RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXX		CASE: PD-2017-04535 BRANCH OF SERVICE: ARMY	SEPARATION DATE: 20070418

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E2, Trainee, medically separated for “bilateral shin splints,” “bilateral quad splints,” “bilateral trochanteric bursitis,” “bilateral patellofemoral syndrome,” “bilateral Achilles tendonitis,” and “bilateral plantar fasciitis,” each rated 0%, with a combined disability rating of 0%.

CI CONTENTION: Review requested of the leg conditions as well as additional conditions (vein reflux, anxiety) not identified by the Medical Evaluation Board (MEB) and Physical Evaluation Board (PEB). 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 PEB to be unfitting for continued military service, and when specifically requested by the CI, those conditions identified by the 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 conditions 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 - 20070410	VARD - 20070809	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Shin Splints	5022	0%	Shin Splints, Right Knee	5022	NSC	

20070601	
			Shin Splints Left Knee	5022	NSC		
Bilateral Quad Splints	5314	0%	Quad Splints, Right	5314	NSC		
			Quad Splints, Left	5314	NSC		
Bilateral Trochanteric Bursitis	5019	0%	Trochanteric Bursitis, Left Hip	5019	10%		
			Trochanteric Bursitis, Right Hip	5019	10%		

Bilateral Patellofemoral Syndrome	
5099-5003	
0%	Patellofemoral Syndrome, Right Knee	5299-5257	NSC		
			Patellofemoral Syndrome, Left Knee	5299-5257	NSC		
Bilateral Achilles Tendonitis	5024	0%	No VA Placement	
Bilateral Plantar Fasciitis	5399-5320	0%	Right Plantar Fasciitis	5284	NSC	20070601	
			Left Plantar Fasciitis	5284	NSC		
COMBINED RATING: 0%	COMBINED RATING OF ALL VA CONDITIONS: 20%	

ANALYSIS SUMMARY: The PEB combined six separate bilateral conditions under a single disability rating for: bilateral shin splints, coded 5022 (periostitis); bilateral quad (thigh) splints, coded 5314 (Group XIV); bilateral trochanteric bursitis, coded 5019 (bursitis); bilateral patellofemoral syndrome, coded 5009-5003 (arthritis, degenerative); bilateral Achilles tendonitis coded 5024 (tenosynovitis); and bilateral plantar fasciitis, coded 5399-5320 (Group XX), with each condition 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 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.

Bilateral Shin Splints. According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI experienced shin splints in both legs during her third week of basic combat training, and X-rays on 20 July 2006 showed an area of cortical graying in both posterior tibial cortex mid shafts consistent with stress injuries. A bone scan on 24 July 2006 revealed a grade 2 stress fracture of the distal right tibia and a grade 1 stress fracture of the mid left tibia. There were also bilateral quad splints (see below). On 15 August 2006, while on crutches, she complained of right foot pain (see below). By 8 September 2006, she reported feeling much better, but had some pain with prolonged walking. She underwent physical therapy (PT), and by 6 December 2006 she had no shin pain prior to or after PT, but did report pain 2 days later. She was able to walk on the treadmill without pain, but had pain while running on concrete. Over time, she had increasing shin pain and progressive thigh pain.

A bone scan on 2 February 2007 revealed bilateral shin splints, quad splints and knee stress changes. At a PT visit on 6 February 2007, the examiner noted no progress had occurred, with pain returning after activity progression and despite diminished pain with reduced activity. Range of motion (ROM) was full with negative percussion to the tibias and tenderness along the medial crests. At a family medicine appointment on 20 February 2007, the CI had an antalgic gait and tenderness of the bilateral extremities over the anterolateral border of both tibias, right greater than left, without edema or effusion. There was also bilateral ankle and mid foot pain. Neurovascular findings were normal, and motor strength and sensation were intact.

The 7 March 2007 MEB NARSUM examination, 1 month prior to separation, noted CI complaints of bilateral lower extremity pain. Physical examination showed a slight antalgic gait. The knees were symmetrical without edema or effusion, and there was no quad atrophy, patellar tilt or laxity.  Right knee flexion was to 105 degrees (normal 140) and extension to 10 degrees (normal
0) after three repetitions; and left knee flexion was to 120 degrees and extension to 10 degrees. Both knee ROM measurements were limited by pain, but there was no instability or evidence of a meniscal tear. Tenderness was documented with palpation over the pes anserine bursae, patellar tendons (without a palpable defect) along the medial borders of both tibias, and over both Achilles tendons. Right and left ankle dorsiflexion was to 3 degrees (normal 20) each, limited by pain, and plantar flexion was to 45 degrees (normal) bilaterally.

