RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00839
BRANCH OF SERVICE:  ARMY 	SEPARATION DATE:  20040317

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, trainee, medically separated for “bilateral lower extremity [LE] pain secondary to stress reactions in the hips, feet and right tibia, and bilateral iliotibial band syndrome,” 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 - 20040211	VARD - 20040505	
Condition	Code	Rating	Condition	Code	Rating	Exam	
BL LE Pain…hips, feet, right tibia and BL Iliotibial Band Syndrome	5099-5003	0%	Stress Reaction with Residual Iliotibial Band Syndrome Left Hip	5299-5252	0%	20040105	
			Stress Reaction with Residual Iliotibial Band Syndrome Right Hip	5299-5252	0%		
			Stress Fracture Right Tibia	5262	0%		
			Stress Reaction, Right Foot	5284	0%		
			Stress Fracture, Left Foot	5284	0%		
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Bilateral LE Pain.  The PEB combined the chronic bilateral hip pain, bilateral foot pain and right tibial stress fracture conditions under a single disability rating, coded 5099-5003 (analogous to arthritis, degenerative) and rated 0% with application of the US Army Physical Disability Agency 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 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 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 chronic bilateral hip pain, bilateral foot pain and right tibial stress fracture conditions are presented separately, with attendant recommendations regarding separate unfitness, and separate rating if indicated.  

Right Hip Pain.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s right hip pain condition began in April 2003 after gradual onset with no history of trauma.  A 27 May 2003 bone scan showed right hip stress reaction (not stress fracture).  Plain film X-rays of the right hip from 25 August 2003 showed no bone or joint abnormalities.  She was treated with medications and activity limiting profiles without improvement in symptoms.  There was no surgical indication.  At the 11 September 2003 orthopedics consult, 6 months prior to separation, the surgeon diagnosed iliotibial band syndrome and opined that due to the complexity of the issues there was little chance the CI’s problem would resolve in order to allow her to fulfill the duties of her MOS.  He recommended a permanent profile and initiation of MEB.  During the 21 November 2003 MEB examination (recorded on DD Forms 2807-1 and 2808), 4 months prior to separation, the CI reported constant pain that increased with prolonged standing, walking and with lying on her hip.  Physical examination showed abduction 45 degrees (normal), adduction 17 degrees (normal 25), flexion 125 degrees (normal) and external rotation 45 degrees (normal 60).  At the 5 January 2004 VA Compensation and Pension (C&P) evaluation, 2 months before separation, the examiner recorded the history and examination provided above from the MEB history and physical (H&P).  

The panel directed attention to its rating recommendation based on the above evidence.  The panel first considered if the right hip pain, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  Panel members agreed the evidence reasonably justified that the functional limitations of the right hip pain condition contributed to the CI’s inability to perform her military duties, and accordingly a separate disability rating is recommended.  The PEB rated the bundled bilateral LE pain condition 0%, coded 5099-5003 (analogous to degenerative arthritis), citing moderate, intermittent pain IAW the US Army Physical Disability Agency pain policy.  The VA rated the right hip pain condition 0%, coded 5299-5252 (analogous to thigh, limitation of flexion), 0% based on the C&P examination 2 months before separation.  

The panel agreed that there was insufficient limitation of range of motion to provide a minimum rating using VASRD codes 5251 (thigh, limitation of extension of), 5252 (thigh, limitation of flexion of) or 5253 (thigh, impairment of).  In addition, there was no indication of a flail joint of the hip to support an 80% rating using code 5254, ankylosing of the hip to support a 60% rating using code 5250 or malunion of a femur fracture to support a 10% or higher rating using code 5255.  There was no evidence of painful motion (VASRD §4.59) to support a minimum rating using any of the above codes.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 0% for the right femur stress fracture condition, coded 5099-5003 (analogous to arthritis, degenerative).  

