RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-05043
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060113

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Trainee, medically separated for “bilateral lower extremity stress fractures” with a disability rating of 10%. 

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 - 20051228	VARD - 20060606	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Lower Extremity Stress Fractures	5099-5003	10%	Stress Fractures, Left Lower Extremity 	5262	10%	20060302	
			Stress Fractures, Right Lower Extremity	5262	10%	20060302	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Bilateral Lower Extremity Stress Fractures.  The PEB combined the left and right lower extremity conditions under a single disability rating, coded 5099-5003 (analogous to degenerative arthritis) 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 VASRD §4.71a rating requirements for code 5003, 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 presented with a complaint of bilateral ankle pain in June 2005 soon after commencing basic training, relating a history of “twisting” injuries to both ankles.  This was initially treated as sprains and improved with a period of non-weight bearing and activity limitation, but recurred with resumption of full activities.  Over time, she developed additional complaints of bilateral foot, lower leg, knee and groin pain.  A bone scan identified bilateral stress fractures of the distal femurs, medial tibial plateaus, calcanei, left distal tibia and left second metatarsal.  Clinical STR entries documented a vacillating clinical course with periods of near-recovery and resumption of running to nearly a 2-mile tolerance, interspersed with periods of inability to run or train without pain.  

There was ample STR documentation of grossly normal ankle and foot range of motion (ROM).  There was no STR evidence for any ROM limitation of the ankles, knees or hips; and, there was no reference to painful motion of any joint.  There was no STR evidence for instability, impingement or other ratable finding for the knee or other involved joints.  There was no STR evidence for malalignment, abnormal weight-bearing, callosities or other ratable findings for the feet.  The gait varied from normal to antalgic.  One provider opined that the observed limp was not consistent with the otherwise mild symptoms and findings.  Later STR entries documented a persistent antalgic gait favoring the right and addressed only residual foot pain.

During the 6 December 2005 MEB NARSUM examination, 1 month prior to separation, the CI complained of bilateral knee, ankle and foot pain that averaged 4/10 and increased to 6/10 with prolonged walking and standing for more than 15 minutes.  The physical examination recorded an antalgic gait favoring the left leg (contralateral to preceding STR entries).  Tenderness was noted of the distal femurs, medial tibial plateaus (knees), lateral ankles, heels and first metatarsal of the left foot; but, there was no associated swelling, atrophy, weakness (strength was 5/5) or other abnormal findings.  The examiner further specified the absence of effusion, impingement (locking) or instability of the knees.  The examiner documented normal ROM of the hips, knees, and ankles with no indication of painful motion.

The MEB’s DA Form 3947 submission and the permanent L3 profile both designated a bilateral condition with no specificity regarding separate extremities, individual joints or the feet.  The commander’s performance statement was likewise not probative to separate fitness implications for either extremity, individual joints or the feet.

The 2 March 2006 VA Compensation and Pension (C&P) examination, 2 months after separation, documented a history of bilateral foot, ankle and knee pain without elaborating current symptoms or functional limitations, although it did note that the foot pain had recently improved.  The physical examination recorded a normal gait, and all lower extremity findings were “completely within normal limits” except for tenderness of both Achilles’ tendons and the right foot (distal first metatarsal, contralateral to NARSUM finding).  No additionally ratable knee or foot findings were documented.  The examiner provided formal ROM measurements for each knee and ankle that were normal in all planes, and made no note of painful motion or degradation with repetition.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral lower extremity condition 10%, coded 5099-5003, citing slight and frequent pain IAW the U. S. Army Physical Disability Agency pain policy.  The VA, referencing the C&P evidence, conferred separate ratings of 10% for each lower extremity under code 5262 (tibia and fibula, impairment of) citing the applicable criterion of “slight” knee or ankle disability.  Code 5262 offers ratings of 20% for “moderate” and 30% for “marked” knee or ankle disability.

The panel first addressed the fitness considerations for potential separate ratings as elaborated above.  This involved not only the question of whether each lower extremity was separately unfitting, but also whether there were separately unfitting knee, ankle or foot conditions.  With regards to the latter, members agreed that there was insufficient performance-based evidence that the knees, ankles or feet were separately unfitting, either individually or bilaterally.  The later STR entries suggested that foot pain was the main complaint, and the C&P evidence indicated that even that was resolving by the time of separation.  There was no indication at separation of any specific acuity for the knees, ankles or feet to justify a conclusion that any of them in isolation would have resulted in MEB referral and medical separation.  Additionally, members agreed that there was not satisfactory evidence of painful motion or other ratable criterion that would violate VASRD stipulations for overall rating under code 5003. 

Having agreed that individual joint or foot ratings were not supported, the panel next considered whether each lower extremity was justified as separately unfitting for individual rating.  In this case, there was no evidence that one extremity caused more functional impairment than the other, and the overall functional impairment at separation was not severe.  Member consensus was, given the clinical acuity and functional limitations described above, that it was reasonable to conclude 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 stress fractures which rendered her unfit.  Members further agreed that rating under code 5262 (as per the VA), that would mandate separate ratings, was not supported since it specifies fracture complications (malunion or nonunion) that were not present; and, especially considering the favorable clinical course at separation, was not well supported by either VASRD §4.20 (analogous ratings) or §4.7 (higher of two evaluations).  Member consensus, therefore, was that a bilateral 10% rating under criteria of code 5003 was appropriate.   After due deliberation, considering all evidence and mindful of VASRD §4.3 (reasonable doubt), the panel consensus was that there was insufficient cause to recommend a change in the PEB adjudication for the bilateral lower extremity stress fractures.

BOARD FINDINGS:  In the matter of the bilateral lower extremity stress fractures and IAW VASRD §4.71a, the panel majority recommends no change in the PEB adjudication.  The single voter for dissent recommends modification to separate 10% ratings for each extremity but does not elect to submit a minority opinion.  There are no other conditions within the panel’s scope of review for consideration.  Therefore, the panel recommends there be no modification or re-characterization of the CI’s disability and separation determination.  

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.
Affairs.

Sincerely,					      
Enclosure