RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-02638
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20070304

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Petroleum Supply Specialist, medically separated for “chronic bilateral lower leg pains…shin splints” and “chronic left, non-dominant, wrist pain,” rated 0% each, with a combined disability rating of 0%.  

CI CONTENTION:  “Left wrist pain, bilateral shin splints (both), left knee pain, P.T.S.D.”  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 - 20070122	VARD - 20071004	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Bilateral Lower Leg Pains	5099-5022	0%	Bilateral Shin Splints	5262	10%	20070412	
Left Knee Pain	Not Unfitting					
Chronic Left, Non-Dominant, 
Wrist Pain	5024	0%	Dequervain's Tenosynovitis of the Left Wrist	5024	10%		
Depression, Not Otherwise Specified	Not Unfitting	Adjustment Disorder 	9440	10%		
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Chronic Bilateral Lower Leg Pains.  The PEB combined the left and right leg pains under a single unfitting condition coded 5099-5022 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 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 (includes code 5022) 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 leg conditions is presented together, with attendant recommendations regarding separate unfitness, and separate rating if indicated.  

According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s bilateral lower leg condition began during basic training, but resolved in about 2-3 weeks.  At a troop medical clinic examination on 26 January 2006, he had pain to palpation of the lower half of the shins and each was warm to the touch without erythema (redness).  X-rays of the lower extremities were normal, but a bone scan demonstrated extremely severe shin splints, left more than right, with multiple occult fractures of both tibias.  A follow-up bone scan in May 2006, showed marked improvement with minimal residual shin splints seen bilaterally and no residual occult fractures.  Subsequently, the CI developed anterior left knee pain as he transitioned to the walk to run program.  X-rays of the left knee were normal on 7 August 2006.  At an orthopedic visit on 14 October 2006, the left knee, after a series of tests and maneuvers, was normal.  However, there was tenderness without localized swelling of the legs or calves but no warmth, erythema or induration.  

During the 24 October 2006 MEB examination (recorded on DD Forms 2807-1 and 2808), 4 months prior to separation, the CI reported bilateral shin splints and left knee pain.  The examiner indicated the CI had a normal lower extremity evaluation, but listed bilateral shin pain and left anterior knee pain in the significant or disqualifying defects section.  At a family practice clinic visit on 31 October 2006, examination of the knees, legs, and ankles was normal.  The commander’s statement dated 20 November 2006 indicated the CI’s performance had been in decline due to bilateral shin splints.  At the 22 December 2006 MEB NARSUM examination, 2 months prior to separation, the CI reported that his “legs and wrists hurt all the time.”  

At the 12 April 2007 VA Compensation and Pension (C&P) examination, 1 month after separation, the CI reported aching and cramping pain at the front of the lower legs.  Physical examination showed a normal gait, but there was tenderness along the right and left tibia and fibula.  There was also tenderness of the left knee with movement of the patella.  Range of motion (ROM) testing of each knee showed extension-to-flexion of 0-140 degrees (normal) with painful motion of the left knee.  There was no instability, laxity or evidence of a meniscal tear of either knee.  Examination of the ankles and ROMs were normal.  X-rays of the left knee, right tibia-fibula and left tibia-fibula were negative.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral leg condition 0%, analogously coded 5099-5022 (periostitis), citing no loss of motion.  The VA rated the bilateral leg condition 10%, coded 5262 (impairment of tibia and fibula), based on the C&P examination, citing painful, but not limited, motion in the left knee, with pain in the bilateral tibia.  

The panel first determined the left and right leg conditions were separately unfitting as supported by the permanent profile and commander’s statement.  The panel noted there was evidence the shin splints affected the left knee, but not the ankles per se.  ROM measurements of the left knee were normal at the VA examination, but there was painful motion.  Examination of the ankles and movements were normal at the VA examination.  Although X-rays of the left knee were negative prior to separation and X-rays of the knees and ankles were negative at the VA examination, the earlier bone scan showed minimal residual shin splints bilaterally and there was clinical tenderness at examinations proximate to separation.  Thus, the panel considered use of code 5299-5262 at 10% for impairment of the left lower extremity with slight knee involvement and code 5299-5262 at 0% for impairment of the right lower extremity without knee or ankle involvement.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the left leg condition, coded 5299-5262 and a disability rating of 0% for the right leg condition, coded 5299-5262.  

