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AF | PDBR | CY2012 | PD2012 01005
Original file (PD2012 01005.rtf) Auto-classification: Approved
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:    CASE NUMBER: PD120 1005
BRANCH OF SERVICE: Army   BOARD DATE: 2013 0703
Separation Date: 20020329


SUMMARY OF CASE : Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty PFC/E-3 (19D / Trainee ) medically separated for chronic bilateral leg pain. The CI developed stress fractures while in basic training. Despite resting, the leg pain could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS) and as the CI was in basic training, he had yet to take a physical fitness test. He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB). The MEB forwarded r ecurrent b ilateral t ibial s tress f ractures to the Physical Evaluation Board (PEB) IAW AR 40-501. No other conditions were submitted by the MEB. The PEB adjudicated c hronic b ilateral l eg p ain due to r ecent t ibial s tress fractures as unfitting, rated 0%, citing the US Army Physical Disability Agency (USAPDA) pain policy. The CI made no appeals and he was medically separated.


CI CONTENTION : The CI elaborated no specific contention in his application.


 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 rating for the unfitting bilateral leg pa in condition is addressed below and no additional conditions are within the DoDI 6040.44 defined purview of the Board. Any conditions or contention either no t requested in this application or otherwise outside the Board’s defined scope of review, remain eligible for future consideration by the Board for Correction of Military Records.


RATING COMPARISON :

Service IPEB – Dated 20020313
 VA - based on Service Treatment Records (STR)
Condition
 Code Rating Condition Code Rating Exam
Chronic Bilateral Leg Pain due to Recurrent Tibial Stress Fractures 5099-5003 0% Tibial Stress Fracture, Left Leg 5299-5010 0% Service Treatment Record (STR)
Tibial Stress Fracture, Right Leg 5299-5010 0% STR
Rating: 0%
 Combined Rating: 0%
Derived from VA Rating Decision (VARD) dated 20050105 ( most proximate to date of separation [DOS]). CI submitted first claim to VA in September 2004, 30 months post-separation.


ANALYSIS SUMMARY : The Disability Evaluation System (DES) is responsible for maintaining a fit and vital fighting force. While the DES considers all of the member's medical conditions, compensation can only be offered for those medical conditions that cut short a member’s career, and then only to the degree of severity present at the time of final disposition. However the Department of Veteran s Affairs (DVA), operating under a different set of laws (Title 38, United States Code), is empowered to compensate service - connected conditions and to periodically re-evaluate said conditions for the purpose of adjusting the V eteran’s disability rating should the degree of impairment vary over time.

The PE B rated the c hronic b ilateral l eg p ain due to r ecurrent t ibial s tress f ractures under the single analogous code 5099-5003 a rthritis, degenerative (hype rtrophic or osteoarthritis) . 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 Veterans Affairs Schedule for Rating Disabilities ( 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 it . Since §4.71a criteria are met for separate joint ratings for the c hronic l eft and r ight l eg p ain due to a r ecurrent t ibial s tress f ractures in this case, the Board is pursuing separate rating and fitness evaluations as follow.

Chronic Left and Right Leg Pain due to Recurrent Tibial Stress F ractures Condition s . The Board first considered if the c hronic l eft and r ight l eg p ain due to a r ecurrent t ibial s tress fractures conditions, having been de-coupled from the combined PEB adjudication, were each reasonably justified as independently unfitting. The service treatment records (STR) document multiple bilateral lower extremity stress fractures that resulted in an inability to complete training. Although the CI initially complained of pain in his right leg only and the c ommander’s s tatement only mentioned the right leg, the CI did have tenderness to palpation of both legs, bone scan evidence of multiple bilateral stress fractures, and his permanent profile was for recurrent bilateral tibial stress fractures. The CI was on a permanent profile with significant limitations that would have resulted from either condition alone. The MEB examiner documented that given the CI’s recurrent symptoms, he would not be able to return to full training status. Therefore, it is reasonably justified that the CI be found unfit for continued military service in his MOS due to his c hronic l eft and c hronic r ight l eg p ain based upon r ecurrent t ibial s tress fractures conditions . All of the members agreed that the c hronic l eft and r ight l eg p ain due to r ecurrent t ibial s tress fractures conditions, as isolated conditions, would each have rendered the CI incapable of continued service within his MOS, and accordingly each merits a separate rating.
There was one evaluation in evidence, with documentation of additional ratable criteria, which the Board weighed in arriving at its rating recommendation , as summarized in the chart below.

