RECORD OF PROCEEDINGS 

PHYSICAL DISABILITY BOARD OF REVIEW 

 

NAME: XXXXXXXXXXXXXXXXXXX BRANCH OF SERVICE: ARMY 

CASE NUMBER: PD1201269 SEPARATION DATE: 20031024 

BOARD DATE: 20130320 

 

 

SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this 
covered individual (CI) was a National Guard PFC/E-3 (92Y/Unit Supply Specialist), medically 
separated for bilateral lower extremity stress reactions. The CI developed bilateral lower 
extremity pain in her third week of basic training. A bone scan revealed multiple stress 
fractures bilaterally in her femurs and in her right tibia and right first metatarsal. The CI 
remained in extensive physical therapy without significant improvement and it was determined 
that she could not return to her basic training. She was issued a permanent L3 and referred for 
a Medical Evaluation Board (MEB). The MEB forwarded “Bilateral Lower Extremity Stress 
Reactions” to the Physical Evaluation Board (PEB). The PEB adjudicated “Bilateral Lower 
Extremity Stress Reactions Preventing Return to Training” as unfitting rated 0% with application 
of the Veterans Affairs Schedule for Rating Disabilities (VASRD). The CI made no appeals, and 
was medically separated with a 0% disability rating. 

 

 

CI CONTENTION: “The doctor who saw me at VAMC, Birmingham, AL on 6 April, 2004 refused 
to look at my records, including the bone scan and X-Rays that I brought with me from Ft. 
Leonard Wood. He took one look at me and before I was even all of the way in the room he 
said, ‘You don't have stress fractures.’ I was confused and tried to hand him the disc telling him 
that it was my bone scan. He said, ‘I don't want to see that, they don't know what they're doing 
up there.’ Of course there was ‘no evidence of a chronic disabling condition’ because he would 
not look at the evidence or listen to my complaints of pain. The answer I received was that I 
could drive an hour and a half to the VA to get Motrin in needed it. When in training, I did not 
go to the clinic until my drill sergeants made me. I was late in week six when I was first seen 
about my pain. I spent several months going to physical therapy and pool therapy every single 
day even though I had been told from the beginning that I would not be able to recover from 
my injuries. I did not want a medical discharge- I wanted to be a soldier. To have a VA doctor 
over-rule the doctors and physical therapists who worked with me all of that time, without 
even giving me a cursory glance, was incredibly disheartening. I lost faith in the VA system and 
saw no reason to try to appeal. I am thankful for the opportunity to finally have my case 
reviewed by a fair and unbiased panel. To this day, I have pain in my legs. It took me years to 
overcome my limp, and it still returns at times. I had to quit my profession as a landscaper and 
return to school. Only through scholarships and student loans have I been able to begin to 
retrain myself for a different future.” 

 

 

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. The rated condition bilateral lower 
extremity stress reactions, as requested for consideration 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 PEB – Dated 20031006 

VA (~5 Mos. Post-Separation) 

Condition 

Code 

Rating 

Condition 

Code 

Rating 

Exam 

Bilateral Lower 
Extremity Stress 
Reactions 

5099-
5003 

0% 

Stress Fracture, Left Lower Extremity 

5299-5260 

Not Service 
Connected 

20040406 

Stress Fracture, Right Lower Extremity 

5299-5260 

Not Service 
Connected 

20040406 

Stress Fracture, Right First Metatarsal 

5299-5284 

Not Service 
Connected 

20040406 

Combined: 0% 

Combined: Not Service Connected 



 

 

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. 

 

Bilateral Lower Extremity Stress Reactions Condition. The PEB rated bilateral lower extremity 
stress reactions under the single analogous 5003 degenerative arthritis code. This coding 
approach is countenanced by AR 635-40 (B.24 f.), but IAW DoDI 6040.44 the Board must apply 
only VASRD guidance to its recommendation. The Board must therefore apply separate codes 
and ratings in its recommendations if compensable ratings for each joint 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 unfitting in and of itself, with the caveat that the final recommendation 
may not produce a lower combined rating as that of the PEB. 

 

The initial clinical evidence shows stress reactions in the right and left femurs, right tibia, and 
right foot. The bone scan in May 2003 (2 months after developing pain in March 2003) showed 
healing Grade I stress fractures and shin splints. No X-rays documented any positive findings 
except the right femur X-ray from September 2003, 6 months after the pain began. This X-ray 
documented cortical thickening consistent with stress remodeling. If any true stress fractures 
had persisted unhealed, there would be positive X-ray findings by the 6-month point. Chronic 
pain can continue after stress reactions or fractures. There is no evidence of any bone 
abnormality at the time of separation except for the right femur. While the narrative summary 
(NARSUM) examination documented tenderness to palpation of both femurs and the right tibia, 
there was no tenderness at the VA Compensation and Pension (C&P) examination within 6 
months of separation. The evidence supports a finding of a significant stress reaction and 
healing stress fracture of the right femur but the stress fractures in the other bones appear to 
have resolved prior to separation. Therefore, only the right femur can be considered 
reasonably justified as separately unfitting, as it is the only bone with evidence of an ongoing 
problem. There is no evidence of left femur, right tibia, or right foot stress reactions or 
fractures at the time of separation, and therefore, none of these conditions can be considered 
as reasonably justified as unfitting. 

