RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW
NAME:  XXXXXXXXXXXXXXXX	CASE: PD-2017-02482
BRANCH OF SERVICE: NAVY	SEPARATION DATE: 20081025

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Field Medical Service Technician, medically separated for “bilateral recalcitrant chronic pain due to tibial shin splints” with a disability rating of 10%.

CI CONTENTION: “Currently I cannot run…even on treadmill without pain…” 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 Medical Evaluation Board (MEB), but determined by the PEB 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. The panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections when appropriate. The panel’s assessment of the PEB rating determination is based on review of medical records and all available evidence relevant to application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards for 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, which operates 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 disability at the time of separation.

RATING COMPARISON:

SERVICE PEB - 20080707	VARD - 20090824	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral … Shin Splints	5022-5003	10%	Bilateral Shin Splints	5022-5003	10%	20090604	
COMBINED RATING: 10%	COMBINED RATING OF ALL VA CONDITIONS: 40%	

ANALYSIS SUMMARY:

Bilateral Shin Splints. The PEB combined the left and right tibial shin splints as a single unfitting condition coded 5022-5003 and 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 or implied adjudication that each condition was separately unfitting. 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 Board 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 shin splints condition is presented together, with attendant recommendations regarding separate unfitness, and separate rating if indicated.

According to the service treatment record and MEB narrative summary (NARSUM), the CI’s shin splints began in late 2004 after running. He was placed on limited duty (LIMDU) in November 2004 for a left tibia stress fracture noted on a bone scan in October 2004. An MRI in 2005 also demonstrated a stress fracture to the left tibia. On 18 September 2006 the CI complained of pain in his left leg with a severity of 5/10. A LIMDU was issued on 26 December 2006 for shin splints. On 18 March 2008 a note indicated the CI’s pain was due to high arches and he was treated with orthotics; however, when he received a new pair that did not fit, the pain returned. On examination he had a normal gait and tenderness to the left and right shins. Treatment consisted of light duty and a nonsteroidal anti-inflammatory drug.

A physical therapy (PT) clinic note dated 31 March 2008 indicated the CI’s symptoms re-flared in November 2007 when he went to field medical school. Pain occurred after running or playing soccer. The examiner’s assessment was chronic bilateral mid-tibial shin splints. A low impact warmup, stretching, and select exercises were recommended. Examination revealed the CI had bilateral pes cavus (high arches) and mild swelling over the medial mid-distal tibias. The range  of motion (ROM) was within normal limits without limited dorsiflexion bilaterally. Motor strength of the lower extremities was normal, and there was exquisite tenderness bilaterally of the posteromedial distal tibias. On 8 May 2008 the CI was again placed on LIMDU for shin splints.

The 19 May 2008 MEB NARSUM examination, 5 months prior to separation, noted complaints of bilateral shin pain with on-going discomfort and pain without resolution from the use of anti- inflammatories, skilled PT, inserts, or activity modification. Bone scans in August 2006 and April 2008 were consistent with uptake on both tibia suggestive of stress changes. Also in April 2008 there were additional changes on the posterior aspect of the ankle with mild asymmetric uptake of tracer. Physical examination showed tenderness in the anterior aspects of the tibia bilaterally. He had bilateral calcaneal valgus approximately 5 degrees. On heel rising, he inverted to varus  in the heel. His ankles had a ROM to 4 degrees bilaterally with the knee extended. Subtalar joint ROM was smooth and there was no tenderness to the osseous structures of the foot. Single heel raising reproduced some symptoms along the posterior aspects of the tibia bilaterally. Muscle strength was normal. The examiner’s diagnosis was bilateral, recalcitrant, chronic pain due to tibial shin splints. The non-medical assessment dated 19 June 2008 indicated his medical condition rendered him unfit for sea duty, non-deployable, and prevented him from satisfactorily performing required tasks. However, he passed the most recent physical fitness test by opting to do the stationary bicycle vice the run.