Bilateral Knee ROM
 MEB ~1.67 Mo. Pre-Sep aration
Left Right
Flexion (140⁰ Normal)
 No ROM’s
Extension (0⁰ Normal)
Bilateral tenderness to palpation (TTP) at proximal to mid tibial shafts medially R>L ; neurovascularly intact distally; “recurrent bilateral shin pain”
§4.71a Rating
 10 % 10 %
invalid font number 31502
The CI started with bilateral shin pain during week 8 of training. He was seen in the m edical c linic for right knee pain, which was aggravated by prolonged running and standing. The CI was seen in a cute m edicine for right knee pain , worse with running , and physical findings of tenderness to palpation ( TTP ) and laxity. At the time of this appointment, the CI was diagnosed with retro patellar pain syndrome and he had been advised to use ice, analgesic balm , and a non-steroidal anti-inflammatory drug ( I bupro f en) . A bone scan was ordered for his right shin and knee pain and revealed multiple stress fractures in the proximal shafts of the medial portions of both tibiae, second metatarsal bone s , second metatarsal phalangeal joint spaces , and dorsal feet, all more intense on the right than the left. In follow-up , the CI was given a p rofile for 30 days and Motrin. The CI was sent to the f itness t raining u nit for intense rehabilitation for stress fracture bilateral tibiae so the he would eventually be able to continue training and graduate as a fully qualified Cavalry Scout . The p odiatrist noted that an X -ray showed mild cortical thickening of the left second metatarsal shaft medially and opined that th e stress fracture for the left foot s econd metatarsal was healing well. A month later, the CI stated he was no longer having problems and no edema or TTP was noted on examination. The examiner opined the stress fractures had resolved but recommended the CI continue running at his own pace and distance for 6 days . However, at a follow-up visit a month later , the CI reported pain and the right tibial plateau and proximal tibial shaft was TTP on examination. The CI was referred to orthopedics and the MEB process was started . The MEB n arrative s ummary (NARSUM ) examination approximately a month prior to separation documented that after the CI had completed the rehabilitation , he was only able to complete 2 weeks of training when the symptoms of intense bilateral shin pain, the right greater than left reoccurred. The examiner rated the pain according to the American Medical Associat ion pain scale at minimal and occasional. The examiner opined, “considering the patient’s recurrent symptoms it is very likely that if he is reintroduced to training, his symptoms will return . ” The MEB physical exam findings are summarized in the chart above. The CI was given a permanent L3 p rofile for recurrent bilateral tibial stress fracture with specific restrictions noted. The c ommander’s s tatement was written prior to the bone scan and it indicated that the CI had multiple stress fractures in the right knee that prevented him from training and interfered with his ability to conduct marches over extensive distances with weight in excess of 75 pounds, conduct dismounted reconnaissance and conduct patrolling up to 48 hours. The CI did not report for a VA Compensation and Pension (C&P) examination that was scheduled for 10 December 2004. The CI did undergo an examination for bilateral tibial stress fractures in May 2007 and “[did] not have any flare-ups of shin pain or knee pain or any pain related to shin splints or stress fractures” at that time. The CI was noted to have a normal gait and no TTP along the medial and posterior tibial lines. Both knees were noted to have full active range-o f - motion (ROM) from 0 to 140 degrees without pain. The examiner also noted the previous radiographic evidence of stress fractures.

The Board directs attention to its rating recommendation based on the above evidence. As described above the PEB bundled both conditions and rating analogous to 5003, assigned a 0% rating, based on the USPDA pain policy . The VA coded t ibial s tress f racture , l eft l eg and t ibial s tress f racture , r ight l eg analogous to 5010 a rthritis, due to trauma, substantiated by X -ray findings. The CI failed to show for his C&P examination in 2004. The VA assigned a d isability rating of 0% to each leg , based on the current absence of objective evidence of painful or limited motion. Although the STR documented pain, the VA required a current assessment of the conditions to assign a rating in 2004 . After the C&P examination in May 2007 was completed, the two 0% ratings were continued. Shin splints and lower extremity stress fractures are typically rated analogous to 5262 t ibia and fibula, impairment of , with the malunion disability rating predicated upon slight, moderate, or marked knee or ankle disability . The MEB NARSUM documented pain with increased activity along with relatively asymptomatic periods after decreased activity as would be expected with stress fractures and stress reactions. This supports a rating of 10% for mild disability. The L3 p rofile was specifically given for recurrent bilateral tibial stress fracture s . A b one scan demonstrated multiple bilateral stress fractures. The MEB examiner clearly documented t hat the CI’s symptoms would re cur if he w ere reintroduced to training - - as is expected with stress fractures and stress reactions . After due deliberation in consideration of the totality of the evidence, the Board concluded that the c hronic l ef t a nd c hronic r igh t l eg p ain due to r ecurrent t ibial s tress fractures were each reasonably justified as unfitting. Considering all of the evidence and mindful of VASRD §4.3 r easonable doubt, the Board recommends a disability rating of 10% coded 5299-5262 IAW VASRD §4.71a for the c hronic l ef t l eg p ain due to s tress f racture and 10% coded 5299-5262 IAW VASRD §4.71a for the c hronic r ight l eg p ain due to s tress f racture .

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 ( 635-40) for rating the chronic bilateral leg pain condition was operant in this case and the condition was adjudicated independently of that policy by the Board. In the matter of the b ilateral t ibial s tress f ractures condition, the Board unanimously recommends that each joint be separately adjudicated as follows: an unfitting c hronic l ef t l eg p ain due to r ecurrent s tress f racture condition coded 5299-5262 and rated 10%, and an unfitting c hronic r ight l eg p ain due to r ecurrent s tress f racture condition, coded 5299-5262 and rated 10%, 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 Lef t Leg Pain due to a Recurrent Tibial Stress F racture 5299-5262 1 0%
Chronic Righ t Leg Pain due to a Recurrent Tibial Stress F racture 5299-5262 10%
COMBINED (w/ BLF)
 2 0%
invalid font number 31502

The following documentary evidence was considered:
Exhibit A. DD Form 294, dated 20 120612 , w/atchs
Exhib it 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 AR20130017867 (PD201201005)
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                                                 
                                                      (Army Review Boards)

CF:
( ) DoD PDBR
( ) DVA

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