Chronic Left, Non-Dominant, Wrist Pain.  According to the STR and MEB NARSUM, the CI’s left wrist condition began in October 2004 while in AIT without known trauma.  He was diagnosed with probable De Quervain’s tenosynovitis (swelling of the sheath around the thumb tendon) and treated with a thumb spica splint.  X-rays of the left wrist in April 2005 were normal.  On 20 April 2005 the Finkelstein’s test was positive (for tenosynovitis), but he had no pain with thumb flexion or extension or with resisted wrist extension or flexion.  The CI in August 2006 declined surgery.  

An occupational therapy ROM evaluation on 22 September 2006 showed left wrist flexion of 75 degrees (normal 80), extension of 75 degrees (normal 70), ulnar deviation of 30 degrees (normal 45) and radial deviation of 20 degrees (normal) with pain in all planes of movement.  Finkelstein’s test of the left wrist was positive.  

During the MEB examination, the CI reported left wrist pain.  Physical examination revealed normal left wrist strength.  The MEB NARSUM examination noted complaints of left wrist pain and referenced the orthopedics examination which showed 10/10 pain without use of a wrist brace and 0/10 pain with the brace.  

At the VA C&P examination, the CI reported 8/10 left wrist pain.  Physical examination showed the CI wore a spica splint on the left wrist.  There were no signs of edema, effusion, weakness, tenderness, redness, heat, abnormal movement, subluxation or guarding of movement.  However, there was tenderness and a positive Finkelstein test.  ROM measurements were dorsiflexion of 70 degrees, palmar flexion of 80 degrees, radial deviation of 20 degrees and ulnar deviation of 45 degrees.  Pain occurred at the end of all motions.  Joint function was limited 5 additional degrees after repetition by pain, but not by fatigue, weakness, lack of endurance or incoordination.  X-rays of the left wrist were negative.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left wrist condition 0%, coded 5024 (tenosynovitis), citing no mechanical loss of motion.  The VA rated the left wrist condition 10%, coded 5024 (tenosynovitis), based on the C&P examination, citing pain limited motion.  

The panel noted the CI had no limitation of motion (code 5215) or wrist ankylosis (code 5214), but had pain at the end of all motions documented by occupational therapy and the VA C&P examination.  Furthermore, without the spica splint, the wrist pain was maximal, but with the splint, the pain was absent.  Therefore, a 10% rating using code 5024 (which is rated IAW code 5003) is supported by satisfactory evidence of functional loss and painful motion IAW VASRD §4.59, §4.40 and §4.45.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the left wrist condition, coded 5024.  

Contended PEB Conditions:  Left Knee Pain and Depression, Not Otherwise Specified.  The panel’s main charge is to assess the fairness of the PEB determination that the contended conditions were not unfitting.  As noted above, any disability from the left knee condition was subsumed in the rating of the left lower leg condition because the left knee pain was either caused by the shin splints or related to them.  Therefore, while a separate rating is warranted, the knee pain rating is subsumed in the rating for the left lower leg condition using code 5299-5262.  An additional rating would be pyramiding (VASRD §4.14), so no additional disability rating is recommended.     

Depression, Not Otherwise Specified.  The condition was neither profiled nor implicated in the commander’s statement and did not fail retention standards.  There was no performance-based evidence from the record that the depression significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded there was insufficient cause to recommend a change in the PEB fitness determination for the depression, so no additional disability rating is recommended.

BOARD FINDINGS:  In the matter of the left leg pain, the panel recommends a disability rating of 10%, coded 5299-5262 IAW VASRD §4.71a.  In the matter of the right leg condition, the panel recommends a disability rating of 0%, coded 5299-5262 IAW VASRD §4.71a.  In the matter of the left wrist condition, the panel recommends a disability rating of 10%, coded 5024 IAW VASRD §4.71a.  In the matter of the contended depression, the panel recommends no change from the PEB determination as not unfitting.  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	
Chronic Left Lower Leg Pain	5299-5262	10%	
Chronic Right Lower Leg Pain	5299-5262	0%	
Chronic Left, Non-Dominant, Wrist Pain	5024	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170329, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20190006128, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX

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.