RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW NAME: XXXXXXXXXXXXXXX BRANCH OF SERVICE: ARMY CASE NUMBER: PD1201524 SEPARATION DATE: 20020828 BOARD DATE: 20130321 SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SPC/E-4 (31P/Microwave Communications System Operator-Maintainer), medically separated for bilateral chronic shin splints. The CI was held over after Advanced Individual Training (AIT) due to his chronic bilateral shin pain. His symptoms first developed in March 2001 while he was trying to improve his run times for his APFT. With an increase in running, he had further shin pain, left greater than right. Despite activity limitation, the CI remained unable to meet the physical requirements of his Military Occupational Specialty (MOS) or satisfy physical fitness standards. He was issued a permanent L3 profile for bilateral chronic shin splints and referred for a Medical Evaluation Board (MEB). The MEB forwarded no other conditions for Physical Evaluation Board (PEB) adjudication. The PEB adjudicated the bilateral chronic shin splints as a single unfitting condition, rated 0%. The CI made no appeals and he was medically separated with a 0% disability rating. CI CONTENTION: 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 conditions “identified but not determined to be unfitting by the PEB.” The ratings for unfitting conditions will be reviewed in all cases. The bilateral chronic shin splints condition meets the criteria prescribed in DoDI 6040.44 for Board purview and is addressed below. 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 20020722 VA – All Effective Date 20030829 Condition Code Rating Condition Code Rating Exam Bilateral Chronic Shin Splints 5022 0% Chronic Shin Splints, Left Leg 5299-5262 10% STR* Chronic Shin Splints, Right Leg 5299-5262 0% STR* Combined: 0% Combined: 10% *No C&P examination completed ANALYSIS SUMMARY: The Board’s authority as defined in DoDI 6040.44, resides in evaluating the fairness of Disability Evaluation System (DES) fitness determinations and rating decisions for disability at the time of separation. The Board utilizes service and VA evidence proximal to separation in arriving at its recommendations and DoDI 6040.44 defines a 12-month interval for special consideration of post-separation evidence. Post-separation evidence is probative only to the extent that it reasonably reflects the disability and fitness implications at the time of separation. The PEB rated the bilateral chronic shin splints condition as a single unfitting condition under the 5022 Periostitis code. This coding approach is countenanced by AR 635-40 (B.24 f.), but IAW DoDI 6040.44 the Board must use Veterans Administration Schedule for Rating Disabilities (VASRD) guidance in arriving at its recommendation. The Board therefore considers separate codes and ratings in its recommendations if compensable ratings for each leg are achieved IAW VASRD §4.71a. If the Board judges that two or more separate ratings are warranted in such cases, however, it must satisfy the requirement that each “unbundled” condition was reasonably justified as separately unfitting. Right and Left Chronic Shin Splints conditions. The Board first considered whether the right and left chronic shin splints conditions, having been de-coupled from the combined PEB adjudication, each remained reasonably justified as unfitting as established above. Treatment notes in the service treatment record (STR) indicated pain in both legs that limited the CI’s ability to perform any significant exertion without bilateral shin pain, left worse than right. Although the typed permanent L3 profile lists “Bilateral Left Chronic Shin Splints” as the profiled condition, the hand-written draft lists “B/L Chronic Shin Splints.” The abbreviation B/L means bilateral, not bilateral left, and this appears to be a typographical error. Additionally, a previous temporary profile was written for bilateral shin stress fractures. The commander’s statement refers to bilateral chronic shin splints as preventing the CI from performing the duties of his MOS and basic soldiering tasks. All Board members agreed that the right and left leg chronic shin splints, as isolated conditions, would have each rendered the CI incapable of continued service within his MOS and accordingly merit separate ratings. The CI had over a year history of bilateral shin pain resulting in medical profiles. At the time of the MEB narrative summary (NARSUM), 3 months prior to separation, the CI reported bilateral shin pain at rest with pain that was present at least three quarters of the day. His pain was generally rated at 4 to 5 out of 10 but increased to 7 out of 10 with weight bearing. His pain increased with exertion and the CI was not able to run, double time march, stand for greater than 30 minutes, or jump. Previous X-rays in April 2001 documented bilateral tibial stress reactions and X-rays taken 3 months later documented bilateral healing stress reactions with increased thickening on the left and no real change on the right. A bone scan a month later noted a Grade I left mid-tibial stress fracture and changes of the left femoral condyle consistent with either an osteochondral injury or a lateral collateral ligament injury. No increased uptake was noted in the right leg. A knee X-ray was normal and left leg X-ray taken approximately 5 months later noted periosteal thickening consistent with the prior stress changes/fracture. The NARSUM also reported that a follow-up bone scan completed in March 2002 showed improvement in the previous findings in the left tibia and knee but not resolution. The actual report is not available for review and the NARSUM did not address the presence or absence of any bone scan findings in the right leg. The MEB NARSUM physical exam, completed approximately 2 months prior to the dictation, noted bilateral tenderness of the medial mid- tibia, left greater than right. No soft tissue swelling or bruising was present. There was no mention of gait, strength, or knee abnormality. There was no VA Compensation and Pension (C&P) exam proximate to separation; the VA rating was based on the CI’s STRs. The Board directs attention to its rating recommendation based on the above evidence. As mentioned above, the PEB combined the two conditions of right and left leg chronic shin splints and using code 5022 assigned a 0% rating, stating “Chronic bilateral leg pain due to shin splints, without limitation of motion.” The VA coded the left leg chronic shin splints analogous to 5262, impairment of tibia and fibula (slight knee or ankle disability) and assigned a 10% disability rating based on the left tibia stress fracture. The VA also coded the right leg chronic shin splints analogous to 5262 but assigned a 0% disability rating based on a stable right leg with only mild tenderness to palpation. While both tibias had been previously noted to have stress reactions, only the left leg showed evidence of an actual stress fracture. There is no evidence of any ongoing or chronic right tibial stress reaction. Therefore, while increased activity would most likely lead to future problems in the right shin, the right leg does not meet the minimum compensable rating criteria of either 5022 or 5099-5262 at the time of separation. After due deliberation in consideration of all of the evidence, the Board concluded that the right and left chronic shin splints were each reasonably justified as unfitting. Considering all of the evidence and mindful of VASRD §4.3 Reasonable doubt, the Board recommends a disability rating of 10% coded 5022 for the chronic shin splints and stress fracture, left leg and a disability rating of 0% coded 5022 for the chronic shin splints, right leg, both IAW VASRD §4.71a. 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. In the matter of the bilateral chronic shin splints condition, the Board unanimously recommends that it be rated for two separate unfitting conditions as follows: chronic shin splints and stress fracture, left leg condition coded 5022 and rated 10%; and chronic shin splints, right leg condition coded 5022 and rated 0%, both IAW VASRD §4.71a. 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 Chronic Shin Splints and Stress Fracture, Left Leg 5022 10% Chronic Shin Splints, Right Leg 5022 0% COMBINED 10% The following documentary evidence was considered: Exhibit A. DD Form 294, dated 20120816, 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 / xxxxxxxxxxxx), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557 SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for xxxxxxxxxxxxxxxxxxxx, AR20130007723 (PD201201524) 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 10% 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 xxxxxxxxxxxxxxxxxxxxxxxxxx Deputy Assistant Secretary (Army Review Boards)