Left Hip Pain.  According to the STR and the MEB NARSUM, the CI’s left hip pain condition began sometime after April 2003 with a gradual onset with no history of trauma, the exact onset is not well documented.  A 27 May 2003 bone scan showed left hip stress reaction (not stress fracture).  Plain film x-rays of the left hip from 25 August 2003 showed no bone or joint abnormalities.  She was treated with medications and activity limiting profiles without resolution of symptoms.  There was no surgical indication.  At the 11 September 2003 orthopedics consult, 6 months prior to separation, the surgeon diagnosed iliotibial band syndrome and opined that due to the complexity of the issues there was little chance the CI’s problem would resolve in order to allow her to fulfill the duties of her MOS.  He recommended a permanent profile and to initiate the MEB.  During the 21 November 2003 MEB examination the CI reported constant pain that increased with prolonged standing, walking and with lying on her hip.  Physical examination showed abduction 45 degrees (normal), adduction 20 degrees (normal 25), flexion 125 degrees (normal) and external rotation 45 degrees (normal).  At the 5 January 2004 C&P evaluation the examiner recorded the history and examination provided above from the MEB H&P.  

The panel directed attention to its rating recommendation based on the above evidence.  The panel then considered if the left hip pain, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  Panel members agreed the evidence reasonably justified that the functional limitations of the left hip pain condition contributed to the CI’s inability to perform her military duties, and accordingly a separate disability rating is recommended.  The PEB rated the bundled bilateral LE pain condition 0%, coded 5099-5003 (analogous to degenerative arthritis), citing moderate, intermittent pain IAW the US Army Physical Disability Agency pain policy.  The VA rated the left hip pain condition 0%, coded 5299-5252 (analogous to thigh, limitation of flexion), 0% based on the C&P examination 2 months before separation.  

The panel agreed that there was insufficient limitation of range of motion to provide a minimum rating using VASRD codes 5251 (thigh, limitation of extension of), 5252 (thigh, limitation of flexion of) or 5253 (thigh, impairment of).  In addition, there was no indication of a flail joint of the hip to support an 80% rating using code 5254, ankylosing of the hip to support a 60% rating using code 5250 or malunion of a femur fracture to support a 10% or higher rating using code 5255.  There was no evidence of painful motion (VASRD §4.59) to support a minimum rating using any of the above codes.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 0% for the left hip pain condition, coded 5099-5003 (analogous to arthritis, degenerative).  

Right Foot Pain.  According to the STR and the MEB NARSUM, the CI’s right foot pain condition began in June 2003 after gradual onset with no history of trauma.  A 27 May 2003 bone scan showed no abnormality of the right foot.  Plain film x-rays of the right foot from 25 August 2003 showed subtle, non-diagnostic findings of the right navicular bone.  She was treated with medications and activity limiting profiles without sufficient improvement in symptoms.  There was no surgical indication.  During the 21 November 2003 MEB examination the CI reported that with decreased activity she was having 2-3 exacerbations of foot pain with standing more than 15 minutes or walking more than 10 minutes that lasted until about 30 minutes after she was able to rest and elevate her feet.  Physical examination showed normal heel-toe and tandem gait.  

At the 5 January 2004 C&P evaluation the examiner recorded the history provided above from the MEB H&P.  Physical examination recorded the same findings as at the MEB H&P and added “no palpable deformities.”  

The panel directed attention to its rating recommendation based on the above evidence.  The panel considered if the right foot pain, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  Panel members noted that the foot pain had only improved somewhat during her time of decreased activity and agreed that it was more likely than not that the foot pain would have returned to its previous intensity had the CI returned to the activities required of a soldier.  The panel agreed the evidence reasonably justified that the functional limitations of the right foot pain condition contributed to the CI’s inability to perform her military duties, and accordingly a separate disability rating is recommended.  The PEB rated the bilateral LE pain condition 0%, coded analogous to 5003 (degenerative arthritis), citing use of the US Army Physical Disability Agency pain policy.  The VA rated the right foot pain condition 0%, coded 5284 (foot injury, other), based on the C&P examination 2 months before separation.  There was no evidence of acquired flatfoot or claw foot to rate under the respective codes (5276, 5278).  There was no evidence of hammertoe (5282), metatarsalgia (5279) or fracture with malunion or nonunion of a tarsal or metatarsal bone (5283) and the panel judged that the severity of the CI’s condition did not rise to the level of “moderate” to satisfy the requirement of code 5284.  There was no evidence of painful motion with functional loss supporting a minimum 10% rating (based on §4.59, §4.40 and §4.45).  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 0% for the right foot pain condition, coded 5099-5003 (analogous to arthritis, degenerative).  

