RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW
NAME:  XXXXXXXXXXXXXXX	CASE: PD-2017-03901
BRANCH OF SERVICE: ARMY	SEPARATION DATE: 20040629

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was a Reserve E2, Trainee, medically separated for “multiple stress reactions of the lower extremities” with a disability rating of 0%.

CI CONTENTION:  No specific contention was made. 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 - 20040605	VARD - 20040702	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Multiple Stress Reactions of the Lower Extremities	
5099-5022	
0%	Stress Reactions of Left Hip	5299-5252	10%	STR	
			Stress Reactions Right Lower Tibia	5299-5262	10%	STR	
			Stress Reactions Right Foot	5299-5284	10%	STR	
COMBINED RATING: 0%	COMBINED RATING OF ALL VA CONDITIONS: 30%	

ANALYSIS SUMMARY:

Multiple Stress Reactions of the Lower Extremities. The PEB combined stress reactions of the bilateral feet, legs, and left hip under a single disability rating, coded 5099-5022 and rated 0%. 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’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. If the panel recommends separate fitness recommendations in this circumstance, it may not recommend a lower combined rating than that of the PEB. The evidence for the multiple stress reactions is presented separately, 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 was evaluated for right foot pain in August 2003 early in basic training. A bone scan showed a right foot navicular stress fracture. In November 2003, the CI reported right and left foot pain. Bone scan showed a healing right foot navicular stress fracture and a normal left foot. The CI had been restricted from running and jumping and was placed in a temporary program; in January 2004 he was returned to basic training during the third week. At a podiatry visit on 10 February 2004, the CI reported bilateral shin and right foot pain. Radiographs were negative for fracture. The CI reported improvement but pain in the tibia when climbing stairs.

At a primary care visit on 1 March 2004, 3 months prior to separation, the CI reported pain in the left thigh. Physical examination showed painful motion of the left hip, but the remainder of the hip examination was normal. A bone scan on 5 March 2004 showed stress reactions of the left acetabulum and right and left tibial shafts. At the primary care follow-up examination a week later, a limp was noted. Physical examination of the hips, thighs, knees, shins, ankle, and foot was normal except for tenderness of the shins. The examiner noted full ROM of the extremities. During the 18 March 2004 MEB examination (recorded on DD Forms 2807-1 and 2808), 3 months prior to separation, the CI reported foot trouble; stress fractures of the right foot and left shin; and stress reactions of the right shin and left hip. Physical examination of the lower extremities and feet was checked as normal.

The 26 April 2004 MEB NARSUM examination, 2 months prior to separation, noted complaints of left hip pain. The examiner reviewed the bone scans and X-rays and noted the most recent bone scan in March 2004 showed stress reactions in the right and left foot, right and left tibia and left hip, and X-rays showed no evidence of fractures. Physical examination showed a normal gait. There were no areas of swelling, heat, redness, or local tenderness consistent with the bone scan findings. There was pain in the left hip adductor region. Left hip range of motion (ROM) testing showed abduction of 25 degrees (normal 45), external rotation of 30 degrees (normal 60) and adduction of 20 degrees (normal 25). The knees were normal and demonstrated full ROM. There was no tenderness of the lower leg muscles. Ankle ROM testing showed dorsiflexion (DF) of 15 degrees (normal 20) and plantar flexion (PF) of 30 degrees (normal 45) on the right, and DF of 20 degrees and PF of 40 degrees on the left. Forefoot mobility was normal, but there was “pain on exam, especially in the right foot.” The commander’s statement indicated the CI’s “legs” hurt, and that the CI had been on an extended profiles which limited physical activity. The permanent profile dated 18 May 2004 listed multiple stress reactions. There was no VA examination proximate to separation in evidence.

The panel first considered if the left and right feet, left and right legs, and left hip stress reactions, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above. The MEB NARSUM determined the CI failed retention standards due to “stress reactions of the bilateral feet, legs, and left hip.” Although the CI reported varying locations of pain in his lower extremities over various clinic visits during basic training, notes in the STR support that he sought treatment predominately for right foot and left hip pain, and to a lesser degree, bilateral tibial pain. The panel concluded the right foot, left and right tibiae and left hip stress reactions were reasonably considered separately unfitting, but there was a preponderance of evidence that showed the left foot stress reactions, by themselves, would not have caused the CI to be referred into the DES or to be found unfit.

The panel directed attention to its rating recommendations based on the above evidence. The PEB rated the lower extremity stress reactions 0%, analogously coded 5099-5022 (periostitis). The VA rated stress reactions of the left hip 10%, analogously coded 5299-5252 (limitation of thigh flexion), based on the STR, citing “slight decreased motion with pain.” The VA also rated stress reactions of the right lower tibia 10%, analogously coded 5299-5262 (impairment of tibia and fibula), based on the STR, citing “slight ankle painful limiting motion” and stress reactions of the right foot 10%, analogously coded 5299-5284 (foot injury, other), based on the STR, citing “moderate painful functional impairment of the right foot.”

Right Foot Stress Reactions. There was evidence of painful limition of motion supporting a 10% rating, coded 5022, or alternatively coded 5271 (limitation of ankle motion) for moderate limitation of ankle motion. The panel considered other VASRD foot and ankle codes but all were less applicable. There was therefore no higher than 10% rating supported for the right foot condition under any applicable VASRD code. 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 right foot condition, coded 5271-5022.

Right and Left Tibiae Stress Reactions. There was no limitation of motion or painful motion of either knee to support a 10% rating for the right or left tibial stress reactions under codes 5022, 5299-5260 (analogous to limitation of leg flexion) or 5299-5262 (tibia or fibula, impairment). Impairment due to limitation of ankle motion or painful ankle motion was considered in the panel’s rating recommendations above for the feet and additional rating of the same impairment cannot be effected without pyramiding (VASRD §4.14). There was therefore no higher than a 0% rating supported for either tibial condition. After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 0% for the right tibia condition and a 0% rating for the left tibia condition, each coded 5022.

Left Hip Stress Reactions. The panel agreed there was insufficient evidence of painful motion of the left hip at the MEB NARSUM examination to support a 10% rating under codes 5022 or 5299- 5252 (analogous to limitation of thigh flexion). The panel considered other VASRD hip and analogous codes and all were less applicable or not advantageous for rating. There was therefore no higher than a 0% rating supported under any applicable VASRD code.

BOARD FINDINGS: In the matter of the multiple stress reactions, the panel recommends that each condition be separately adjudicated as follows: an unfitting right foot condition coded 5271- 5022 and rated 10%; an unfitting right tibial condition, coded 5022 and rated 0%; an unfitting left tibial condition, coded 5022 and rated 0%; and, an unfitting left hip condition, rated 0% and coded 5022, all IAW VASRD §4.71a, and a not unfitting left foot condition. 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	
Right Foot Stress Reaction	5271-5022	10%	
Right Tibial Stress Reaction	5022	0%	
Left Tibial Stress Reaction	5022	0%	
Left Hip Stress Reaction	5022	0%	
	COMBINED	10%	

The following documentary evidence was considered:

AR201900011862 

Dear XXXXXXXXXXXXXX:

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.