RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW NAME: XXXXXXXXXXXXXXXXXXXX BRANCH OF SERVICE: ARMY CASE NUMBER: PD1200728 SEPARATION DATE: 20020123 BOARD DATE: 20130319 SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty PV2/E-2 (77F/projected, but not earned), medically separated for “bilateral lower extremity pain secondary to stress fractures to include bilateral femor, right foot and left tibia.” In the third week of training, the CI developed left lower extremity pain attributed to running and other lower body activities required in basic training. Evaluations noted a right foot stress fracture and a left tibial stress fracture with bilateral femoral stress reactions. The left lower leg pain did not respond adequately to conservative treatment to meet the physical requirements of his projected Military Occupational Specialty or satisfy physical fitness standards. He was issued a permanent L3 profile for bilateral lower leg stress fractures and referred for a Medical Evaluation Board (MEB). The MEB forwarded 1) right foot stress fracture and 2) Left tibial stress fracture with bilateral femoral stress reactions as the only conditions for Physical Evaluation Board (PEB) adjudication. The PEB adjudicated the right foot stress fracture and the left tibial stress fracture with bilateral femoral stress reactions as a single unfitting condition, rated 0%, with cited application of the US Army Physical Disability Agency (USAPDA) pain policy. The CI made no appeals, and was medically separated with a 0% disability rating. CI CONTENTION: “I received 30% disability rating from the VA back in 2003 then lost benefits for a no show.” The CI elaborated no specific contention in his application. SCOPE OF REVIEW: The Board wishes to clarify that the scope of its review as defined in DoDI 6040.44, Enclosure 3, paragraph 5.e. (2) is limited to those conditions which were determined by the PEB to be specifically unfitting for continued military service; or, when requested by the CI, those condition(s) “identified but not determined to be unfitting by the PEB.” The ratings for unfitting conditions will be reviewed in all cases. Any conditions or contention not requested in this application, or otherwise outside the Board’s defined scope of review, remain eligible for future consideration by the Army Board for Correction of Military Records. RATING COMPARISON: Service IPEB – Dated 20011226 VA (STR Used) – All Effective Date 20020124 Condition Code Rating Condition Code Rating Exam BLE Pain secondary to stress fractures 5099-5003 0% RLE Stress Fracture 5299-5014 10% STR LLE Stress Fracture 5299-5014 10% STR R Foot Stress Fracture 5299-5014 10% STR .No Additional MEB/PEB Entries. 0% X 0 / Not Service-Connected x 0 Combined: 0% Combined: 30%* *VA proposed a reduction in ratings due to a C&P no show and then did reduce all ratings to 0% effective December 1, 2006. ANALYSIS SUMMARY: The PEB disability description was: “Bilateral lower extremity pain secondary to stress fractures to include bilateral femor, right foot and left tibia. Rated as minimal, occasional.” Right Foot Stress Fracture and Left Tibial Stress Fracture with Bilateral Femoral Stress Reactions. The narrative summary (NARSUM) dated 30 October 2001 indicated the CI was a trainee in week three of training who presented with a chief complaint 6 November 2001 of left lower extremity pain. The CI had been initially evaluated by the Troop Medical Clinic, and failed to respond to conservative treatment. The examiner stated “This occurred as a result of running and other lower body activities required in basic training” and the CI was not taking any medications. The MEB physical exam noted diffuse tenderness to palpation over the left tibial shaft and femoral condyle with no palpable or visible deformity. There was full active range-of- motion (ROM) of the joints above and below the tibia with no neurovascular deficits. The examiner noted tenderness to palpation at the right navicular bone (foot) and stated “He has normal motor function throughout the lower extremity bilaterally.” Plain radiographs were normal on 19 November 2001. Bone scan from 27 November 2001 “revealed stress reaction of the bilateral tibia. There is also a stress fracture noted in the dorsum of the right foot. There is also focal uptake in the bilateral medial femoral condyles which is consistent with significant stress reaction. IMPRESSION: 1. Right foot stress fracture; 2. Left tibial stress fracture with bilateral femoral stress reactions.” The L3 profile listed “bilateral lower leg stress fractures.” The commander’s statement indicated complaints of leg pains, noted “stress fractures in both lower legs” without improvement following being “sent to the Fitness Training Unit to undergo Reconditioning for his injury.” Clinic evaluation on 27 November 2001 was a follow-up from the bone scan (not finalized) and the CI was on acetaminophen (Tylenol). Exam indicated “decreased” left leg extension with tenderness to palpation over the distal third of the tibia with edema and vibratory sensation change. Diagnosis was left tibial stress fracture. Clinical exam the following day indicated chief complaint of left tibial pain and bone scan results of “stress reaction tibial, stress fracture of dorsal right foot bone, and right distal femur abnormality at condyle medially.” Exam documented 1+ edema with tenderness to palpation of the left tibial midshaft. Orthopedic clinic consult had findings and diagnoses essentially similar to the typed NARSUM. The DD Form 2808 exam dated 10 December 2001 documented an antalgic gait, walking with crutches and tenderness to palpation to bilateral lower extremities. There was no VA Compensation and Pension (C&P) exam and the VA rating was based on service treatment records. The Board directs attention to its rating recommendation based on the above evidence. The PEB combined the right foot stress fracture, the left tibial stress fracture, and left and right femoral stress reaction conditions under a single disability rating, coded analogously to 5003. Although the Veterans Affairs Schedule for Rating Disabilities (VASRD) §4.71a permits combined ratings of two or more joints under 5003, it allows separate ratings for separately compensable joints. IAW DoDI 6040.44 the Board must follow suit if the PEB combined adjudication is not compliant with the latter stipulation, provided that each unbundled condition can be reasonably justified as separately unfitting in order to remain eligible for service rating. If the members judge that separately