Left Foot Pain.  According to the STR and the MEB NARSUM, the CI’s left foot pain condition began in June 2003 after gradual onset with no history of trauma.  A 27 May 2003 bone scan showed a stress fracture in the left foot.  Plain film x-rays of the left foot from 25 August 2003 showed no bone abnormalities.  She was treated with medications and activity limiting profiles without sufficient improvement in symptoms.  There was no surgical indication.  During the 21 November 2003 MEB examination the CI reported that with decreased activity she was having 2-3 exacerbations of foot pain with standing more than 15 minutes or walking more than 10 minutes that lasted until about 30 minutes after she was able to rest and elevate her feet.  Physical examination showed normal heel-toe and tandem gait.  

At the 5 January 2004 C&P evaluation the examiner recorded the history provided above from the MEB H&P.  Physical examination recorded the same findings as at the MEB H&P and added “no palpable deformities.”  

The panel directed attention to its rating recommendation based on the above evidence.  The panel then considered if the left foot pain, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  As above, panel members noted that the foot pain had only improved somewhat during her time of decreased activity and agreed that it was more likely than not that the foot pain would have returned to its previous intensity had the CI returned to the activities required of a soldier.  The panel agreed the evidence reasonably justified that the functional limitations of the right foot pain condition contributed to the CI’s inability to perform her military duties, and accordingly a separate disability rating is recommended.  The PEB rated the bilateral LE pain condition 0%, coded 5099-5003 (analogous to degenerative arthritis), citing use of the US Army Physical Disability Agency pain policy.  The VA rated the left foot pain condition 0%, coded 5284 (foot injury, other), 0% based on the C&P examination 2 months before separation.  There was no evidence of acquired flatfoot or claw foot to rate under the respective codes (5276, 5278).  There was no evidence of hammertoe (5282), metatarsalgia (5279) or fracture with malunion or nonunion of a tarsal or metatarsal bone (5283) and the panel judged that the severity of the CI’s condition did not rise to the level of “moderate” to satisfy the requirement of code 5284.  There was no evidence of painful motion with functional loss supporting a minimum 10% rating (based on §4.59, §4.40 and §4.45).  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 0% for the left foot pain condition, coded 5099-5003 (analogous to arthritis, degenerative).  

Right Tibial Stress Fracture.  According to the STR and the MEB NARSUM, the CI’s right tibial stress fracture condition began sometime prior to July 2003 with a gradual onset with no history of trauma, the exact onset is not well documented.  A 27 May 2003 bone scan showed a grade 1 stress fracture of the right tibia.  Plain film x-rays of the right tibia from 25 August 2003 showed no bone abnormalities.  She was treated with medications and activity limiting profiles and appears to have resolved prior to the MEB.  There was no surgical indication.  During the 21 November 2003 MEB examination the CI reported her right leg did not bother her much anymore and that the pain was not as bad as in her feet and hips.  She reported “occasional” sharp pain that lasted a minute or two.  Physical examination showed a normal heel-toe and tandem gait but did not address the right tibia.  

At the 5 January 2004 C&P evaluation the examiner recorded the history provided above from the MEB H&P.  Physical examination showed a normal and steady gait but did not address the right tibia.  The examiner concluded that the right tibial stress fracture was resolved and there were no significant sequelae.  

The panel directed attention to its rating recommendation based on the above evidence.  The panel then considered if the right tibial stress fracture, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  Although the condition was implicated in the profile and the commander’s statement, there is a paucity of evidence that this condition was ever unfitting in the STR.  In addition, prior to separation this condition appears to have resolved with appropriate treatment.  After due deliberation, the panel concluded that there was insufficient cause to recommend an additional disability rating for the resolved right tibial stress fracture condition.  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 LE pain condition.  

BOARD FINDINGS:  In the matter of the bilateral LE pain condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  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 20160919, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

AR20170015824, 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