RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01116
BRANCH OF SERVICE:  ARMY 	SEPARATION DATE:  20040518

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 “transverse inferior pubic ramus stress fracture” and “multiple stress reactions lower extremities” rated at 0% each, with a combined rating of 0%.   

CI CONTENTION:  Her conditions were found not to be service-related, but they would not have occurred had she not undergone Army training.  She continues to experience pain in all affected areas that will worsen in the future.  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 - 20040415	VARD - 20070706	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Transverse Inferior Pubic Ramus Stress Fracture	5099-5003	0%	Transverse Inferior Pubic Ramus Stress Fracture, Right (Coccyx)	5099-5003	NSC	STR	
Multiple Stress Reactions Lower Extremities	5022	0%	Stress Fractures, Right Foot (Claimed as Feet-Plantar)	5299-5284	NSC	STR	
			Stress Fractures, Left Foot (Claimed as Feet-Plantar)	5299-5284	NSC	STR	
			Stress Fractures, Left Knee (Also Claimed as Multiple Fractures)	5099-5022	NSC	STR	
			Stress Fractures, Right Knee (Also Claimed as Multiple Fractures)	5099-5022	NSC	STR	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS NA	

ANALYSIS SUMMARY:  

Transverse Inferior Pubic Ramus Stress Fracture.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s transverse inferior pubic ramus stress fracture condition began as hip pain in late August 2003 or early September 2003 during basic training.  On 16 October 2003 the CI complained of discomfort of the right inferior pubic ramus (IPR).  On examination she had a positive FABER’s test (to determine hip pathology) and a positive scour’s test (to determine hip dysfunction) with focal pain to palpation at the right IPR.  The examiner’s impression was a stress fracture of the right IPR.  Treatment consisted of crutches, Naprosyn (naproxen, a nonsteroidal anti-inflammatory drug (NSAID)), and physical therapy evaluation.  Because of bilateral hip pain, the left worse than the right, X-rays of the hips were obtained on 9 December 2003.  X-rays of the left hip were normal; however, X-rays of the right hip demonstrated a healing transverse fracture through the right inferior pubic ramus with a normal right hip.  Examination in the family medicine clinic on 9 December 2003 revealed a full range of motion (ROM) of both hips with no masses, lesions, or deformities, but with tenderness to palpation of the greater trochanter areas.  Treatment consisted of calcium carbonate and continued NSAID use.  A bone scan dated 11 December 2003 of the pelvis and lower extremities demonstrated “focally increased activity in the right superior and inferior pubic rami consistent with stress fracture” and “increased activity in the knees and feet consistent with stress reactions.”  On 12 December 2003 it was recommended that no running occur for 3 to 4 months and then progressively increasing thereafter.  Examination on 20 January 2004 revealed tenderness along the tibial shafts bilaterally, tenderness to the metatarsals bilaterally, and tenderness to palpation of the right pubic rami.  Average ROM measurements of the left hip were flexion 97 degrees (normal 125), extension 25 degrees (normal 20), internal rotation 80 degrees (normal 45), external rotation 90 degrees (normal 45), and abduction 50 degrees (normal 45).  Examination at the family practice clinic on 27 January 2004 revealed tenderness on palpation of the pelvic girdle, right pubic tubercle, right side of the pubic symphysis, right ischial tuberosity, and sacrococcygeal joint. 

During the 17 February 2004 MEB examination (recorded on DD Forms 2807-1 and 2808), 3 months prior to separation, the CI reported “I broke my right pelvic bones in September 2003.”  Physical examination revealed tenderness to palpation of the right pubic rami.  The 5 March 2004 MEB NARSUM examination, 2 months prior to separation, noted complaints of hip pain, which limited her from running, jumping, ruck sacking, or crawling.  Physical examination showed no erythema swelling, ecchymosis, or bruising.  There was tenderness to palpation over the greater trochanter, and the CI had a full ROM of the left lower extremity.  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 rated the pelvic condition 0%, coded 5099-5003 (arthritis, degenerative), citing no loss of joint motion.  Members noted the CI’s symptoms were initially to the right IPR; however subsequent X-rays and a bone scan indicated that the right pubic rami (superior and inferior) had stress fracture evidence that was healing.  However, there is no VASRD code for pelvic fracture(s).  Therefore, members considered use of VASRD codes related to the hip and thigh.  There was no ankylosis of the hip (code 5250), thigh limitation of extension or flexion (codes 5251 or 5252), thigh impairment (code 5253), hip flail joint (code 5254), or femur impairment (5255) per se; however, use of an analogous code 5299-5255 for malunion of the femur for slight knee or hip disability is not unreasonable at 10% since flexion of the hip was decreased to 97 degrees, although all other motions were above their normal ROMs. While tenderness to palpation of the femoral trochanter and pelvic ramus, there was no painful motion to support a 10% rating using code 5099-5003.  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 transverse inferior pubic ramus stress fracture condition, coded 5299-5255.

