RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-04143
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20080117

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was a National Guard E3, Trainee, medically separated for “bilateral stress reactions of the lower extremities” with a disability rating of 10%.  

CI CONTENTION:  “Upon separation, only one issue was addressed because there was a LOD.  VA rating is currently 40% service connected.  Left hip and lower back were never addressed.  Right hip/legs were the main issue while in the service.  The left side was hardly addressed.  The lower back issue is in relation to the hips and vice versa, the hips effect the lower back.  At the time of separation and going through the MEB, PTSD was never addressed.  Separation anxiety and PTSD was heightened during separation and still today.  Documentation provided.”  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 – 20071024	VARD - 20090323	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Stress Reactions of the Lower Extremities 	5022	10%	Right Hip Overuse Syndrome due to Femur Osteopenia 	5252	10%	20090305	
			Left Shin Splint with Distal Left Femur Stress Response	5299-5262	10%	20090305	
			Right Shin Splint with Calcaneus Stress Fracture	5299-5262	10%	20090305	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30% 	

ANALYSIS SUMMARY:  

Bilateral lower extremity pain.  The PEB combined the right hip, right tibia, left tibia, and right heel conditions as a single unfitting condition coded 5022 (periostitis) and rated 10%, citing two or more joints with positive imaging and no loss of motion.  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.  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 right hip, right tibia, left tibia and left heel conditions are presented separately, with attendant recommendations regarding separate unfitness, and separate rating if indicated.  

Right Hip Pain:  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s right hip condition began in October 2004.  A February 2005 bone scan showed a normal hip.  A July 2007 X-ray showed no pelvis or hip abnormalities.  A bone density study done in June 2005 showed reduced bone mass (osteopenia).  During the 28 February 2007 orthopedic examination, 11 months prior to separation, the CI reported persistent right hip pain.  Physical examination showed full active hip range of motion (ROM) with 5/5 motor strength throughout hip extension and flexion.  There was some tenderness in the area of the inguinal ligament in her right groin.  She had some subjectively mild symptoms in flexion, external rotation and abduction of her right hip.  The CI had pain upon standing into her right hip but was not reproducible on examination.  She was able to heel-toe-walk and had a normal gait pattern.  She demonstrated no limitations with activity.  She was able to carry her suitcase with her as she was leaving after the examination.  

The 26 July 2007 MEB NARSUM examination, 6 months prior to separation, noted complaints of constant dull ache to a sharp stabbing 3-9/10 variable right hip pain made worse with prolonged sitting, standing and weight bearing.  Physical examination showed tenderness over the greater trochanter and the right inguinal crease.  Right hip active ROM testing showed flexion of 90 degrees (normal 125), extension of 10 degrees (normal 20), abduction of 25 degrees (normal 45) and no limitation in adduction.  

At the 5 March 2009 VA Compensation and Pension (C&P) evaluation, 13 months after separation, the CI reported constant right hip pain with moderate to severe flare-ups worse with standing.  Physical examination showed right hip active ROM with flexion of 115 degrees, extension of 30 degrees and abduction of 45 degrees.  The CI could cross her right leg over her left and could rotate her toes out greater than 15 degrees.  After three repetitions of ROM there was no objective evidence of pain or additional limitations.  There were no functional limitations to standing or walking by examination.  

The panel concluded there was not a preponderance of evidence of the service records that overcame the panel’s presumption that the bundled right hip condition was reasonably considered separately unfitting.  The panel then considered its rating recommendation for the unfitting right hip condition at the time of separation.  The panel directed attention to its rating recommendation based on the above evidence.  The VA rated the right hip condition 10%, analogously coded 5252 (limitation of flexion of thigh), based on the C&P examination, citing painful or limited motion of a major joint or group of minor joints.  The panel agreed there was no limitation of flexion or extension that supported a rating under the VASRD diagnostic codes for limitation of motion (5251 or 5252).  There was no limitation of abduction, adduction or rotation that supported a rating under the VASRD diagnostic codes for limitation of motion (5253).  There was no hip flail joint that supported a rating under the VASRD diagnostic code (5254).  There was no impairment of the right femur with fracture of shaft or anatomical neck with nonunion; or fracture of the surgical neck with a false joint; or malunion with slight knee or hip disability to justify a rating under 5255 (femur, impairment of).  However, there was evidence of painful motion of the right hip with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45).  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the right hip condition, coded 5003.

