RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW
NAME:  XXXXXXXXXXXXXXXXX	CASE: PD-2017-03913
BRANCH OF SERVICE: ARMY	SEPARATION DATE: 20080207

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E2, Armored Reconnaissance Specialist, medically separated for “bilateral knee and ankle stress reactions” with a disability rating of 10%.

CI CONTENTION: “The reason I believe my rating should be raised is that my legs and feet get worse every day. My knee is constantly causing me pain, which limits my ability to work, walk long distance or provide for my family. My heels are still swelling whenever I am on my feet for any period of time. The treatment I received when I first started with the V.A. was massive narcotic pain killers, which made me worse off than the pain. I decided to live with the pain since the pain killers pretty much made me a zombie and sort of a[n] addict. I suffer every day from my injuries and have major issues providing for myself and family.” 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 - 20080426	VARD - 20081029	
Condition	Code	Rating	Condition	Code	Rating	Exam	

Bilateral Knee and Ankle Stress Reactions	
5022	
10%	Stress Fracture, Left Knee	5260	10%	20080818	
			Stress Fracture, Right Knee	5260	NSC	20080818	
			Stress Fracture, Right Ankle	5271	NSC	20080818	
			Stress Fracture, Left Ankle	5271	NSC	20080818	
COMBINED RATING: 10%	COMBINED RATING OF ALL VA CONDITIONS: 10%	

ANALYSIS SUMMARY:

Bilateral Knee and Ankle Stress Reactions. The PEB combined bilateral knee and the bilateral ankle stress reaction conditions under a single disability rating, coded 5003, 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 knee and ankle conditions is presented together, with attendant recommendations regarding separate unfitness, and separate rating if indicated.

According to the service treatment record and MEB narrative summary (NARSUM), the CI’s bilateral stress reaction (knees and ankles) began in September 2007 during the second week of basic training when there was an increase in strenuous activities. X-rays were normal, however, a bone scan showed a significant increased uptake in the bilateral medial tibial plateaus and left and right calcaneus. Despite profiles and being in the Physical Training Rehabilitation Program for almost 5 weeks, no significant improvement was noted in his symptoms. He did become pain- free during normal ambulation, but once he attempted to slow jog or march the pain returned. He occasionally took ibuprofen (a nonsteroidal anti-inflammatory drug) and tramadol (an opioid- like drug) for the pain.

The 16 November 2007 MEB NARSUM examination, 3 months prior to separation, noted complaints of bilateral knee pain and bilateral ankle pain. Physical examination showed a mild antalgic gait. Both the knees and the ankles were without an effusion and he had full range of motion (ROM) with no painful motion noted but moderate discomfort was described. There was significant tenderness over the medial tibial plateaus and he was non-tender about the shins. He was significantly tender over the calcaneus in both ankles. The knees and ankles were stable to stress. The examiner’s diagnosis was bilateral knee and ankle stress reactions and a permanent L3 profile was issued. The commander’s statement dated 19 November 2007 indicated the CI was diagnosed with bilateral knee and ankle stress reactions which would limit his participation in any training, and he would be unable to perform any of his assigned duties.   During the        14 December 2007 MEB examination (recorded on DD Forms 2807-1 and 2808), 2 months prior to separation, the CI reported stress fractures of the knees, ankles, and heels. Physical examination revealed tenderness to the heels around the medial malleoli to the medial knees.

At the 5 June 2008 VA Compensation and Pension (C&P) examination, 4 months after separation, the CI reported pain in both knees and ankles. He complained of pseudo-buckling of the left knee over the prior 10 months and occasional pain in the left knee with vigorous physical activity. Physical examination showed no evidence of a meniscal tear. A patellar grind test was negative. There was no crepitus (grinding sensation), deformity, erythema, effusion, or instability; however, there was medial tenderness. The left knee ROM was flexion 0-140 degrees (normal) with no loss of motion with repetition and gait was normal. There was tenderness of both heels, no evidence of abnormal weight bearing, no functional limitation on walking or standing, no foot edema, weakness, deformity, or instability, and no hallux valgus deformity. There was flexible pes planus and the Achilles tendon was in proper alignment with no tenderness on manipulation

of the Achilles tendon. The CI declined examination for both ankles and his right knee. X-rays of the left knee and both heels were negative. At a VA clinic visit on 18 August 2008, the CI was noted to have bilateral pes planus and at a VA podiatry examination on 30 September 2008 he was evaluated for painful bilateral heels. The examiner’s assessment was “bilateral heel arthralgia rule out bilateral plantar fascial ruptures.” Inserts were prescribed and MRIs were ordered.

