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AF | PDBR | CY2012 | PD2012 01512
Original file (PD2012 01512.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XX         CASE: PD1201512
BRANCH OF SERVICE: NAVY  BOARD DATE: 20130416
SEPARATION DATE: 20031016


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SR/E-1 (Seaman Recruit/Unrated) medically separated for bilateral shin splints. During initial recruit training in 2003, she complained of left lower extremity pain. X-rays and a bone scan were consistent with bilateral stress reactions. Her condition included left hip pain, diagnosed as left trochanteric bursitis, and left knee pain. Despite light duty, the CI could not be adequately rehabilitated to meet the physical requirements of boot camp and was referred for a Medical Evaluation Board (MEB). The leg, hip and knee conditions, characterized as “bilateral shin splints,” “right tibial plafond stress reaction,” “bilateral femoral stress reactions,” and “left greater trochanteric bursitis & PFPS [p atellofemoral pain syndrome ] ,” were forwarded to the Physical Evaluation Board (PEB) IAW SECNAVINST 1850.4E. No other conditions were submitted by the MEB. The PEB adjudicated “ bilateral shin splints ” as unfitting, rated 10 % each leg . The remaining conditions were determined to be C ategory III ( n ot separately u nfitting and d o n ot contribute to the u nfitting c ondition ). The CI made no appeals and was medically separated with a 2 0% combined disability rating.


CI CONTENTION: The application states simply, “I think the rating should be changed because I have this extremely sharp burning pain in both my legs when I walk for a long distance on them. Sometimes my legs get so stiff that I can barely walk up and down stairs and also my knee bone has this pulling sensation when I go to sit down or stoop to pick up something.” [sic] The CI does not elaborate further or specify a request for Board consideration of any additional conditions.


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 shin splints condition is addressed below. The requested knee condition, which was determined to be not unfitting by the PEB, is likewise addressed below under the discussion of PFPS. Of the conditions determined to be not unfitting by the PEB, members judged that the bilateral leg pain contention was specified sufficiently by the MEB’s identification of right tibial and bilateral femoral stress reactions, and left hip bursitis and PFPS to meet the DoDI 6040.44 scope requirements; accordingly, these are addressed below. Any other conditions or contention not requested in this application, remain eligible for future consideration by the Board for Correction of Naval Records.



RATING COMPARISON :

Service IPEB – Dated 20030820
 VA - Examination 10 Mos. Post-Separation and based on Service Treatment Records (STR)
Condition
 Code Rating Condition Code Rating Exam
Bilateral Shin Splints 5003-5262 10% Stress Injuries of the LLE 5255-5262 10% STR & 20040817
5003-5262 10% Stress Injuries of the RLE 5255-5262 10% STR & 20040817
Right Tibial Plafond Stress Reaction Category III Subsumed under VA DX 2 STR & 20040817
Left Greater Trochanteric Bursitis and PFPS Category III Subsumed under VA DX 1 STR & 20040817
Bilateral Femoral Stress Reactions Category III Subsumed under VA DX 1 & 2 STR & 20040817
No Additional MEB/PEB Entries
 Other x 1 STR & 20040817
Combined: 20%
 Combined: 20%
Derived from VA Rating Decision (VA RD ) dated 200 40102 ( most proximate to date of separation [ DOS ] but based on the STR ) and VARD dated 20041007 (supported by a VA C&P dated 20040817) . The rating did not change between the two VARDs.


ANALYSIS SUMMARY: The CI initially had symptoms of left leg, foot, and hip pain, after 9 days of active duty training. She was found to have bilateral leg stress reactions of the distal femur, and anterior tibia, and right tibial plafond. She was placed on a recovery protocol, and referred to podiatry. Follow-up X-ray and bone scan 3 months later and 3 months prior to separation were normal. It was thought that the CI would need another 2 to 3 months to improve enough clinically to resume training and that her prognosis to complete training and remain in the military was poor. The commander’s assessment stated that the CI missed 30 hours per week for medical appointments and physical therapy, and she was unable to participate in training as a recruit due to stress reactions and shin splints.

Bilateral Leg Pain Condition (includes Bilateral Shin Splints, Bilateral Femoral Stress Reactions, Left Greater Trochanteric Bursitis, and Left PFPS): The narrative summary, 4 months prior to separation, notes evaluations for left lower extremity (LLE) pain, left hip trochanteric bursitis pain, left knee pain, and feet pain. She was placed on light duty, started physical therapy stress fracture protocol, and transferred to the recruit convalescent unit. Physical examination noted left knee tenderness over the anterior patella and positive compression test; the right knee had tibial plafond, tenderness. The tibial shafts were tender as were the left greater trochanter and posterior femoral shaft. There was normal strength, sensation, and normal pulses. Range-of-motion (ROM) are noted in chart below. At the VA Compensation and Pension (C&P) exam performed on 17 August 2004, 10 months after separation, the CI reported some slow improvement in pain with treatment. She described a pulling sensation along the medial right tibia, like her bone is going to crack; the left leg pain was of the anterior calves, and heel, with occasional swelling of the left knee, exacerbated by prolonged walking, pain on the distal end of femur, and right heel. She described the bilateral leg pain as worse than previously reported. Pain was aggravated by prolonged walking, sitting, and at nighttime in bed. Physical exam revealed mild thigh tenderness in the distal quarter of the femur. Knees were normal in appearance, no lateral, anterior, or posterior, instability, no crepitus, and negative McMurray’s sign, with left patellar pain with motion of the patella, no grinding, and slight lateral joint line tenderness, no effusion, erythema, or warmth. There was bilateral tibial tenderness, medial and lateral muscular tenderness, and posteriorly along the gastrocnemius muscle bilaterally. Her feet were tender at the arches, with fallen arches, normal strength, normal sensation, deep tendon reflexes normal at the knee (2+), and 1+ at the ankles which falls under normal variance, gait was normal, with slight eversion of feet, and slight valgus deformity at the knees when standing. She was employed as a clerk.