At the 1 June 2007 VA Compensation and Pension (C&P) examination, 1 month after separation, the CI reported intermittent pain in both legs precipitated by prolonged standing or walking. Physical examination showed a non-antalgic gait. There was point tenderness of the right medial patella region, no instability, and normal muscle strength.  Knee ROM was from 0-140   degrees

bilaterally, without pain or loss of motion with repetition. Bilateral ankle ROM measurements showed dorsiflexion from 0-20 degrees and plantar flexion from 0-45 degrees. There was no varus or valgus deformity. Lower leg X-rays were normal except for a minute bony density by the tip of the lateral malleolus on the right, which was of no clinical significance.

The panel directed attention to its rating recommendation based on the above evidence. As noted above, the PEB bundled the right and left shin splints and applied a single 0% rating, coded 5022, citing no ratable limitation of motion. The VA determined the bilateral shin splints were not service-connected, citing no objective evidence of any permanent residual or chronic disability. The panel first considered whether right and left shin splints, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above, and concluded that there was not a preponderance of evidence in the service records that overcame the presumption that the conditions were reasonably considered separately unfitting. Panel members then considered rating recommendations for the unfitting right and left shin splints at the time of separation, noting that the condition is best rated using code 5262 (tibia and fibula, impairment of: malunion of), since a bone scan in February 2007 demonstrated shin splints in each leg. The panel then discussed the disparity between ankle and knee ROM measurements  at the NARSUM and VA examinations, and determined that improvement to normal ROM without pain by the time of the VA examination warranted a 0% rating, but no higher, under code 5262. 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 right and left shin splints.

Bilateral Quad Splints. According to the STR and MEB NARSUM, the CI’s bilateral quad splints began approximately the same time as the shin splints, and were revealed during the 24 July 2006 bone scan. At a PT visit on 31 January 2007, she complained of shin pain and progressive thigh pain in the proximal femurs and pelvis. The February 2007 bone scan showed bilateral shin splints, quad splints, and knee stress changes, and she had an antalgic gait at the family medicine visit in late February 2007.

The MEB NARSUM examination noted a slightly antalgic gait with tenderness over the greater trochanteric bursae as well as along the tensor fascia lata bilaterally, but no tenderness within the right or left inguinal and posterior hip regions. After three repetitions, right hip flexion was to 110 degrees (normal 125) and abduction to 30 degrees (normal 45); left hip flexion was to 110 degrees and abduction to 45 degrees, with both hips limited by pain. There was no quad atrophy, patellar tilt or laxity.

The C&P examiner documented a non-antalgic gait with no asymmetry, instability, or crepitus of the hips. Bilateral hip flexion was from 0-90 degrees and abduction was from 0-45 degrees, with pain in both planes.  With repetition there was limitation of motion of 5 degrees.

The panel directed attention to its rating recommendation based on the above evidence. The PEB bundled the right and left quad splints and applied a single 0% rating, coded 5314, citing slight impairment. The VA determined the bilateral quad splints were not service-connected, citing no objective evidence of any permanent residual or chronic disability. The panel first considered whether the right and left quad splints, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above, and concluded that there was not a preponderance of evidence in the service records that overcame the presumption that the conditions were reasonably considered separately unfitting. Panel members then considered rating recommendations for the unfitting right and left quad splints, noting that the condition was best rated using code 5255 (femur, impairment of: malunion of), since the February 2007 bone scan demonstrated bilateral quad splints. Both the NARSUM and VA examinations documented painful, less than full hip ROM measurements, and the panel thus determined there

was at least a slight disability for each hip at the time of separation, which warranted a 10% rating.

Bilateral Trochanteric Bursitis. According to the STR and MEB NARSUM, the bilateral trochanteric bursitis began after the CI developed the tibial stress fractures.   At a family medicine visit on     5 December 2006, the assessment was “joint pain, localized in the hip,” without any further details or examination. At a PT examination on 9 January 2007, during passive ROM testing, there was tightness in the rectus femoris (one of the four quadriceps muscles) bilaterally. The provider also noted a positive Thomas test (to determine flexibility of the hip flexor muscles), and bilateral hamstring tightness in the 90/90 degrees position. At the 31 January PT session, the CI reported complaints of shin pain and progressing thigh pain in the proximal femurs and pelvis, and crutches were prescribed. The February 2007 bone scan showed bilateral linear femoral and tibial uptake.

The panel directed attention to its rating recommendation based on the STR, MEB NARSUM and C&P examination findings for the hips as already discussed in the analysis for the bilateral quad splints. The PEB bundled the right and left trochanter bursitis and applied a single 0% rating, coded 5019, citing no ratable limitation of motion. The VA rated the left and right hip trochanteric bursitis 10% each, coded 5019, based on the C&P examination, citing painful or limited motion of a major joint or group of minor joints. The panel first considered whether the right and left trochanteric bursitis, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above, and concluded that there was not a preponderance of evidence in the records that overcame the presumption that the conditions were reasonably considered separately unfitting. Panel members then considered rating recommendations for the unfitting right and left trochanter bursitis, noting that the condition can be rated using code 5099-5003 due to painful motion, but not significant limited motion. Both the NARSUM and VA examinations documented painful, less than full hip ROM measurements, and the panel thus determined there was at least a slight disability from the right and left trochanter bursitis at the time of separation, which warranted a 10% rating. However, because the bilateral quad splints and the bilateral trochanteric bursitis were associated with a right and left femur/hip disability, assigning separate ratings would invoke pyramiding, which is to be avoided IAW VASRD §4.14. Thus, panel members determined that a 10% rating each for the right and left femur/hip conditions secondary to quad splints and trochanteric bursitis, coded 5255, is warranted.

Bilateral Patellofemoral Syndrome. According to the STR and MEB NARSUM, the bilateral patellofemoral syndrome also began after the bilateral tibial stress fractures. Based on the STR, MEB NARSUM and C&P examination findings for the shin splints, as already discussed above, the panel directed attention to its rating recommendation. The PEB bundled the right and left knee conditions and applied a single 0% rating, coded 5099-5003, citing without ratable limitation of motion. The VA determined the right and left knee conditions were not service connected, citing no objective evidence of any permanent residual or chronic disability. The panel first considered whether the right and left patellofemoral syndrome, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above, and concluded that there was not a preponderance of evidence in the service records that overcame the presumption that the conditions were reasonably considered separately unfitting. Panel members then considered rating recommendations for the unfitting right and left patellofemoral syndrome at the time of separation, noting that the condition was best rated using code 5262 (tibia and fibula, impairment) since a bone scan in February 2007 demonstrated mild bilateral increased activity at the knees. The panel then discussed the disparity between knee ROM measurements at the NARSUM and VA examinations, and determined that improvement to normal ROM without pain by the time of the VA examination warranted a 0% rating, but no higher, under code 5262 or 5099-5003. However, because the bilateral shin splints and the bilateral patellofemoral syndrome were associated with a right and left tibia/knee disability, assigning  separate  ratings

would invoke pyramiding, which is to be avoided IAW VASRD §4.14. Thus, panel members determined that a 0% rating each, coded 5262, is warranted for the right and left tibia/knee conditions secondary to shin splints and patellofemoral syndrome

Bilateral Achilles Tendonitis. According to the STR and MEB NARSUM, the bilateral Achilles tendonitis developed secondary to the bilateral tibial stress fractures. At the family medicine visit in February 2007, the CI had an antalgic gait with bilateral ankle and mild foot pain. The MEB NARSUM examiner documented tenderness over the bilateral Achilles tendons with positive step offs and plantar flexion with gastrocnemius muscle compression. There was tenderness along the medial borders of both tibias, but compartments were soft, subtalar and drawer tests were negative, and tibial tit testing caused minimal discomfort. Right and left ankle dorsiflexion was to 3 degrees and limited by pain; plantar flexion was to 45 degrees.

At the C&P examination, the CI did not report any issues related to the bilateral Achilles tendonitis. Physical examination showed bilateral ankle dorsiflexion to 20 degrees and plantar flexion to 45 degrees, with no pain or no evidence of a varus or valgus deformity.

The panel directed attention to its rating recommendation based on the above evidence. The PEB bundled the right and left Achilles tendonitis and applied a single 0% rating, coded 5024, citing without ratable limitation of motion. There was no VA placement for this condition. The panel first considered whether the right and left Achilles tendonitis, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above, and concluded that there was not a preponderance of evidence in the service records that overcame the presumption that the conditions were reasonably considered separately unfitting, albeit they were not profiled or mentioned in the commander’s statement, but were found to be unfitting by the PEB. Panel members then considered rating recommendations for the unfitting right and left Achilles tendonitis, noting that the decreased, painful dorsiflexion documented in the NARSUM was a result of irritation or inflammation from the bilateral shin splints. However, because of ankle motion normalization by the time of the VA examination, there was no obvious disability as the shin splints had resolved. Thus, the panel agreed that a 0% rating using code 5099-5003 was appropriate for each ankle. 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 right and left Achilles tendonitis.

