Search Decisions

Decision Text

AF | PDBR | CY2014 | PD-2014-02015
Original file (PD-2014-02015.rtf) Auto-classification: Approved
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXX    CASE: PD-2014-02015
BRANCH OF SERVICE: Army  BOARD DATE: 20150319
SEPARATION DATE: 20020530


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-3 (Army Diver) medically separated for a lower extremity stress condition. The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS) or satisfy physical fitness standards or but was authorized to perform an alternate physical fitness test. He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB). The “severe stress reactions versus stress fracture of the tibial shaft on the left side” and “severe stress reaction of the right tibial which is moderately symptomatic,” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. No other condition was submitted by the MEB. The Informal PEB adjudicated “bilateral lower extremity stress reactions without evidence of fracture” as unfitting, rated 0%. The CI made no appeals and was medically separated.


CI CONTENTION: “I am still in college, pursuing a new career after multiple attempts at my previous two career avenues of structural welder and OTR Truck driver being unable to perform either task due to my injuries in both legs: daily irritation, inability to run, jump, lift over 50 lbs” [sic] “no service connection could be granted” for the claim of: “Lumbar strain (also claimed as thorasic [sic] secondary to bilateral stress fractures.” This decision should be reconsidered in conjuction with current diagnosis of arthritis in spine and shoulder.


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 when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting. Any conditions outside the Board’s defined scope of review and any contention not requested in this application may remain eligible for future consideration by the Board for Correction of Military/Naval Records. Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate. The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards to the unfitting medical condition at the time of separation. The Board has neither the role nor the authority to compensate for post-separation progression or complications of service-connected conditions. That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws. The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation.
RATING COMPARISON :

IPEB – Dated 20020430
 VA* - (~12 yrs. Post-Separation)
Condition
 Code Rating Condition Code Rating Exam
Bilateral Lower Extremity Stress Reaction w/o Evidence of Fractures 5099-5022 0% Medial Stress Syndrome Tibial Shaft…Right Side 5262 0% 20140319
Medial Stress Syndrome Tibial Shaft…Left Side 5262 0% 20140319
Other x 0 (Not In Scope)
 Other x 1 (Not in Scope)
RATING: 0%
 RATING: 0%
* Derived from VA Rating Decision (VA RD ) dated 20 140328 (most proximate to date of separation [ DOS ] ) .


ANALYSIS SUMMARY: The PEB combined bilateral lower extremity stress reactions as a single unfitting condition coded analogously to 5022, which is rated IAW code 5003. The Board must apply separate codes and ratings in its recommendations, if compensable ratings for each condition 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 unfitting. Thus the Board must exercise the prerogative of separate fitness recommendations in this circumstance, with the caveat that its recommendations may not produce a lower combined rating than that of the PEB.

Bilateral Lower Extremity Stress Reaction w/o Evidence of Fractures Condition. The earliest note in the service treatment record is dated 7 December 2001 at which time the CI presented to the podiatry service with a complaint of bilateral ankle pain with swelling for 3 days during the first week of Basic Training. Examination revealed tenderness to touch of both ankles and legs with edema. X-ray studies on 7 December 2001 of the ankles and feet revealed normal feet with a bipartite medial sesamoid bone (located on the underside of the base of the big toe) of the left first metatarsal phalangeal joint and accessory cuboid bone on the left and no other significant abnormalities or signs for stress fracture injury and no fractures or bony lesion of the tibia or fibula of either leg. Follow-up X-rays of the right leg were normal on 4 January 2002. Physical therapy was carried out for 5 weeks with persistence of pain and tenderness to palpation and pitting edema noted on 12 February 2002 of both mid tibias (shins) more on the left. Follow-up X-rays of the both anterior tibia (legs) on 12 February 2002 were normal. A bone scan of both tibia on 5 March 2002 revealed diffuse uptake bilaterally, a stress fracture of the left medial (inner) femoral condyle (back upper part of the knee joint) and severe stress changes versus an early stress fracture of the mid to distal (lower) left tibia. At a follow-up physical therapy examination on 26 March 2002, there was still tenderness to palpation on both distal tibias, although minimal on the right.

The MEB narrative summary dated 28 March 2002 indicated the CI noted severe bilateral leg pain (left great than right) in early December 2001, which was exacerbated by running, jumping, and twisting activities as well as prolonged standing and marching. In the office the pain was 3/10 (10 being the worst pain) and when running it was 8/10. He had been in Physical Training and Rehabilitation Program for 2 months, but still had pain sufficient enough to preclude his return to basic training. Physical examination revealed tenderness to palpation about the medial (inner) aspect of the left lower extremity at the junction of the middle and distal thirds, while the right lower extremity was minimally tender to palpation throughout. No skin changes were present on either leg. The X-rays of both legs were reviewed and some cortical thickening was noted on the left at the junction of the middle and distal thirds with no obvious stress fracture; and, review of the bone scan was consistent with a severe stress reaction versus a stress fracture of the left tibia as well as severe stress reactions in the right tibia. Modification of activities failed to ameliorate the pain of the left leg, which was moderately to severely symptomatic and the right leg, which was moderately symptomatic. A permanent P3 profile was issued on 28 March 2002 for severe stress reaction of both legs with limitations of no running, jumping, marching, physical fitness testing, and wearing a backpack. No commander’s statement was available for review. At the MEB examination dated 2 April 2002, the CI reported stress fractures/stress reactions in both tibia, left knee and right metatarsal while training. The MEB physical examination noted increased tenderness in both tibia and the left knee. The temporally remote (almost 11 years and 10 months after separation) VA Compensation and Pension examination was reviewed; however, it offered very limited or no probative after separation evidence of any significant value, but indicated the bilateral leg pain became better for about one to two years then he began to notice increase after jumping, trying to run or carry a weight over about 75 pounds.