Bone scan performed on 12 May 2003, bilateral femoral diaphysis stress reaction, bilateral anterior tibial, and right tibial plafond stress reaction. X-rays of the left tibia/fibula: were normal. Repeat bone scan was normal on 8 July 2003. Another repeat bone scan performed on 24 August 2004 by the VA showed very mild uptake in the mid shaft of the right tibia suggestive of status post (s/p) stress fracture/old trauma. Knee X-rays performed by the VA on
17 August 2004, revealed mild bilateral degenerative joint disease (DJD). The knee goniometric ROM evaluations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.

Knee ROM
 (Degrees)
 MEB ~ 3 ½ Mo. Pre-Sep
(20030729 ) 		VA C&P ~ 10 Mo. Post-Sep
(20040817)
Left Right Left Right
Flexion (140 Normal)
 120 120 130 130
Extension (0 Normal)
 0 0 -5 (past 0) -5 (past 0)
Comment
 L Knee TTP over ant. Patella; (+) compression; TTP R Tibial plafond, bilat. Tibial shafts, L greater trochanter, & L posterior femoral shaft knee.
Motor: bilateral LE muscles 5/5; sensation to light touch intact bilat LE; dorsalis pedis & posterior tibial pulses 2+		 B Knees normal in appearance. No patellar grinding noted. Pain in L knee with patellar motion & slight lateral joint line tenderness. No erythema, effusion or increased warmth. No evidence of lateral instability. (-) anterior and posterior drawer sign. No crepitus. (-) McMurray's.
§4.71a Rating
 10 % 10 % 10 % 10 %

The Board directed attention to its rating recommendation based on the above evidence. The PEB rated each lower extremity at 10% using the codes 5003, degenerative arthritis, and 5262, impairment of the tibia and fibula. The VA also rated each lower extremity at 10%, but used codes 5262 and 5255, impairment of the femur. The Board considered VASRD diagnostic codes 5003-5262 degenerative arthritis – impairment of tibia and fibula used by the PEB for a 10% right and 10% left rating. The Board did not find any evidence in the treatment record of any periods of incapacitation, bed rest, or need for immediate medical attention, that would indicate disability above the slight level for the knee or ankle. Although the CI could not perform the rigors of basic training, she was employed as a clerk after separation without apparent limitations, and bone scan indicating only a healing right tibial stress fracture at that time 10 months after separation. The Board then considered the VA codes 5255-5262 (impairment of femur – impairment of tibia and fibula) for a 10% right and 10% left rating. The Board found no evidence in the clinical treatment record of the sequelae of stress reactions of the legs caused knee, ankle, or hip disability that required bed rest, emergent medical treatment, or incapacitation, that could be described as above the level of slight disability for adjudication in the CI’s favor. Although the VA codes 5255-5262 surmised the clinical picture of leg, knee, and hip pain in a more comprehensive manner, there was no rating advantage to the CI for the Board to change it. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the bilateral leg pain condition.

Contended PEB Conditions: The Board’s main charge is to assess the fairness of the PEB’s determination that “Right Tibial Plafond Stress Reaction,” “Bilateral Femoral Stress Reactions,” and “Left Greater Trochanteric Bursitis and PFPS,” were not unfitting. The Board’s threshold for countering fitness determinations is higher than the VASRD §4.3 (reasonable doubt) standard used for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard. The stress reactions were implicated in the commander’s statement, but were all healed by repeat bone scan at the time of separation, as is the natural course of stress reactions of the bones once the inciting factor, in this case training, is removed. The bursitis and PFPS were not mentioned in the commander’s statement as duty limiting. It is difficult to assess the effect of new conditions on fitness for a CI already in a recruit convalescent unit without resorting to undue speculation. The initial complaints of shin splints (the common name for stress reactions of the tibia and fibula) were the conditions for which she was removed from duty after a week of training and placed in the convalescent unit. The subsequent development of left trochanteric bursitis, and left knee pain, did not add new limitations to the duty limitations already imposed by the original conditions, and thus could not be considered as individually and separately unfitting by the Board. 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 any of the contended conditions and so no additional disability ratings were recommended. All the conditions were subsumed by VASRD codes 5003, 5262, and 5255 which include knee, ankle, and hip disability, and did not rise to a level above slight for adjudication in the CI’s favor. As indicated in the prior discussion, the VA’s chosen codes were more descriptive of the CI’s condition and the overall disability picture, but changing the codes did not provide a rating advantage to the CI.


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. The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised. In the matter of the bilateral shin splints condition and IAW VASRD §4.71a, 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
Bilateral Shin Splints Left 5003-5262 10%
Right 5003-5262 10%
COMBINED (w/ BLF)
 20%


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20120814, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans’ Affairs Treatment Record




         XX
         Director of Operations
         Physical Disability Board of Review


 MEMORANDUM FOR DIRECTOR, SECRETARY OF THE NAVY COUNCIL OF REVIEW
BOARDS

Subj: PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS

Ref: (a) DoDI 6040.44
(b) CORB ltr dtd 31 May 13

In accordance with reference (a), I have reviewed the cases forwarded by reference (b), and, for the reasons provided in their forwarding memorandum, approve the recommendations of the PDBR that the following individual’s records not be corrected to reflect a change in either characterization of separation or in the disability rating previously assigned by the Department of the Navy’s Physical Evaluation Board:
- X former USMC
- X former USN
- X former USMC
- X former USN
- X former USN
- X former USN



                                                     
                                                     Assistant General Counsel
                                                      (Manpower & Reserve Affairs)

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