Multiple Stress Reactions Lower Extremities.  The PEB combined the hip, knee, and feet conditions as a single unfitting condition coded 5022 and rated 0%.  The 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 Board 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 hip, knee, and feet conditions are presented together, with attendant recommendations regarding separate unfitness, and separate rating if indicated.  

According to the STR and MEB NARSUM, the CI’s multiple stress reactions of the lower extremities condition began in late August 2003 or early September 2003 during basic training.  A bone scan dated 9 December 2003, ordered for pain in both hips, left greater than right,  demonstrated focally increased activity in the right superior and inferior pubic rami consistent with stress fracture and increased activity in the knees and feet consistent with stress reactions.  Examination on 20 January 2004 revealed tenderness along the tibial shafts bilaterally, tenderness to the metatarsals bilaterally, and tenderness to palpation of the right pubic rami.  The CI was recommended not to run for 3 to 4 months.  Examination at the family practice clinic on 27 January 2004 revealed tenderness on palpation of both legs, which was localized in the tibial shafts of both legs with edema of both legs anteriorly, left greater than right.  No leg abnormalities were seen and appearance of the legs was normal.  There was no tenderness on ambulation of the legs and there was no crepitus (grinding sensation).  There was tenderness on palpation of both feet in the area of the metatarsal bones and mid foot.  The feet had a normal appearance; foot motion was normal; and no pain was elicited by motion of the feet.  At an orthopedic clinic visit on 10 February 2004 the CI reported bilateral hip, knee and foot pain since she started basic training and her pain was worse with activities and was relieved with rest.  An L3 profile was issued on 16 February 2004 for bilateral hip, knee, and foot pain (stress fractures).

During the 17 February 2004 MEB examination (recorded on DD Forms 2807-1 and 2808), 3 months prior to separation, the CI reported her knees swelled when she was on her feet for a long time and her legs were “messed up.”  Physical examination demonstrated tenderness to palpation of the greater trochanter bilaterally, the left femur, the knee joint lines bilaterally, and the plantar surface of both feet as well as tenderness to palpation of the coccyx.  The commander’s statement dated 27 February 2004 indicated the CI was not capable of qualifying in her MOS due to physical ailments since she would not be able to keep up physically to perform the duties of a Patriot [missile] crew member operator/maintainer.  The 5 March 2004 MEB NARSUM examination, 2 months prior to separation, noted complaints of bilateral hip, knee, and foot pain.  Physical examination showed no erythema, swelling, ecchymosis, or bruising and the skin was intact.  The CI had tenderness to palpation over the greater trochanters.  There was a full active ROM of the left lower extremity.  Sensation was intact distally and pulses were palpable.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the multiple stress reactions lower extremities condition 0%, coded 5022 (periostitis), citing normal x-rays and positive bone scan with pain precluding continued duty.  Other than bone scan findings of stress reactions in the knees and feet and tenderness to palpation of the greater trochanters, knees and feet, the STR was silent on painful motion and only noted left lower extremity full ROM, but not the right lower extremity ROM.  Therefore, with insufficient information to accurately determine fitness or unfitness for each anatomical site of the lower extremities, members agreed with the PEB findings that bundled the multiple stress reactions of the lower extremities as a single condition.  However, since there were changes on the bone scan that showed increased activity in the knees and feet consistent with stress reactions, the use of code 5099-5003 (arthritis, degenerative) at 10%, especially since code 5022 is rated using code 5099-5003, is not unreasonable based on “X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups” in the absence of limitation of motion, albeit there was only limited information related to painful motion, although the PEB acknowledged “pain precluding continued duty.”  Furthermore, panel members are aware that stress reactions resolve with time and removal of the inducing factors such as running or marching; however, follow-up information in the form of imaging studies prior to separation as well as within 12 months thereafter was not available.  Therefore, it would be speculative whether the stress reactions resolved or did not resolve prior to separation.  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 multiple stress reactions lower extremities condition, coded 5099-5003.  

BOARD FINDINGS:  In the matter of the transverse inferior pubic ramus stress fracture condition, the panel unanimously recommends a disability rating of 10%, coded 5299-5255 IAW VASRD §4.71a.  In the matter of the multiple stress reactions lower extremities condition, the panel recommends a disability rating of 10%, coded 5099-5003 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	
Transverse Inferior Pubic Ramus Stress Fracture	5299-5255	10%	
Multiple Stress Reactions Lower Extremities	5099-5003	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160705, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Records

AR20170018548, 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