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AF | PDBR | CY2013 | PD-2013-02762
Original file (PD-2013-02762.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXX     CASE: PD-2013-02762
BRANCH OF SERVICE: NAVY           BOARD DATE: 20141022
SEPARATION DATE: 20071030


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SN/E-3 (Seaman) medically separated for bilateral shin splints, bilateral upper leg pain, a bone loss condition and bilateral tibial stress fractures. The conditions could not be adequately rehabilitated to meet the physical requirements of her rating or satisfy physical fitness standards. She was placed on limited duty and referred for a Medical Evaluation Board (MEB). The MEB forwarded the following four conditions to the Physical Evaluation Board (PEB) for consideration: “distal tibia stress fx,”, “bilat shin splints,” “bilat greater trochanteric bursitis,” and “osteopenia.” No other conditions were submitted by the MEB. The PEB adjudicated all four of the aforementioned conditions as unfit, stipulating: “Category I: The overall effect of the following diagnoses contribute to the unfit finding,” with likely application of DoDI 1332.38. The CI made no appeals and was medically separated.


CI CONTENTION: Nothing contended.


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 overall effect concerning the unfitting bilateral shin splints, bilateral hip, bilateral tibia stress fractures and osteopenia is addressed below and, no additional conditions are within the DoDI 6040.44 defined purview of the Board. 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 Board for Correction of Naval Records.


RATING COMPARISON :

Service IPEB – Dated 20070801
 VA – based on Service Treatment Record (STR)
Condition
 Code Rating Condition Code Rating Exam
Bilateral Shin Splints No code used. Overall Effect cited. 0% Bilateral Shin Splints with Distal Bilateral Tibial Stress Fractures 5299-5262 NSC STR
Distal Bilateral Tibial Stress Fractures
Osteopenia Osteopenia 5099-5003 NSC STR
Bilateral Greater Trochanteric Bursitis Bilateral Greater Trochanteric Bursitis 5299-5252 NSC STR
Other x 0 (not in scope)
 Other x 0 STR
Combined: 0%
 Combined: NONE (NSC)
Derived from VA Rating Decision (VA RD ) dated 200 81107 ( most proximate to date of separation [ DOS ] ).


ANALYSIS SUMMARY: The Board’s main charge with respect to the PEB’s finding of overall effect regarding the four conditions as referred by the MEB, is an assessment of the fairness of the PEB’s determination that each condition in and of itself was not unfitting. The Board’s threshold for countering fitness determinations is higher than the VA Schedule for Rating Disabilities (VASRD) §4.3 (reasonable doubt) standard used for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard. Should the Board judge that any condition considered under the overall effect designation by the PEB was most likely separately incompatible with military service, a disability rating IAW the VASRD, based on the degree of disability evidenced at separation, will be recommended.

As all conditions were evaluated together on most clinical examinations, the Board will discuss the clinical conditions together and then address fitting and rating decisions separately.

Bilateral Shin Splints, Distal Bilateral Tibial Fractures, Bilateral Hip Pain. The narrative summary (NARSUM) notes the CI to develop pain in both lower legs while running during boot camp in April 2006. Routine X-rays at that time were negative. Nuclear bone scan study performed on 21 April 2006, revealed multiple stress fractures involving the high left upper leg bone (proximal femur) and both mid lower leg bones (mid tibias). The hips were normal. The CI was treated with rest and anti-inflammatory medication with improvement in pain. By May 2006, she was able to run 12 laps in 14:43 minutes and “hop 12 times” without pain. On 25 July 2006 the CI presented to sick call noting pain in both lower legs, worse with running and left thigh pain and new pain in both hips. On exam gait was normal. Both tibia and hips were tender to palpation with hip pain increasing with range-of-motion (ROM). A “clunking sound” was noted on movement of the right hip. By September 2006, the CI was able to walk with “minimal” discomfort in the lower legs and none in hips or upper legs. Gait at this time was normal. On 20 December 2006 the CI presented with hip and lower leg pain, but noted pain was controlled by medication. Gait at this time was normal. A repeat nuclear bone scan obtained in March 2007 revealed diffuse shin splints and bilateral lower leg stress fractures (distal tibias) in the “healing phase.” On examination 3 April 2007 (first NARSUM) gait was normal. ROM of the hips was normal with only slight tenderness of the lateral hip area. Tenderness over the inguinal (groin crease) ligament of both hips and pain with resisted extension of the hip was noted. On clinic visit 25 April 2007, the CI reported no leg or hip pain. A bone density study, obtained on 23 May 2007, revealed reduced bone density (osteopenia) in the total lumbar spine, consistent with an increased risk of fracture, but not in the hips or bilateral upper legs. An evaluation of the lower legs was not included in this study. On clinic visit 5 June 2007, the CI reported mild pain in her shins. On exam tenderness in the low back “radiating to the left hip” was reported. Gait, motor and neurologic exams were normal. At the MEB/NARSUM exam performed on 16 July 2007, 3 months prior to separation, the CI reported pain in both lower legs left worse than right, and pain in both hips. The MEB physical exam noted the gait to be normal. Exam of the hips revealed some tenderness to palpation (TTP) over the hip points (greater trochanters). ROM of the hips, knees and ankles was normal without pain. Exam of the lower legs revealed no swelling or gross deformity. Diffuse pain on palpation was noted on the front inner middle 1/3 of both lower leg bones. Routine X-rays of the legs revealed no evidence of stress fractures; X-rays of the hips and pelvis were normal. No VA Compensation and Pension (C&P) was performed due to CI non-attendance. The first C&P examination performed on 13 April 2013, 5 years after separation, well outside the probative value period for Board consideration.

The Board directs attention to its rating recommendation based on the above evidence. As noted above, the PEB combined all conditions and rated 0% for overall effect. The Board first determined the fitness of each individual condition. The Board unanimously agreed that the clinical symptoms of the stress fracture and shin splint conditions were similar precluding their separation for individual evaluation. These were considered together as right and left lower leg conditions for determination of fitness.

Left Shin Splints/Left Distal Tibial Stress Fractures. The Board agreed that the left leg condition was mild with severity occurring with running. The Board noted frequent clinic visits where pain was either mild or absent. The Board noted multiple ROM evaluations to be normal without pain. Motor and sensory exams were always normal. The Board noted all gait analysis to be normal. The Board noted the condition to be limited to a small area in the mid anterior medial areas in the lower legs and to be healing on bone scan studies at time of separation. No swelling, edema or redness was ever recorded. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board agreed that there was no preponderance of evidence in record to support change in the PEB adjudication of not separately unfit for the left leg condition. The Board concluded, therefore, that this condition could not be recommended for additional disability rating.

Right Shin Splint/Right Stress Fracture. The Board agreed this condition to be less severe than that of the right leg. The Board agreed that findings above were apropos to the right leg. After due deliberation, considering all of the evidence, the Board agreed that there was no preponderance of evidence in record to support change in the PEB adjudication of not separately unfit for the right leg condition. The Board concluded, therefore, that this condition could not be recommended for additional rating.

Left Hip Bursitis. The Board agreed the left hip condition was mild. The records noted periods of both hip pain and no hip pain. Routine X-rays, bone scans of the hips revealed no pathology. On examination gait was always normal. ROM was noted to be normal with both no pain and TTP over the trochanters in varying exams. Motor and sensory exams were normal without swelling or crepitus. The Board noted the report of the CI at the time of the NARSUM that left hip pain “radiated from the back.” After due deliberation, considering all of the evidence, the Board agreed that there was no preponderance of evidence in record to support change in the PEB adjudication of not separately unfit for the left hip condition. The Board concluded, therefore, that this condition could not be recommended for additional disability rating.

Right Hip Bursitis. The Board agreed the right hip condition was mild. The Board agreed that all findings above were applicable to the right hip. The Board noted the “clunking sound” reported shortly after onset of pain, but not reproduced in subsequent hip evaluations. After due deliberation, considering all of the evidence, the Board agreed that there was no preponderance of evidence in record to support change in the PEB adjudication of not separately unfit for the right hip condition. The Board concluded, therefore, that this condition could not be recommended for additional rating.

Osteopenia. The Board agreed this condition was a finding on a laboratory examination. On this test the condition was limited to the lumbar spine with no report of the condition in the hips or legs. On review of the record the Board found no sequellae of this condition, i.e. evidence of bone fractures in areas of osteopenia, to suggest an impact on duty performance. The Board agreed that, if the leg stress fractures were related to the osteopenia condition, that they would be adjudicated, as above, as sequellae of this condition. After due deliberation, considering all of the evidence, the Board agreed that there was no preponderance of evidence in record to support change in the PEB adjudication of not separately unfit for the osteopenia condition. The Board concluded, therefore, that this condition could not be recommended for additional disability rating.

In conclusion, the Board unanimously recommends the conditions were not separately unfit, not subject to rating, and therefore, recommends no change in the PEB determination.


BOARD FINDINGS: The Board noted from the record the PEB ruling in this case likely used DoDI 1332.38 in its citing of overall effect. 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 matters of the bilateral shin splint, distal bilateral tibial stress fracture, bilateral greater trochanteric bursitis and osteopenia conditions, 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 re-characterization of the CI’s disability and separation determination.


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20131217, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans’ Affairs Treatment Record






                 
XXXXXXXXXXXXXX
President
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 22 Apr 15

In accordance with reference (a), I have reviewed the cases forwarded by reference (b), and, for the reasons provided in their forwarding memorandums, 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:
- XXXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXXX, former USN


                                                      XXXXXXXXXXXXXXX
                                            Assistant General Counsel
                  (Manpower & Reserve Affairs)

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