Directing attention to its recommendations, the panel first considered if the bilateral knee and ankle conditions met the panel’s threshold for separate rating (as elaborated above). Based on the CI’s permanent profile and the commander’s statement, the panel determined each knee and each ankle 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 were without an effusion and both knees had full ROM with moderate discomfort and significant tenderness over each medial tibial plateau. The panel adjudged a rating for each knee is warranted.

The panel next directed attention to its rating recommendation based on the above evidence. As noted, the PEB bundled the bilateral stress reaction conditions and applied a single 10% rating, coded 5022 (periostitis), citing the USAPDA Issue and Guidance Memo #8, noting full ROM, tenderness and imaging evidence of involvement of two or more major joints. The VA rated the left knee stress fracture condition 10%, coded 5260 (limitation of motion of the leg), based on the C&P examination, citing painful motion. The VA determined the right knee and bilateral ankle stress reaction conditions were not service connected and did not rate them.

The evidence of mild discomfort (judged equivalent to painful motion) with functional loss supports a 10% rating (based on §§4.59, 4.40 and 4.45) for each knee. The panel considered other VASRD knee and analogous codes, but all 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 10% for the left knee stress reaction condition, coded 5099-5003 and a disability rating of 10% for the right knee stress reaction condition, coded 5099-5003.

The panel next addressed the bilateral ankle condition and noted that each ankle had the same findings at the NARSUM examination. Both ankles were without effusion or swelling. The ROM for each ankle was full with mild discomfort, and there was significant tenderness over the calcaneus in each foot/ankle.  The panel adjudged a rating for each ankle is warranted.

The panel then directed attention to its rating recommendation based on the above evidence. There was no limitation of motion of the either the left ankle joint or the right ankle joint to support a rating under diagnostic code 5271 (limitation of motion). The gait was slightly antalgic at the NARSUM examination and normal at the VA examination, and there was no evidence of functional loss that would impact functioning in the average civil occupation. VASRD §4.59 addresses painful motion. In this instance, the examiner noted mild discomfort for each ankle and there were no reported facial expressions or evidence of wincing. With only mild discomfort with motion and no painful motion noted, the disability picture related to painful motion is so limited that IAW VASRD 4.7, the panel majority determined that there was insufficient evidence of pain to warrant a rating higher than 0% (using code 5099-5003) for either the left or right ankle stress reactions. The panel considered alternative VASRD ankle and analogous codes, but all were less applicable and/or not advantageous to 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 ankle stress reaction condition, coded 5099-5003, and a disability rating of 0% for the right ankle stress reaction condition, coded 5099-5003.

BOARD FINDINGS: In the matter of the left knee stress reaction condition, the panel majority recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a. In the matter of the right knee stress reaction condition, the panel majority recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a. The single voter for dissent recommends no change and did not elect to submit a minority opinion. In the matter of the left ankle stress reaction condition, the panel majority recommends a disability rating of 0%, coded 5099-5003 IAW VASRD
§4.71a. In the matter of the right ankle stress reaction condition, the panel majority recommends a disability rating of 0%, coded 5099-5003 IAW VASRD §4.71a. The single voter for dissent recommends no change 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	
Left Knee Stress Reaction	5099-5003	10%	
Right Knee Stress Reaction	5099-5003	10%	
Left Ankle Stress Reaction	5099-5003	0%	
Right Ankle Stress Reaction	5099-5003	0%	
	COMBINED	20%	

AR20190010903, XXXXXXXXXXXXXXXXXXXXXX 

Dear XXXXXXXXXXXXXXX

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.