[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.

Enclosure

RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXX.	CASE:  PD-2017-04806
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060718

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E6, Corrections Specialist, medically separated for “recurrent bilateral lower leg pains diagnosed as shin splints” with a  disability rating of 0%. 

CI CONTENTION:  Review requested of shin splint, toe and thumb conditions as well as additional conditions 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 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 - 20060418	VARD - 20060905	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Recurrent Bilateral Shin Splints	5022	0%	Right Leg Shin Splints	5299-5262	0%	20060706	
			Left Leg Shin Splints	5299-5262	0%	20060706	
Osteoarthritis of the Bilateral Acromioclavicular [AC] and 1st Metatarsophalangeal [MTP] Joints 	Not Unfitting	Degenerative Joint Disease [DJD] of the Right and Left Shoulder	5201-5010	10%	20060706	
		DJD of the Right 1st MTP	5003-5284	0%	20060706	
		DJD of the Left 1st MTP	5003-5284	0%	20060706	
Bilateral Thumb Pain	Not Unfitting	Right Thumb Pain	5299-5228	NSC	20060706	
		Left Thumb Pain	5299-5228	NSC	20060706	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Bilateral Shin Splints.  The PEB combined the bilateral lower leg conditions under a single disability rating, coded 5022 (periostitis), and 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 VASRD §4.71a rating requirements for code 5022, 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.  

According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s shin splints began in 1998 during basic training and were exacerbated without trauma while deployed in 2002.  A bone scan in October 2005 demonstrated bilateral tibial stress reactions (shin splints) without evidence of stress fractures, and serial X-rays remained normal.  Clinical STR entries documented bilateral tibial tenderness as the only positive finding.  There was ample evidence of a normal gait and full, pain-free bilateral knee and ankle range of motion (ROM).  There was no contrary STR documentation of any additional ratable criteria for the lower legs and contiguous joints.

The 7 December 2005 MEB orthopedic addendum, 7 months before separation, recorded nonspecific bilateral shin pain, left worse than right, which prevented the CI from running.  Physical examination revealed normal lower extremity findings, with no tenderness, and full active bilateral knee and ankle ROM; painful motion not addressed.  The 31 January 2006 MEB NARSUM examination, 7 months prior to separation, stated, “The Soldier reports an average of 1 to 2 hours per day of dull pain in his anterolateral shins at a pain level of 2/10 that worsens with running, fast walking or wearing heavy gear.”  The MEB NARSUM repeated the addendum physical findings, but also documented the absence of pain and crepitus with ankle and knee motion.  The MEB NARSUM diagnosis, MEB Proceedings submission, and profile all designated a bilateral condition; and, the commander’s performance statement was not probative to separate fitness considerations for either extremity.

At the 6 July 2006 VA Compensation and Pension (C&P) examination, 12 days before separation, the CI complained of bilateral shin pain, rated at 4/10, and occurring 4 times a week and lasting about 6 hours each time.  The examiner noted that pain was “elicited by physical activity” without elaboration of specific limitations, but stated, “There is no functional impairment resulting from the [bilateral shin splint] condition.”  The CI continued to work in his corrections officer military specialty (corroborated by the commander).  Physical examination recorded a normal gait without an assistive device, and bilateral tibial tenderness with no other positive findings.  Bilateral ankle and knee ROM was normal in all planes with no pain during motion or repetition.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral shin splints 0%, coded 5022 (periostitis), citing full motion.  The VA rated the right and left shin splints 0% each, analogously coded 5299-5262 (tibia and fibula, impairment), based on the C&P examination, citing a noncompensable examination.  Members first considered whether a separate unfitting rating for each extremity was supported.  Although the MEB orthopedic addendum indicated that the left leg was more symptomatic than the right,  there was no corroborating evidence that either extremity caused more functional impairment than the other.  Furthermore, the C&P examination indicated that the overall functional impairment at separation was not severe.  The panel consensus, given the clinical acuity and functional limitations in evidence, was that it could be reasonably concluded that the performance limitations confined to either extremity alone would not have rendered the CI incapable of continuing military service; and that more likely, it was the combined effect of the bilateral condition which rendered him unfit.

The panel deliberated over an appropriate rating and noted that the code 5022 was a good match for the clinical pathology of shin splints and defaults to criteria of code 5003 (arthritis, degenerative) which directed at joint disability, and in the case of the tibial condition, would reflect the joint function of the knees and ankles.  In that regard, there was no ROM limitation to support a rating greater than 0%, and members agreed that there was no satisfactory evidence of painful motion to support the minimum 10% rating IAW VASRD §4.59.  Painful motion was not corroborated by any examiner and was refuted by some service evidence, and definitively so by the C&P examiner.  There was neither a clinically defined condition nor ratable criterion in evidence for the knee and ankle joints to justify alternative rating under any §4.71a joint code.  The panel considered alternative rating under 5299-5262, but members agreed that this could not be endorsed since code 5262 requires separate extremity ratings which were not reasonably justified as discussed above.  After due deliberation, considering all evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded there was insufficient cause to recommend a change in the PEB adjudication of the bilateral shin splints (with a minority caveat that each lower extremity was reasonably justified as separately unfitting, but rated 0% each).

Contended PEB Conditions: Osteoarthritis of the Bilateral AC and 1stt MTP Joints, and Bilateral Thumb Pain.  There were conflicting accounts regarding initial bilateral shoulder pain, although the earliest STR entry in evidence described a 2005 onset (or exacerbation) with push-ups.  The MEB orthopedic addendum examiner diagnosed bilateral AC osteoarthritis, likely from past joint separations, and documented normal bilateral shoulder ROM with no signs of impingement or other significant finding.  The MEB NARSUM examination duplicated the addendum findings which were corroborated by the C&P examiner.  The CI complained of bilateral great toe pain dating to 2005 (no injury) that was diagnosed as MTP arthritis.  The MEB NARSUM documented that orthotics had been dispensed by podiatry and were helping.  A complaint of bilateral thumb pain dated to 2004 (no injury) and was diagnosed in the orthopedic addendum as early stage arthritis (X-ray normal).  There were no functionally significant examination findings for the great toes and thumbs.

The MEB orthopedic addendum examiner opined that all of the above conditions met retention standards (corroborated by the MEB NARSUM and MEB Proceedings submission.  The profile (U1/L3) listed only the shin splints, which was also the only condition implicated in the commander’s performance statement.  The C&P examiner opined that there was no functional impairment resulting from any of these conditions.

The panel’s main charge is to assess the fairness of the PEB’s determination that all of the above conditions were not unfitting.  There was no performance-based evidence from the record that any of them significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded there was insufficient cause to recommend a change in the PEB fitness determination for the bilateral shoulder, great toe, and thumb conditions, so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the bilateral shin splints and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the contended osteoarthritis of the bilateral acromioclavicular and first metatarsophalangeal joints, and the bilateral thumb conditions, the panel recommends no change from the PEB determinations as not unfitting.  There are no other conditions within the panel’s scope of review for consideration.  Therefore, the panel recommends that there be no modification or re-characterization of the CI’s disability and separation determination.

The following documentary evidence was considered: