[AR Number], XXXXXXXXXX. 

XXXXXXXXXX
XXXXXXXXXX
XXXXXXXXXX

Dear XXXXXXXXXX:

	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.

RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXX.  	CASE:  PD-2017-04619
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20090515

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 knee and leg pain secondary to right proximal tibial stress fracture and bilateral tibial cortices” with a disability rating of 20%. 

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 – 20090428	VARD - 20091030	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Knee and Leg Pain…	5299-5262	10%	Stress Fracture Right Proximal Tibia	5262	10%	20090717	
		10%	Reaction Changes Left Tibia	5262	10%	20090717	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

Bilateral Knee and Leg Pain.  The PEB combined the bilateral knee and leg conditions under a single disability rating, analogously coded 5299-5262 (tibia and fibula, impairment of), and rated 10% for each knee, with a combined rating of 20%.  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.  When the panel recommends separate fitness recommendations in this circumstance, its recommendations may not produce a lower combined rating than that of the PEB.  

According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s bilateral knee/leg complaints developed during the third week of basic training and continued to worsen.  A bone scan on 29 October 2008 showed a right proximal tibial stress fracture and stress changes in the “remainder of the tibias.”  A second bone scan on 7 January 2009 showed right leg findings consistent with a stress fracture of the tibial shaft and probably the lateral aspect of the tibial plateau or proximal fibular head.  No findings were reported concerning the left leg.

During the 13 January 2009 MEB examination (recorded on DD Forms 2807-1 and 2808), 4 months prior to separation, the CI reported stress fractures and bone pain from “knees to ankles,” and the examiner noted “stress fractures, right proximal tibia.”  The 4 February 2009 MEB NARSUM examination, 3 months before separation, noted complaints of constant bilateral knee and leg pain, rated at 5/10, and increased to 8/10 with exacerbation.  Physical examination showed mild tenderness along both medial tibial plateaus and along the midshaft of the right tibia, but not the left.  Knee range of motion (ROM) was normal with tenderness along the patellofemoral areas; there was no pain with ankle ROM.  The examiner expected the pain to “resolve with time” once the stress fractures healed.

At the 17 July 2009 Compensation and Pension (C&P) examination, 2 months after separation, the CI reported bilateral knee and leg pain that did not improve with time and rest, and that the majority of the pain was in the right lower leg.  Physical examination showed a normal gait and no swelling or effusion.  There was tenderness of the anterior tibial bone (right greater than left) extending from the distal to proximal tibia, and the iliotibial bands were mildly taut at the distal insertion, but not tender when palpated.  Bilateral knee ROM was normal (0-140 degrees) and the examiner documented subjective report of bilateral knee pain without current abnormal objective findings.  Bilateral tibia and fibula X-rays were normal with a small accessory ossification about the tip of the left lateral malleolus.  A lower extremity MRI showed no abnormalities.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral knee/leg conditions 10% each, analogously coded 5299-5262, citing slight knee disability.  The VA rated the right stress fracture condition 10%, and the reaction changes of the left tibia 10% (both coded 5262), based on the STR and C&P examinations, citing evidence of right proximal tibial stress fracture with pain, a small ossified fragment distal to the tip of the left fibula, and a diagnosis of reaction changes in the left tibia with pain.  

The panel first considered whether each knee and leg condition, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  Bilateral knee and leg pain was profiled and implicated in the commander’s statement, and thus members agreed the evidence reasonably justified that the functional limitations of each knee and leg contributed to the CI’s inability to perform her military duties, and accordingly separate disability ratings are recommended.  The panel noted there was no limitation of flexion or extension which supported a rating under the diagnostic codes 5260 or 5261 for the knee or leg conditions.  There was no fracture, nonunion or malunion of the femur to support consideration under the respective codes for knee impairment related to long bone conditions (5255); and there was no evidence of moderate knee disability to support a 20% rating under code 5262.  No additional functional limitation was evidenced by the examinations and there was therefore no VASRD §4.71a rating higher than the 10% adjudicated by the PEB under any applicable code.  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 knee/leg condition.  

BOARD FINDINGS:  In the matter of the bilateral knee and leg pain secondary to stress fractures 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: