RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  	CASE:  PD 1201267
BRANCH OF SERVICE:  Army	BOARD DATE:  20130424
SEPARATION DATE:  20011011

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an Active Duty SPC/E-4 with a projected Military Occupational Specialty (MOS) of 91K10, Armament Repairer.  She was medically separated for multiple stress reaction conditions.  The CI reported an onset of foot pain 4 weeks into basic training in 2001, followed by pelvic and hip region pain that did not respond adequate to anti-inflammatory medication and physical therapy (PT) to meet the physical requirements of her MOS or satisfy physical fitness standards.  She was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The right proximal femur intertrochanteric stress fracture; left femoral diphyseal stress fracture; bilateral Achilles insertion tendinitis; stress fractures of the base of first metatarsal and medial cuneiform and bursitis of the left hip greater trochanteric region conditions were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other conditions were submitted by the MEB.  The Informal PEB (IPEP) adjudicated multiple stress reactions encompassing:  right proximal femur intertrochanteric stress fracture; left femoral diphyseal stress fracture; bilateral Achilles insertion tendinitis; stress fractures of the base of first metatarsal and medial cuneiform and bursitis of the left hip greater trochanteric region conditions as unfitting, rated 20%, citing criteria of the US Army Physical Disability Agency (USAPDA) pain policy.  The CI made no appeals, and was medically separated with a 20% disability rating.  

CI CONTENTION:  “The 20% rating was from the Army and the VA gave me 0% disability.  I feel I should have gotten higher from the VA.”  

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e.(2).  It is limited to those conditions determined by the PEB to be unfitting for continued military service and those conditions identified but not determined to be unfitting by the PEB when specifically requested by the CI.  The ratings for the unfitting multiple stress reactions (encompassing right proximal femur intertrochanteric stress fracture; left femoral diphyseal stress fracture; bilateral Achilles insertion tendinitis; stress fractures of the base of first metatarsal and medial cuneiform and bursitis of the left hip greater trochanteric region) conditions are addressed below; and, thus are within the DoDI 6040.44 defined purview of the Board.  Any other conditions or contention not requested in this application, remain eligible for future consideration by the Army Board for Correction of Military Records.  The Board acknowledges the CI’s assertions that her VA disability disposition should have been rated higher.  It is noted for the record that the Board has no jurisdiction to investigate or render opinions in reference to such allegations; and, this contention must be redressed with the VA’s disability claim system.  

RATING COMPARISON:  

Service IPEB – Dated 20010920	VA - (~4 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Multiple Stress Reactions…	5022-5003	20%	No VA Entry	20020220	
	Right Proximal Femur…Fx			Right Proximal Femur…Fx	5255	NSC	20020220	
	Left Femoral Diphyseal…Fx			Left Femoral Diphyseal…Fx	5255	NSC	20020220	
	Bilateral Achilles…			Achilles’ Tendon…Left	5399-5311	NSC	20020220	
				Achilles’ Tendon…Right	5399-5311	NSC	20020220	
	Stress Fx, First Metatarsal and Medial Cuneiform			Stress Fx, First Metatarsal and Medial Cuneiform, Left Foot	5284	NSC	20020220	
	Bursitis Left Hip…			Bursitis of Left Hip	5019-5252	NSC	20020220	
No Additional MEB/PEB Entries	Other x 2	20020220	
Combined:  20%	Combined:  NSC*	
Derived from VA Rating Decision (VARD) dated 20020830 (most proximate to date of separation (DOS)).  
*Not service connected with subsequent VARDs, C&Ps and VA treatment records 

ANALYSIS SUMMARY:  The PEB combined the right proximal femur intertrochanteric stress fracture; left femoral diphyseal stress fracture; bilateral Achilles insertion tendinitis, left side more symptomatic than right; stress fractures of the base of first metatarsal and medial cuneiform; bursitis of the left hip greater trochanteric region conditions under a single disability rating, coded analogously to 5022 (periostitis), 5003 (arthritis, degenerative).  Although VASRD §4.71a permits combined ratings of two or more joints under 5003, it allows separate ratings for separately compensable joints; and, IAW DoDI 6040.44, the Board must follow suit if the PEB combined adjudication is not compliant with the latter stipulation.  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 ratings.  If the members judge that separate ratings are indicated IAW VASRD §4.7 (higher of two evaluations), however; each unbundled condition must be reasonably justified as separately unfitting to remain eligible for service rating.  When the Board recommends separate ratings in this circumstance, the result may not be lower than the overall combined rating from the PEB.  