ratable conditions are justified by performance based fitness criteria and indicated IAW VASRD §4.7 (Higher of Two Evaluations), separate ratings are recommended; with the stipulation that the result may not be lower than the overall combined rating from the PEB. The Board also considered the provisions of VASRD §4.14 Avoidance of Pyramiding. The Board’s initial charge in this case was therefore directed at determining if the PEB’s combined adjudication was justified in lieu of separate findings of unfit and separate ratings. There was no physician diagnosis or imaging evidence of stress fractures of the right tibia, left femoral condyle or right femoral condyle and these areas were documented as stress reactions (versus stress fractures of the left tibia and right foot). The Board first considered if the left lower extremity stress fracture condition, having been de- coupled from the combined PEB adjudication, remained reasonably justified as unfitting. The record demonstrated that the left lower extremity was always the chief complaint and focus of exams and medical record discussion supporting conclusion of unfitting. Members agreed that the functional limitations in evidence justified the conclusion that the left lower extremity stress fracture condition was integral to the CI’s inability to perform; and, accordingly a separate rating is recommended. There was sufficient evidence of painful motion of the left lower extremity to warrant a 10% rating IAW VASRD §4.59 (Painful Motion) and §4.40 (Functional Loss) analogous to osteomalacia (5299-5014) or degenerative arthritis (5099-5003) slight tibia and fibula impairment (5099-5262). The Board next considered if the left femoral stress reaction having been de-coupled from the combined PEB adjudication, remained itself unfitting as established above. The Board considered that there was no separating this condition from the symptoms and disability of the unfitting left lower extremity stress fracture condition and any disability was appropriately considered under that condition and rating. After due deliberation, the members agreed that the evidence does not support a conclusion that the left femoral stress reaction condition was separately unfitting and cannot recommend a separate rating for it. The Board next considered if the right foot stress fracture condition, having been de-coupled from the combined PEB adjudication, remained reasonably justified as unfitting. Despite the record indicating that the left lower extremity was always the chief complaint, the commander’s statement and profile indicated bilateral lower extremity duty-impacting conditions, while clinical exams focused on the left leg pain. Members agreed that the functional limitations in evidence justified the conclusion that the right foot stress fracture condition was reasonably unfitting and accordingly a separate rating is recommended. There was sufficient evidence of painful motion of the right foot and lower extremity to warrant a 10% rating IAW VASRD §4.59 (Painful Motion) and §4.40 (Functional Loss) analogous to osteomalacia (5299-5014) or degenerative arthritis (5099-5003) or Tibia and fibula impairment (5099-5262). After due deliberation, members agreed that the bilateral leg condition, IAW VASRD §4.71a rating criteria and accepted principles for fitness determination, warrants a recommendation for separate right and left disability ratings of 10% coded 5099-5262 to encompass each lower extremities disability. The Board next considered if the right femoral stress reaction having been de-coupled from the combined PEB adjudication, remained itself unfitting as established above. The Board considered that there was no separating this condition from the symptoms and disability of the unfitting right foot stress fracture condition and any disability was appropriately considered under that condition and rating. After due deliberation, the members agreed that the evidence does not support a conclusion that the right femoral stress reaction condition was separately unfitting and cannot recommend a separate rating for it. BOARD FINDINGS: IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication. As discussed above, PEB reliance on the USAPDA pain policy for rating the CI’s lower extremity conditions was operant in this case and those conditions were adjudicated independently of that policy by the Board. In the matter of the combined bilateral lower extremity pain secondary to stress fractures to include bilateral femor, right foot and left tibia condition(s), the Board unanimously recommends that it be rated for two separate unfitting conditions as follows: left lower extremity pain and tibial stress fracture coded 5099-5262 with a disability rating of 10%, and right lower extremity pain and foot stress fracture coded 5099-5262 with a disability rating of 10% both IAW VASRD §4.71a; and the left and right femoral stress reaction conditions determined to be not unfitting and thereby not subject to disability rating. There were no other conditions within the Board’s scope of review for consideration. RECOMMENDATION: The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of his prior medical separation: UNFITTING CONDITION VASRD CODE RATING Left Lower Extremity Pain and Tibial Stress Fracture 5099-5262 10% Right Lower Extremity Pain and Foot Stress Fracture 5099-5262 10% COMBINED (w/ BLF) 20% The following documentary evidence was considered: Exhibit A. DD Form 294, dated 20120605, w/atchs Exhibit B. Service Treatment Record Exhibit C. Department of Veterans’ Affairs Treatment Record xxxxxxxxxxxxxxxxxxxxx, DAF Acting Director Physical Disability Board of Review SFMR-RB MEMORANDUM FOR Commander, US Army Physical Disability Agency (TAPD-ZB / xxxxxxxxxxx), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557 SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for xxxxxxxxxxxxxxxxxx, AR20130006869 (PD201200728) 1. I have reviewed the enclosed Department of Defense Physical Disability Board of Review (DoD PDBR) recommendation and record of proceedings pertaining to the subject individual. Under the authority of Title 10, United States Code, section 1554a, I accept the Board’s recommendation to modify the individual’s disability rating to 20% without recharacterization of the individual’s separation. This decision is final. 2. I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum. 3. I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures. BY ORDER OF THE SECRETARY OF THE ARMY: Encl xxxxxxxxxxxxxxxxxxxxxxxxx Deputy Assistant Secretary (Army Review Boards)