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AF | PDBR | CY2012 | PD2012 01502
Original file (PD2012 01502.rtf) Auto-classification: Approved
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:    BRANCH OF SERVICE: Army
CASE NUMBER: PD1201502   SEPARATION DATE: 20040104
BOARD DATE: 20130411


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SPC/E-4 (92Y10/Unit Supply Specialist), medically separated for bilateral leg pains without any specific history of trauma or injury. Despite profiles, activity modifications, anti-inflammatories, and physical therapy the CI did not improve adequately with treatment to meet the physical requirements of her Military Occupational Specialty (MOS) or satisfy physical fitness standards. She was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB). The MEB forwarded bilateral stress reaction for Physical Evaluation Board (PEB) adjudication. The PEB adjudicated bilateral leg pains without any specific history of trauma or injury condition as unfitting, rated 0% with 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: “My condition has worsened and I am having an even more difficult time going up and down stair, sitting and standing. I have seen my private family doctor about these issues recently and because my knees are injured - it has caused my hips to start hurting. The hips are taking the weight load versus using my knees. They have continued to crack and I am unable to walk sometimes unless I crack them. My knee problem (diagnosed as Patella Fermoral [sic] Pain Syndrome) I believe has worsened. I will continue to visit my family doctor insured with Tricare prime south.”


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 unfitting bilateral leg pain/stress reaction condition is addressed below. The requested knee and hip conditions are not within the Board’s purview. 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 20031201
 VA (21 Mos. Post-Separation) – All Effective Date 20050705
Condition
 Code Rating Condition Code Rating Exam
Bilateral Leg Pain 5099-5003 0% Bilateral Chronic Tibia Stress Fractures 5299-5262 NSC 20051025
↓No Additional MEB/PEB Entries↓
 Chondromalacia Right Knee 5257 10% 20051025
Chondromalacia Left Knee 5257 10% 20051025
Not Service-Connected x 5 others 20051025
Rating: 0%
 Combined: 20%


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 leg pain condition under a single analogous 5003 degenerative arthritis code. This coding approach is countenanced by AR 635-40 (B.24f.), 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.

Right and Left Leg Pain Conditions. The CI had a greater than 3 year history of bilateral leg and knee pain with no history of trauma nor surgery, resulting in medical profiles with both sides being essentially equivalent. Both legs were included on both temporary and permanent profiles as well as all outpatient visits related to leg pain. Both the right and left leg alone would have led to the same profile restrictions and either leg alone would have rendered the CI unfit to perform her required military duties. The commander’s statement noted the CI was unable to perform required duties but did not mention any specific condition. All Board members agreed that the right and left leg pain conditions were each reasonably justified as unfitting.

The CI was first seen for bilateral shin pain in February 2000 and had multiple visits and temporary profiles without relief of her symptoms. An outpatient visit for bilateral tibia-fibula pain in September 2001 noted normal X-rays and a plan for a profile and a bone scan. That initial bone scan noted only stress related changes in both feet. However, the CI’s symptoms continued and she was unable to resume military activities without pain. In February 2002, the CI reported right worse than left leg pain for 2 years that was progressively worsening. She reported a constant dull ache with significantly increased pain with ten minutes of running. She also reported numbness and Orthopedics considered the diagnosis of exertional compartment syndrome. A repeat bone scan at that time documented mild bilateral stress related periosteal reactions throughout the tibiae with no evidence of a recent stress fracture. The CI reasonably declined needle compartment testing and orthopedics recommended a MEB. This was apparently delayed due to pregnancy with delivery in March 2003. A rheumatology consult in June 2003 ruled out any generalized inflammatory or metabolic disorder.

The MEB narrative summary (NARSUM) was completed approximately 3 months prior to separation and it noted tenderness to palpation along the medial borders of the tibia without any gross deformity or reactions. Normal sensation and 5/5 muscle strength was also noted bilaterally. At the VA Compensation and Pension (C&P) exam, approximately 22 months after separation, the CI reported pain on the tibial area associated with flare-ups with prolonged walking and running. Prolonged walking and trying to run lead to increased pain and rest made it better. She reported this condition did not affect her daily activities or her job. The physical exam indicated a normal bilateral leg exam, without tenderness to deep palpation in the anterior tibial region, limping, muscle atrophy, nor lack of strength.

The Board directs attention to its rating recommendation based on the above evidence. As discussed above, the PEB combined the two conditions of right and left leg pain coded 5099-5003 at 0% IAW the USAPDA pain policy. The VA determined the bilateral chronic tibia stress fractures condition was not service-connected because the condition had resolved. The CI’s right and left leg pain prevented her from performing her required military duties. The MEB NARSUM examination was completed at a time closer to the date of separation than the VA examination and it is therefore afforded a greater probative value by the Board. This exam documented ongoing symptoms of chronic stress reactions with tenderness to palpation of each tibia. Although no specific VASRD code exists for this condition, 5262 tibia and fibula, impairment of is frequently used. The available record does not support a determination of impairment greater than slight for either leg. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 Reasonable doubt, the Board recommends each leg as unfitting with coding 5299-5262 at 0% for the right leg pain condition and 5299-5262 at 0% for the left leg pain condition. Additionally, IAW 38 CFR Ch I § 3.324 Multiple noncompensable service-connected disabilities, the Board recommends an overall disability rating of 10%.
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 5299-5003 was operant in this case and the condition was adjudicated independently of that policy by the Board. In the matter of the bundled right and left leg pain conditions, the Board unanimously agrees that each leg was separately unfitting and by a vote of 2:1, recommends a disability rating of 0% for right leg pain, coded 5299-5262 IAW VASRD §4.71a and 0% for left leg pain, coded 5299-5262 IAW VASRD §4.71a and an overall rating of 10% IAW 38 CFR Ch I § 3.324. The single voter for dissent (who recommended rating each leg at 10% with a combined 20% disability rating) 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
Right Leg Pain 5299-5262 0%
Left Leg Pain 5299-5262 0%
COMBINED
 10%


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20120728, 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 AR20130010221 (PD201201502)
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                                                 
                                                      (Army Review Boards)

CF:
( ) DoD PDBR
( ) DVA

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