation for the panel to review.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral stress fractures in the knees and feet with bilateral shin pain condition 0%, analogously coded 5099-5003 (degenerative arthritis), citing the USAPDA pain policy.  The VA rated the knee conditions 10% each, analogously coded 5099-5014 (osteomalacia), based on the STR, citing painful functional impairment.  The VA rated the ankle conditions 0% each, also coded 5099-5014, citing no evidence of painful or limited motion.

The panel considered whether the knee and ankle stress fractures and bilateral shin pain were separately unfitting conditions.  Bone scans indicated stress fractures of both knees and they remained tender on examination at separation.  The CI continued to use crutches and had a painful gait during some examinations.  Panel members agreed the evidence supported a finding that each knee was separately unfitting.  Limitation of motion was not clearly documented, but painful motion was present and supports a 10% rating for both knees using code 5003 (degenerative arthritis) applicable to two major joints IAW VASRD §4.59 (painful motion).

The examinations of the ankles proximate to separation were unremarkable when commented upon.  The panel agreed the evidence does not support a recommendation that each ankle be found separately unfitting, and observed that even if found unfitting, no rating higher than 0% could be supported by the evidence, providing no advantage to the CI.  Members also determined that the bilateral shin pain was a symptom and not a diagnosis with no STR evidence indicating whether a stress reaction or stress fracture was present; tenderness was not recorded on the final DD Form 2808 examination.  The panel agreed the evidence does not support a recommendation that the bilateral shin pain was a separately unfitting condition.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the bilateral knee stress fracture condition, coded 5003.

BOARD FINDINGS:  In the matter of the bilateral knee stress fractures condition, the panel unanimously recommends a disability rating of 10%, coded 5003 IAW VASRD §4.71a.  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 Knee Stress Fractures	5003	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20120620, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170015811, 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