RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXX	CASE:  PD-2017-03911
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060714

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E2, Multichannel Communications Operator, medically separated for “chronic pain due to stress fractures, bilateral tibial plateau and right calcaneus” with a disability rating of 10%.   

CI CONTENTION:  “Continued pain.  Have fallen down several times unexpectedly, legs pop now when I walk or bend down.”  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 - 20060621	VARD - 20061023	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Pain Due to Stress Fractures, Bilateral Tibial Plateau and Right Calcaneus	5099-5003	10%	R Ankle Sprain…	5099-5024	10%	20060622	
			S/P L Tibial Stress Fracture	5099-5010	0%		
			S/P R Tibial Stress Fracture	5099-5010	0%		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Chronic Pain Due to Stress Fractures.  The PEB combined the bilateral tibial plateau and right calcaneus stress fractures under a single disability rating, analogously coded 5099-5003 (arthritis, degenerative), 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.  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 bilateral tibial plateau and the right calcaneus stress fractures 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 chronic pain due to stress fractures began in January 2006 during basic training after increased physical activity and a right ankle inversion injury.  Bilateral leg X-rays were unremarkable, but a bone scan on 6 February 2006 demonstrated stress fractures of both medial tibial plateaus and the right posterior calcaneus.  The CI was treated with crutches and underwent physical therapy and rehabilitation, but experienced pain in the knees, the right ankle, and heel when running.  Knee X-rays on 15 March 2006 were normal with no evidence of stress fracture, callus, or joint effusion, while a right foot X-ray still showed a stress fracture of the right calcaneus in the posterior superior margin.  At an examination on 9 May 2006, the CI was noted to have a significant decrease in subtalar mobility secondary to a navicular abnormality, pes cavus with significant rigidity, and a positive calcaneal squeeze. 

The 30 May 2006 MEB NARSUM examination, 1 month prior to separation, noted complaints of some mild pain and persistent right ankle and heel pain limiting his ability to walk normally.  He also could not run without a marked increase in pain.  Physical examination showed a slight limp favoring the right ankle, tenderness on both of the medial proximal tibial plateaus, and mild pretibial discomfort, but knee ligaments were intact.  There was significant tenderness over the Achilles area and the posterior calcaneus with a 3+ positive calcaneus squeeze test.  The right ankle range of motion (ROM) was -15 (normal 20) to 45 degrees (normal) with slight discomfort over the right foot metatarsal area and pes cavus bilaterally.  

At the 22 June 2006 VA Compensation and Pension (C&P) examination, 3 weeks before separation, the CI reported tibial and right heel pain.  Physical examination showed an abnormal gait with asymmetry due to right heel pain, but he did not use an assistive device for ambulation and denied any incapacitation.  Examination of the both tibias and fibulas revealed normal findings, with no signs of edema, effusion, weakness, tenderness, redness, heat, abnormal movement, or guarding of movement of either knee.  Knee ROM was from 0-140 (normal) bilaterally without pain, laxity or instability.  The right ankle showed no signs of edema, effusion, weakness, tenderness, redness, abnormal movement, or guarding of movement.  Dorsiflexion was to 15 degrees and plantar flexion to 40 degrees with pain at motion endpoints.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bundled stress fractures 10%, coded 5099-5003, citing slight and constant pain IAW the US Army Physical Disability Agency pain policy.  The VA rated the three stress fracture locations separately, with the right ankle at 10%, coded 5099-5024 (analogous to tenosynovitis), citing painful or limited motion.  Each knee was separately rated 0%, coded 5099-5010 (analogous to arthritis due to trauma), based on the C&P examination, citing no objective evidence of painful or limited motion of the right and/or left leg.  The panel first considered whether the stress fractures met the threshold for separate rating (as elaborated above), and agreed that based on the CI’s permanent profile and the commander’s statement, each knee (tibial plateau stress fracture) and the right calcaneus stress fracture was separately unfitting.  

The panel then addressed the knees and noted that each knee had the same findings at the NARSUM examination.  Both the left knee and the right knee had tenderness on the medial proximal tibial plateau and there was mild pretibial discomfort bilaterally, while at the VA examination both tibias and fibulas had normal findings.  Knee ROMs were 0-140 bilaterally without pain.  There was no laxity or instability of either knee.  Therefore, the panel determined a rating for each knee is warranted.  

As noted, the PEB bundled the bilateral stress fractures of the tibial plateau bilaterally and the right calcaneus stress fracture and applied a single 10% rating.  The VA determined the right knee and left knee stress fractures were not service connected and did not rate them.  In the absence of painful motion at the VA examination, which was the most proximate examination to separation, a 0% rating (based on §§4.59, 4.40 and 4.45) is the maximum rating for each knee using code 5099-5003.  Furthermore, X-rays prior to separation showed no evidence of fracture of either the tibias or fibulas.  The panel considered other VASRD knee and analogous codes, including code 5262 (tibia and fibula, impairment of), but there was no knee ankle disability of significance, and all other codes were less applicable and not advantageous for rating.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel majority recommends a disability rating of 0% for the left tibial plateau (knee) stress fracture condition, coded 5099-5003 and a disability rating of 0% for the right tibal plateau stress fracture condition, coded 5099-5003.  

The panel next addressed the right calcaneal fracture and noted there was significant tenderness over the Achilles area and over the posterior calcaneus with a 3+ positive calcaneus squeeze test at the NARSUM examination.  There was also an abnormal gait due to pain in the right heel with normal ankle ROMs with pain at the end of the motions.  Therefore, the panel determined a rating was warranted for the right calcaneus stress fracture that was still noted on X-rays proximate to separation.

The panel then directed attention to its rating recommendation based on the above evidence.  The CI’s gait was slightly antalgic at the NARSUM examination due to pain at the right heel. There was no limitation of motion of the right ankle joint to support a rating under diagnostic code 5271 (limitation of motion), but there was pain at the end of the motions at the VA examination.  
Therefore, there was evidence of functional loss that would impact functioning in the average civil occupation.  Thus, the panel determined that there was sufficient evidence of pain to warrant a rating of 10% (using code 5099-5003) for the right calcaneal stress fracture.  The panel considered alternative VASRD ankle and analogous codes, but all were less applicable and/or not advantageous to rating, except for the use of code 5284 (foot injuries, other) at 10% for a moderate disability.  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 right calcaneal fracture condition, coded 5099-5003.  

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 tibial plateau stress fracture condition, coded 5099-5003 and a disability rating of 0% for the left tibial plateau stress fracture condition, coded 5099-5003.  The panel recommends a disability rating of 10% for the right calcaneal stress fracture, coded 5099-5003 or 5284.  Since there is no change in the overall rating and 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 chronic pain due to stress fractures of the bilateral tibial plateau and right calcaneus condition.  

BOARD FINDINGS:  In the matter of the chronic pain due to stress fractures, bilateral tibial plateau and right calcaneus 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.  

	PD-2017-03911

AR20190011700, XXXXXXXXXXXXXXXXXXXXXX 

Dear XXXXXXXXXXXXXXXXX

	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-2017-03911