Right Tibia Pain:  According to the STR and MEB NARSUM, the CI’s right tibia condition began in August 2004 during basic training.  After conservative treatment she recovered and was returned to full duty and passed the Army physical fitness test.  Her symptoms returned in October 2004.  August 2004 and February 2005 bone scans revealed right tibial shin splints.  A bone density study done in June 2005 showed reduced bone mass (osteopenia).  

During the 28 February 2007 orthopedic examination, 11 months prior to separation, the CI reported resolution of her right lower extremity tibial pain.  Physical examination showed full active and passive ROM of the knees and ankles.  She had mild focal tenderness of the proximal aspect of her right tibia over the tibial spine approximately 6 to 7 cm distal to her knee joint.  There were no palpable masses.  She was able to heel-toe walk, had a normal gait and demonstrated no limitations with activity.  She was able to carry her suitcase into the room as she was leaving after the examination.  

At the 26 July 2007 MEB NARSUM examination, 6 months prior to separation, the CI stated that the right lower extremity pain had essentially resolved since being sent home for medical recovery in March 2005.  Physical examination showed no tenderness over the right anterior tibial shaft.  The right lower extremity revealed full active ROM of the knee and ankle.  

During the 5 March 2009 C&P evaluation the CI reported shin flare-ups with of 15-20 minute brisk walks.  Physical examination showed there were no functional limitations to standing or walking by examination.  Heel-toe and tandem walking were both normal.  There was tenderness of the right medial tibial shaft.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded the preponderance of evidence showed the right tibia condition would not reasonably have caused the CI to be referred into the DES or be found unfit.  

Left Tibia Pain:  According to the STR and MEB NARSUM, the CI’s left tibial condition began in August 2004 during basic training.  After conservative treatment she recovered and was returned to full duty and passed the Army physical fitness test.  Her symptoms returned in October 2004.  August 2004 and February 2005 Bone Scans revealed left tibial shin splints.  A bone density study done in June 2005 showed reduced bone mass (osteopenia).  

During the 28 February 2007 orthopedic examination, 11 months prior to separation, the CI reported resolution of her right lower extremity tibial pain.  Physical examination of the left leg was almost entirely normal without any areas of tenderness.  She was able to heel-toe walk, had a normal gait and demonstrated no limitations with activity.  She was able to carry her suitcase with her into the room as she was leaving after the examination.  

At the 26 July 2007 MEB NARSUM examination, 6 months prior to separation, the CI stated that the left lower extremity pain had essentially resolved since being sent home for medical recovery in March 2005.  Physical examination showed no tenderness over the left anterior tibial shaft.  The left lower extremity revealed full active ROM of the knee and ankle.  
During the 5 March 2009 C&P evaluation the CI reported shin flare-ups with of 15-20 minute brisk walks.  Physical examination showed there were no functional limitations to standing or walking by examination.  Heel-toe and tandem walking were both normal.  There was tenderness of the left anterior/medial tibial shaft.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded the preponderance of evidence showed the left tibia condition would not reasonably have caused the CI to be referred into the DES or be found unfit.  

Right Heel Pain:  According to the STR and MEB narrative summary (NARSUM), the CI’s bilateral lower extremity condition began in August 2004 during basic training.  After conservative treatment, she recovered and was returned to full duty and passed the Army physical fitness test.  An August 2004 Bone Scan revealed a right calcaneal minor stress fracture.  A repeat bone scan in February 2005 showed no calcaneal involvement.  A bone density study done in June 2005 showed reduced bone mass (osteopenia).  

During the 28 February 2007 orthopedic examination, 11 months prior to separation, the CI reported that her heel pain had mostly resolved.  Physical examination revealed she was able to heel-toe walk, had a normal gait and demonstrated no limitations with activity.  She was able to carry her suitcase with her into the room as she was leaving after the examination.  

The 26 July 2007 MEB NARSUM examination, 6 months prior to separation, noted complaints of continued constant 2-9/10 right heel pain that varied from soreness to a sharp sudden pain shooting up the calf.  The symptoms were increased with prolonged standing, walking and impact activities.  Physical examination showed the right calcaneus was mildly tender without swelling, erythema or bruising.  

At the 5 March 2009 C&P evaluation the CI reported constant right heel pain.  Physical examination showed minimal right calcaneal tenderness, but there was pain to the calcaneus on dorsiflexion of the foot.  There were no functional limitations to standing or walking by examination.  Heel-toe and tandem walking were normal.  There was tenderness of the left anterior/medial tibial shaft.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded the preponderance of evidence showed the right heel condition would not reasonably have caused the CI to be referred into the DES or be found unfit.  

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

Exhibit A.  DD Form 294, dated 20170330, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20180006258, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

	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.

Sincerely,					      
Enclosure