RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXX  	CASE:  PD-2017-02548
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20040126

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E2, Basic Trainee, medically separated for “bilateral tibial stress fractures” with a disability rating of 0%.  

CI CONTENTION:  “On going issues has caused more issues in surrounding areas.”  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 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 – 20040102	VARD - 20040428	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Tibial Stress Fractures 	5022	0%	Status Post Bilateral Stress Fractures and Mid Shaft Tibia and Achilles Tendonitis, Left Ankle	5022-5262	10%	20040428	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  20% 	

ANALYSIS SUMMARY:  

Bilateral Tibial Stress Fractures.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s bilateral tibial fractures condition began in August 2003 during basic training.  Because of more pain on the left, she was provided crutches and referred to physical therapy.  Initial X-rays were normal, but a bone scan on 28 August 2003 revealed a Grade II mid left tibia stress fracture as well as a severe stress reaction or early developing stress fracture of the right tibial shaft.  There were also stress reaction changes of the mid femur, knees, tibial shafts, ankles, and feet.  Despite convalescent leave for a month and rehabilitation thereafter, she reported slight improvement at a physical therapy clinic visit on 12 November 2003, but still complained of bilateral tibial pain, greater on the right than the left as well as with left Achilles pain and right hip pain.  

The 10 December 2003 MEB NARSUM examination, one month prior to separation, noted the complaint of pain in the right and left legs.  Physical examination of the bilateral lower extremities revealed tenderness of the mid-shaft of each tibia.  Bilateral knee range of motion (ROM) was from 0 to 135 degrees (normal 0-140) for each knee. Varus and valgus testing (for laxity) was negative. Bilateral Lachman’s and the pivot shift tests (for instability) of the anterior cruciate ligament (ACL) were normal.  X-rays revealed a healing left tibia stress fracture.  A bone scan revealed a stress reaction of the right tibial shaft and a Grade 2 left tibial stress fracture.  There were stress reaction changes of the mid-femur and knees, tibial shafts, feet, and ankles.  

At the 28 April 2004 VA Compensation and Pension (C&P) examination, 3 months after separation, the CI reported intermittent right anterior mid-shaft tibial pain with activities and left ankle pain as a result of limping due to the stress fractures.  Physical examination of left and right knees revealed full flexion to 140 degrees (normal).  The left ankle ROM following repetition showed dorsiflexion of 20 degrees (normal) and plantar flexion of 45 degrees (normal).  Tenderness of the mid shaft tibia was greater on right than left.  There was no effusion, swelling or erythema of the knee.  Lachman's and McMurray's (to determine a meniscal tear) testing was negative.  There was no joint line tenderness or any medial or lateral tibial condyle tenderness.  There was tenderness of the Achilles tendon and calcaneus (heel), and there was guarding with inversion of the left ankle.  A Tinel's sign (to determine nerve irritation) was positive.  An EMG (electromyogram) indicated a normal left lower extremity with no evidence of a sensory neuropathy or lumbosacral radiculopathy noted.  X-rays of the left foot showed no fracture or dislocation and no increase in soft tissue density.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral tibial stress fractures 0%, analogously coded 5022 (periostitis), citing no loss of joint function.  The VA rated the bilateral tibial stress fractures 10%, analogously coded 5022-5262 (periostitis-tibia and fibula, impairment) based on the C&P examination, citing malunion of the tibia and fibula with slight knee or ankle disability.  

The panel determined that the left tibial stress fracture and the severe stress reaction or early developing stress fracture of the right tibial shaft were each separately unfitting in the absence of a preponderance of evidence indicating the condition would not cause the CI to be referred into the DES or be found unfit because of physical disability.  While bone scan evidence clearly showed a left mid tibia stress fracture, the right tibia findings were less clear.  Proximate to separation there were still changes of each tibia.  Therefore, use of code 5022, which is rated under code 5003 (degenerative arthritis) at 10% in the absence of occasional incapacitating exacerbations with X-ray evidence of involvement of two or more major joints or two or more minor joint groups, is reasonable.  Alternatively, the STR indicated at a visit prior to separation, the right tibia was more symptomatic than the left; however, there was no significant knee or ankle disability documented prior to separation, although there was left Achilles and heel tenderness.  Therefore, use of code 5262 (tibia, fibula, impairment) cannot provide a rating higher than 0% for either tibia.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel majority recommends a disability rating of 10% for the bilateral tibial stress fractures condition, coded 5262-5022.  

BOARD FINDINGS:  In the matter of the bilateral tibial stress fractures, the panel majority recommends a disability rating of 10%, coded 5262-5022 IAW VASRD §4.71a.  The single voter for dissent recommends no change and no re-characterization and did not elect to submit a minority opinion.  There are no other conditions within the panel’s scope of review for consideration.  

The panel recommends the CI’s prior determination be modified as follows, effective the date of medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Bilateral Tibial Stress Fractures	5262-5022	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170220, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

	PD-2017-02548

AR20200000628, XXXXXXXXXXXXXXXXX 

Dear XXXXXXXXXXXXXXXX

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.

	PD-2017-02548