RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW
NAME:  XXXXXXXXXXXXXXXX	CASE: PD-2017-03781
BRANCH OF SERVICE: ARMY	SEPARATION DATE: 20080229

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty, Multichannel Transmission Systems Operator Maintainer, medically separated for “bilateral lower extremity pain” with a disability rating of 0%.

CI CONTENTION: “Left and right tibial periostitis.” 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 - 20080307	VARD - 20080325	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Lower Extremity Pain	5099-5003	0%	Right Tibial Periostitis	5399-5312	10%	20071119	
			Left Tibial Periostitis	5399-5312	10%	20071119	
COMBINED RATING: 0%	COMBINED RATING OF ALL VA CONDITIONS: 50%	

ANALYSIS SUMMARY:

Bilateral Lower Extremity (BLE) Pain. The PEB combined the BLE conditions under a single disability rating, analogously coded 5099-5003 and rated 0% with application of the U.S. 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 BLE conditions is presented together with attendant recommendations regarding separate unfitness, and a separate rating for each lower extremity, if indicated will be assigned.

According to the service treatment record and MEB narrative summary (NARSUM), the CI’s BLE condition was diagnosed as shin splints in February 2006. A whole body bone scan dated 20 April 2006 demonstrated bilateral increased uptake along the tibial shafts suggesting shin splints with a stress fracture of the right tibia. A note dated 14 November 2006 indicated the CI had unresolving shin splints and a right tibial stress fracture. X-rays of the left tibia/fibula dated 15 November 2006 were normal and X-rays of the right tibia demonstrated a subtle relative increased thickness of the medial cortex of the mid shaft of the tibia at or within normal limits, which may have been related to the prior stress fracture. At a primary care clinic visit on 25 April 2007, the CI complained of bilateral shin and calf pain. On examination there was tenderness of the tibial shafts of both legs without swelling, warmth, or erythema of the legs. There was pain on the medial aspect of the lower legs with flexion against resistance. Treatment consisted of a nonsteroidal anti-inflammatory drug and the CI was referred to physical therapy.

A bone scan dated 15 June 2007 demonstrated some slight asymmetry on the right compared to the left, although it was not compelling for acute stress periostitis. A primary care examination on 26 June 2007, 8 months prior to separation, noted constant bilateral shin pain with a severity of 6/10. Physical examination documented no abnormalities of the knees or ankles. At an orthopedic examination on 28 June 2007, the CI complained of lower leg pain regardless of his activity. Physical examination showed a change in gait favoring both sides. There was no edema, deformity, or ecchymosis of the lower extremities. He was tender over the pad of the tibialis posterior tendons bilaterally and minimally tender over the tibias. Ankle range of motion (ROM) was limited in plantar flexion only. Strength of the left lower extremity was decreased for the tibialis posterior and there was peroneal pain on the right. There was no sign of any stress fracture, although there was perhaps very mild periostitis. Despite activity modification, a trial of arch supports, physical therapy, and profiles, the BLE pain did not subside enough for the CI to resume his primary military duties. The 4 October 2007 MEB NARSUM examination, 5 months prior to separation, noted complaints of chronic bilateral leg pain related to shin splints. No physical examination findings were recorded. The examiner’s diagnosis was chronic bilateral shin splints.

At the 19 November 2007 VA Compensation and Pension (C&P) examination, 3 months before separation, the CI reported [bilateral shin] pain, occasional swelling, and occasional redness, warmth, swelling and tingling with running. He also experienced flare-ups with walking or climbing steps, which was relieved with Tylenol (acetaminophen, a pain reliever). He denied his legs gave way and he was able to perform activities of daily living. Physical examination showed a non-antalgic gait. There was tenderness anteriorly and medially of the knees. Flexion of the right and left knees was 0-130 degrees (normal 0-140) without pain or loss of motion following repetition. Dorsiflexion of each ankle was 20 degrees (normal) and plantar flexion was 40 degrees (normal 45) without pain or loss of motion following repetition. There was tenderness of the tibia at the mid one-third bilaterally.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the BLE condition 0%, analogously coded 5099-5003 (degenerative arthritis), citing the
U.S. Army Physical Disability Agency pain policy. The VA rated each lower leg pain condition 10%,

analogously coded 5399-5312 (Group XII. Function: anterior muscles of the leg), based on the C&P examination, citing a moderate muscle disability.

The panel first considered whether each lower extremity condition was separately unfitting and determined that both the left lower extremity condition and right lower extremity condition were each separately unfitting and each warranted a separate rating. The panel noted the CI had persistent pain since an initial bone scan was consistent with bilateral shin splints and a right tibial stress fracture. However, follow-up imaging studies did not identify either the shin splints or the right tibial stress fracture, although there was slight asymmetry on the right compared to the left, but the findings were not compelling for acute stress periostitis. Therefore, in view in the lack of limitation of motion of either leg for flexion or extension (code 5260 or 5261) or ankle pathology, for rating purposes code 5262 (tibia and fibula, impairment) is most appropriate. However, in the absence of either a knee or ankle disability, a rating higher than 0%, using code 5262 for either lower extremity, is not achievable. Neither muscle code 5312 (Group XII), as used by the VA, nor code 5311 (Group XI. Function: muscles of the calf) has any basis to achieve a rating higher than 0% in the absence of significant objective evidence of a residual disability. 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 BLE pain condition.

BOARD FINDINGS:  In the matter of the bilateral lower extremity pain 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:

PD-2017-03781

AR20190010844, XXXXXXXXXXXXXXX 

Dear XXXXXXXXXXXXXXX

	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.

PD-2017-03781