Multiple Stress Reactions Condition(s) (Encompassing:  Right proximal femur intertrochanteric stress fracture; left femoral diphyseal stress fracture; bilateral Achilles insertion tendinitis, left side more symptomatic than right; stress fractures of the base of first metatarsal and medial cuneiform; bursitis of the left hip greater trochanteric region).  At the MEB/NARSUM exam, approximately a month before separation, the CI reported a history of bilateral lower extremity complaints with onset in the first month of basic training.  Initial symptoms were left foot that led to pelvic pain/hip pain after an 8-K road march.  There were no definitive fractures (3 June 2001 X-ray had possible 4mm bone fragment at left hip, was not shown on later radiographs).  Bone scan on 3 Jul 2001 revealed multiple stress fractures in the bilateral upper legs, bilateral ankles and left midfoot.  The CI was treated conservatively including convalescent leave from 3 July 2001 (over 60 days).  The CI had continued pain and use of a crutch on return from convalescent leave and was considered a poor candidate for return to duty.  The NARSUM indicated the CI elected a MEB instead of prolonged rehabilitation before return to training.  Medications include Tylenol (as-needed) and Ultram “when things are more severe,” but which was not taken regularly due to side-effect of sleepiness.  Pain was reported as 4 out of 10.  Physical exam documented normal arches and normal Q angles at her knees.  Hip range-of-motion (ROM) was “full bilaterally.”  There was pain into the right groin with right external rotation and resisted straight leg raise (SLR), and left hip pain with internal rotation.  Knee and ankle ROM was full bilaterally without effusions and all joints were stable.  Both feet had normal subtalar motion with tenderness to palpation about the insertion of the left Achilles tendon, and mid-foot bilaterally where the tibialis anterior tendon inserts.  Neurologic, reflex and motor exams were without deficits.  Radiographs at the time of the NARSUM did not show any obvious bony abnormalities.  Bone scan done on 3 July 2001 reported no abnormal uptake in the pelvis, with mild to minimum uptake in the left and right proximal femurs (hip) and the posterior calcaneus of each foot near the insertion of the Achilles tendon, and in the left midfoot.  At follow-up on 9 July 2001, right hip series was interpreted as normal.  Follow-up femur series showed normal right femur and left femur findings consistent with a small healing stress fracture.  

At the VA Compensation and Pension (C&P) exam, approximately 4 months after separation, the CI reported constant aching pain in both hips and both hips were stiff and pop and crack in the morning on wakening.  There was no weakness of the hips legs or feet and no ankle pain or stiffness.  The CI was taking no medication and had stopped using a cane in mid-December.  Exam demonstrated normal gait “and there are no functional limitations on standing or walking.  There are no callosities, breakdown, or unusual shoe wear pattern that would indicate abnormal weight bearing.”  Left hip ROM was flexion to 110 degrees (normal 125 degrees), adduction 25 degrees (normal 45 degrees), and all other hip motions were normal; there was no evidence of painful motion.  Ankle ROM was dorsiflexion to 10 degrees each side (normal 20 degrees) and normal plantar flexion with no objective evidence of pain on motion.  There was tenderness to palpation at the midfoot bilaterally and at the left Achilles insertion area.  X-rays of the right & left femur, bilateral hips, bilateral ankles and bilateral feet were normal.  The examiner’s diagnostic impression of the CI was that “she suffered from bilateral Achilles tendonitis in the service that has healed with no sequelae.  She suffered from multiple stress fractures, including her bilateral femurs, calcanei, and left mid-foot, which have healed with no sequelae.  She had left hip bursitis, which has healed with no sequelae.”  

The Board directs attention to its rating recommendation based on the above evidence.  The PEB combined the multiple lower extremities at 20% as noted above, and the VA adjudicated that the conditions were healed without sequelae and not ratable (not service-connected, not incurred/caused by service).  The MEB and Service exams and the VA exams were substantively different.  It is obvious that there is a clear disparity between the MEB/Service examinations and the VA examinations, with very significant implications regarding the Board's rating recommendation.  The Board thus carefully deliberated the probative value assignment to these conflicting evaluations, and carefully reviewed the record and disability conditions.  The evidence indicated that the multiple stress reactions were not adequately healed by the time of the MEB, and the NARSUM indicated recovery sufficient to return to training was likely, but would be prolonged (good prognosis).  The VA exam, proximate to separation demonstrated resolution of the MEB conditions with all VA examinations of the lower extremity stress areas noted as “healed with no evidence of sequelae.”  Although there was mild foot tenderness and non-painful slight limited motion of the left hip, there were no continuing diagnoses, abnormal imaging, objectively indicated painful motion or functional limitations at the time of the VA examination.  Regardless of which individual conditions would be determined to be unfitting, there was no path to a rating higher than the 20% awarded by the PEB.  After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the multiple stress reactions condition.  The Board concluded therefore that this condition could not be recommended for additional disability rating.  

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 multiple stress reactions condition was operant in this case and the condition was adjudicated independently of that policy by the Board.  In the matter of the multiple stress reactions manifested by recurrent pain on vigorous exertion and positive bone scan condition, the Board unanimously recommends no change in the PEB adjudication.  There were no other conditions within the Board’s scope of review for consideration.  

RECOMMENDATION:  The Board, therefore, recommends that there be no recharacterization of the CI’s disability and separation determination, as follows:  

UNFITTING CONDITION	VASRD CODE	RATING	
Multiple Stress Reactions Manifested by Recurrent Pain on Vigorous Exertion and Positive Bone Scan	5022-5003	20%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20120612, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

	           Physical Disability Board of Review

SFMR-RB									

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(TAPD-ZB), 

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for AR20130010823 (PD201201267)

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 and hereby deny the individual’s application.  
This decision is final.  The individual concerned, counsel (if any), and any Members of Congress who have shown interest in this application have been notified of this decision by mail.

 BY ORDER OF THE SECRETARY OF THE ARMY:

Encl						
						         (Army Review Boards)

CF: 
(  ) DoD PDBR
(  ) DVA