At the 28 May 2009 VA Compensation and Pension (C&P) examination, 7 months after separation, the CI reported continued pain in his left shin and in the foot arch when running. He had no flare-ups. Physical examination showed his posture and gait were normal. He did not use any crutches or braces, but he frequently used arch supports. The right and left knees were stable with ROM of 0-140 degrees for each knee without pain or change in findings for either knee. There was no evidence of a meniscal tear in either knee. The right and left ankle ROMs were dorsiflexion 0-20 degrees (normal) and plantar flexion 0-40 degrees (normal 0-45), both motions were without pain and findings were unchanged after three repetitions. The os calcis on both the right and left were normal in relation to the long axis of the tibia and fibula of each lower extremity. The examiner’s diagnoses were bilateral shin splints and left tibial fracture without any increase in functional limitation of any of the examined joints.

The panel directed attention to its rating recommendation based on the above evidence. The PEB and the VA both rated the shin splints 10%, dual-coded 5022-5003 (periostitis- degenerative arthritis). The VA based the rating on the C&P examination, citing painful or limited motion of a major joint or group of minor joints, which may also be applied once to multiple joints, if there is no limited or painful motion.

The panel first determined if the left and right shin splint conditions were separately unfitting The CI had two LIMDU episodes in 2006 and 2008 for shin splints; he was unable to perform his duties at sea and as a field medical technician. The panel noted there was no evidence that the shin splints affected the knees or the ankles per se, although a bone scan did show the posterior aspect of the ankle (unclear whether it was one, the other, or both) with mild asymmetric uptake of tracer. Furthermore, panel members noted at a PT visit, 6 weeks prior to the NARSUM examination, ankle ROM was not limited, while at the NARSUM examination ankle ROM was to 4 degrees bilaterally with the knee extended. However, at the VA examination the ankle ROM was within normal limits. Therefore, panel members concluded that how ROM was measured, whether there was pain before, during, or after the motions, and whether they were of dorsiflexion or plantar flexion, was all unclear. Therefore, in the absence of evidence-based findings, the panel could not conclude that there was sufficient ankle impairment to warrant a separate rating greater than 0% using code 5262 (tibia and fibula, impairment: malunion) for either the right or left shin splints condition. While it is unclear how the PEB arrived at a 10% rating using code 5022-5003, bone scans did show stress changes of the tibias proximate to separation and uptake at the posterior aspect of the ankle, which would arguably fall within the VASRD requirements of using the analogous code 5099-5003 at 10% for “X-ray (imaging) evidence of involvement of two or more major joints or two or more minor joint groups.” After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded there was insufficient cause to recommend a change in the PEB adjudication for the bilateral tibial shin splints condition.

BOARD  FINDINGS:       In the matter of the  bilateral tibial shin splints condition and IAW VASRD
§4.71a, the panel recommends no change in the PEB adjudication. There are no other conditions within the panel’s scope of review for consideration. Therefore, the panel recommends 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 20170315, w/atchs Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record

DEPARTMENT OF THE NAVY
SECRETARY OF THE NAVY COUNCIL OF REVIEW BOARDS 720 KENNON STREET SE STE 309
WASHINGTON NAVY YARD, DC 20374-5023

IN   REPLY   REFER TO,
1850
CORB: 003 20May20

From: 

Director, Secretary of the Navy Council of Review Boards 

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW  (PDBR)

Ref:	(a) DoDI 6040.44
(b) PDBR ltr dtd 4 Mar 19

1.	Pursuant to reference (a), the PDBR reviewed your case and forwarded its recommendation (reference (b)) to the Department of the Navy on 5 Mar 2020 for appropriate action.

2.	On 20 March 2020, the Assistant Secretary of the Navy (Manpower & Reserve Affairs) accepted the recommendation of the PDBR of no change to your characterization of separation or disability rating assigned by the Department of the Navy's Physical Evaluation  Board.

3.	The Secretary's decision on your PDBR application is final and is not subject to appeal or additional review by the Board for Correction of Naval Records.

Copy to: PDBR