 

A bone scan in May 2003 revealed multifocal healing Grade I stress fractures involving bilateral 
femurs, right tibia, and right foot; stress changes in the right mid tibia and bilateral shin splints; 
and a small foci of mild increased uptake in the medial aspect of the left mid foot and right first 
metatarsal. The CI had extensive physical therapy treatment without any improvement in pain 
reduction with activity. The orthopedic evaluation indicated tenderness to palpation over both 
medial femurs at the junction of the middle and distal thirds and tenderness to palpation over 


the medial right tibia proximally 6 cm distal to the joint; however, there was an ability to do a 
full squat, and an ability to do good heel-toe walking bilaterally and no foot pain or arch pain 
with good arch morphology. The examiner opined that it did not seem that the CI was “going 
to progress to a pain-free situation anytime soon.” Bilateral femur X-rays documented a 
normal left femur and cortical thickening of the right femoral diaphysis consistent with reaction 
to stress injury. The CI was issued a P3 Profile for bilateral lower extremity stress reactions with 
restrictions of no running, jumping, and marching. The MEB NARSUM examination 
approximately a month prior to separation documented that there was bilateral lower 
extremity pain which increased with runs and marching. The CI’s painful bilateral femurs 
prevented her from running, walking up hills, or marching. The physical exam findings were the 
same as the orthopedic evaluation. The diagnosis was bilateral lower extremity stress 
reactions. The C&P examination approximately 5 months after separation noted that the CI 
had some pain in her legs with long distance walking or running but no significant pain with 
normal activity. The physical exam documented the absence of tenderness in the upper legs, 
right tibial area, and the right first metatarsal bone. The examiner stated her X-rays were 
repeated and the results for the feet documented small marginal osteophytes on the posterior 
aspect of the talocalcaneal joint. The X-ray reports are not available for direct review. The 
examiner opined the CI had healing stress fractures of the upper legs, right tibia, and right first 
metatarsal with no significant loss of function and no additional limitations. 

 

The Board directs attention to its rating recommendation based on the above evidence. The 
PEB coded the bilateral lower extremity stress reactions analogous to 5003 arthritis, 
degenerative (hypertrophic or osteoarthritis) and rated 0%. The VA determined the stress 
fracture, left lower extremity; stress fracture, right lower extremity; and stress fracture, right 
first metatarsal were not service-connected because no chronic condition was present. At the 
time of separation, the CI had documented X-ray evidence of an ongoing right femur stress 
reaction and increased pain with activity. While no specific VASRD code exists for the 
condition, it can be rated analogous to 5003. The CI had well documented pain with activity 
that did not resolve with physical therapy in the service treatment record (STR). The 
orthopedist opined that the CI’s pain was not going to resolve and would continue to impede 
her ability to perform duties required of a soldier. The VA examiner noted some leg pain with 
long distance walking or running. After due deliberation, considering all of the evidence and 
mindful of VASRD §4.3 (Resolution of reasonable doubt), a majority of the Board recommends a 
disability rating of 10% for right femur stress reaction, coded 5099-5003. 

 

 

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 right 
femur stress reaction condition, the Board, by a majority vote of 2:1, agrees that it was unfitting 
and recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a. The single 
voter for dissent who recommended no recharacterization of the PEB rating 5099-5003 at 0% 
did not elect to submit a minority opinion. 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 her prior medical separation: 

 

UNFITTING CONDITION 

VASRD CODE 

RATING 

Stress Reaction, Right Femur 

5099-5003 

10% 

COMBINED 

10% 



 

 

The following documentary evidence was considered: 

 

Exhibit A. DD Form 294, dated 20120708, w/atchs 

Exhibit B. Service Treatment Record 

Exhibit C. Department of Veterans’ Affairs Treatment Record 

 

 

 

 

xxxxxxxxxxxxxxxxxxxxxxx, DAF 

Acting Director 

Physical Disability Board of Review 

 


SFMR-RB 


 

 

MEMORANDUM FOR Commander, US Army Physical Disability Agency 

(TAPD-ZB / xxxxxxxxxxxxx), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557 

 

 

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation 

for xxxxxxxxxxxxxxxxxxxxx, AR20130007452 (PD201201269) 

 

 

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 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 xxxxxxxxxxxxxxxxxxxxxxxx 

 Deputy Assistant Secretary 

 (Army Review Boards)