Bilateral Plantar Fasciitis. According to the STR and MEB NARSUM, in August 2006, while on crutches, the CI complained of right foot pain, but X-rays on 15 August 2006 showed normal alignment and mineralization, with no abnormal lucency, sclerosis, or erosion within the osseous structures, and normal soft tissues. At a PT examination on 19 September 2006, there was negative percussion of the heels bilaterally, and 3 days later, removable, pre-molded foot arch supports were dispensed for foot pain (soft tissue). At PT visits on 24 October 2006, 14 November 2006, 13 December 2006, and 19 January 2007, bilateral pes planus was noted, which was worse on the left. Active ROM was full at all visits and there was negative percussion of the heels bilaterally. At the February 2007 family medicine appointment, the CI had mid foot pain and strength and sensation were intact.

The MEB NARSUM examiner noted a slight antalgic gait and bilateral tenderness at the insertion of the plantar fascia as well as in the flexible arch. ROM measurements were “good” with positive extensor hallucis longus, flexor hallucis longus, extensor digitorum brevis, and flexor digitorum brevis.  Toe signs were negative and hind foot varus with toe rise was normal.

At the C&P examination, the CI reported intermittent pain in both feet precipitated by prolonged standing or walking. She wore arch supports while working and relieved soreness by soaking her feet 3-4 times a week. Physical examination showed no redness, warmth, swelling, or unusual shoe wear pattern. Bilateral ROM measurements demonstrated ankle dorsiflexion to 20 degrees

and plantar flexion to 45 degrees. There was no evidence of a varus or valgus deformity, weakness, fatigability, incoordination, or lack of endurance with repetition. Foot X-rays were normal.

The panel directed attention to its rating recommendation based on the above evidence. The PEB bundled the right and left plantar fasciitis and applied a single 0% rating, coded “5399-5320,” which should have been 5399-5310 (Group X. Function: movements of forefoot and toes; propulsion thrust in walking), citing slight disability. The VA determined the bilateral plantar fasciitis was not service connected, citing no objective evidence of any permanent residual or chronic disability. The panel first considered whether the right and left plantar fasciitis, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above, and concluded that there was not a preponderance of evidence in the service records that overcame the presumption that the conditions were reasonably considered separately unfitting. Panel members then considered rating recommendations for the unfitting right and left plantar fasciitis, noting that the NARSUM only documented tenderness of the plantar fascia insertions and the flexible arches, while the VA examination did not mention any tenderness. Therefore, a 0% rating using code 5399-5310 for the right and plantar fasciitis was appropriate. 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 bilateral plantar fasciitis.

BOARD FINDINGS: In the matter of the bilateral shin splints and bilateral patellofemoral syndrome, the panel recommends that each lower extremity be separately adjudicated as unfitting right and left tibia shin splints/knee patellofemoral syndrome, coded 5262 and rated 0%, both IAW VASRD §4.71a. In the matter of the bilateral quad splints and bilateral trochanteric bursitis, the panel recommends that each be separately as unfitting right and left femur quad splints/hip trochanteric bursitis, coded 5255 and rated 10%, both IAW VASRD §4.71a. In the matter of the bilateral Achilles tendonitis and bilateral plantar fasciitis, 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.

The panel recommends the CI’s prior determination be modified as follows, effective the date of medical separation:

CONDITION	VASRD CODE	PERMANENT RATING	
Right Tibia Shin Splints/Knee Patellofemoral Syndrome	5262	0%	
Left Tibia Shin Splints/Knee Patellofemoral Syndrome	5262	0%	
Right Femur Quad Splints/Hip Trochanteric Bursitis	5255	10%	
Left Femur Quad Splints/Hip Trochanteric Bursitis	5255	10%	
Bilateral Achilles Tendonitis	5024	0%	
Bilateral Plantar Fasciitis	5399-5310	0%	
	COMBINED w/BLF	20%	

The following documentary evidence was considered:

AR20190012734, 

Dear XXXXXXXXXXXX:

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.