The Board directed attention to its rating recommendation based on the above evidence. The PEB assigned a 0% rating using code 5099-5022 (Periostitis) for bilateral lower extremity stress reactions without evidence of fracture on X-ray. The VA, almost 12 years after separation, assigned a 0% rating using code 5262 (Tibia and fibula impairment) for the stress syndrome of the left tibial shaft and a 0% rating using code 5262 (Impairment tibia and fibula) for the stress syndrome of the right tibial shaft. The Board first considered whether the left lower extremity stress reaction, having been de-coupled from the combined PEB adjudication, remained itself unfitting as established above. Members agreed that the functional limitations in evidence justified the conclusion that the condition was integral to the CI’s inability to complete training or perform his MOS; and, accordingly a separate rating is recommended. The Board then considered whether the right lower extremity stress reaction, having been de-coupled from the combined PEB adjudication, remained itself unfitting as established above. Members agreed that the functional limitations in evidence justified the conclusion that the condition was integral to the CI’s inability to complete training or perform his MOS; and, accordingly a separate rating is recommended. Code 5262 is appropriate to address the CI’s clinical and imaging findings. The left tibia had findings of severe stress changes versus early stress fracture at mid to distal tibia, which brings the anatomical changes on bone scan imaging closely congruent to code 5262 for a 10% rating since the knee joint involvement is supported by the finding of a stress fracture at the femoral condyle and the ankle is represented by changes at the distal tibia. On the other hand, the stress changes of the right tibia do not truly represent a malunion. Therefore, use of an analogous code 5299-5262 addresses the anatomical locus of the stress changes; however, in the absence of slight knee or ankle disability the appropriate rating is 0% for the right tibia; and no route to a higher rating could be found. The Board also discussed the use of the analogous code 5022, which is rated according to limitation of motion using code 5003. However, there was no limitation of motion of either the knee or ankle joints, and there were not actual X-ray changes, but instead there were the bone scan imaging changes. Even if the bone scan imaging changes were used in lieu of the X-rays, a 10% rating is the maximum that can be assigned for two or more major joints in the absence of incapacitating exacerbations with the use of code 5003. However, Note (2) of code 5003 indicated that rating conditions under diagnostic codes 5013 to 5024 cannot be utilized with code 5003; and, therefore, code 5022 is precluded from use. Alternatively, the Board considered using analogous code 5099-5003 for the imaging rating in the absence of a limitation of motion, but the Board members felt an individual rating for each tibia was more appropriate and on point. Muscle codes were discussed, but could not provide a route to a higher rating since there was no evidence to support the use of any muscle code. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the left lower extremity stress reaction/stress fracture condition and recommends a disability rating of 0% for the right lower extremity stress reaction condition.


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 left leg stress reaction/stress fracture condition, the Board unanimously recommends a disability rating of 10%, coded 5262 IAW VASRD §4.71a. In the matter of the right leg stress reaction condition, the Board unanimously recommends a disability rating of 0%, coded 5299-5262 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:

CONDITION
 VASRD CODE RATING
Left Leg Stress Reaction/Stress Fracture 5262 10%
Right Leg Stress Reaction 5299-5262 0%
COMBINED
 10%


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 201w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans Affairs Treatment Record







XXXXXXXXXXXXXXX
President
DoD Physical Disability Board of Review
SAMR-RB                                                                         


MEMORANDUM FOR Commander, US Army Physical Disability Agency
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557


SUBJECT: Department of Defense Physical Disability Board of Review Recommendation
for XXXXXXXXXXXXXXX, AR20150013701 (PD201402015)


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                       XXXXXXXXXXXXXXX
                                    Deputy Assistant Secretary of the Army
                                    (Review Boards)

CF:
( ) DoD PDBR
( ) DVA

Similar Decisions

  • AF | PDBR | CY2013 | PD-2013-01511

    Original file (PD-2013-01511.rtf) Auto-classification: Denied

    The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards to the unfitting medical condition at the time of separation. Right Femoral Shaft Stress Fracture Condition . The diagnoses were listed asright femoral shaft stress fracture; bilateral medial tibial plateau stress reactions; right second metatarsal stress reaction; and bilateral...

  • AF | PDBR | CY2012 | PD2012 01512

    Original file (PD2012 01512.rtf) Auto-classification: Denied

    The leg, hipand knee conditions, characterized as “bilateral shin splints,” “right tibial plafond stress reaction,” “bilateral femoral stress reactions,” and “left greater trochanteric bursitis & PFPS [patellofemoral pain syndrome],” were forwarded to the Physical Evaluation Board (PEB) IAW SECNAVINST 1850.4E. Bilateral Leg PainCondition (includes Bilateral Shin Splints,Bilateral Femoral Stress Reactions, Left Greater Trochanteric Bursitis, and Left PFPS) :The narrative summary, 4 months...

  • AF | PDBR | CY2012 | PD2012 00695

    Original file (PD2012 00695.rtf) Auto-classification: Denied

    No other conditions were submitted by the MEB.The PEB adjudicated “multiple stress reactions/healing stress fractures”as unfitting rated20%,with likely application of Veterans Affairs Schedule for Rating Disabilities (VASRD).The remaining conditions,left cuboid stress fracture, bilateral medial tibial plateau stress fracture and right femoral shaft stress fracture, were determined to be Category II (contributing to unfit condition). Bone scan on 22 August 2001 demonstrated healing stress...

  • AF | PDBR | CY2012 | PD 2012 01437

    Original file (PD 2012 01437.txt) Auto-classification: Denied

    Post-Separation) – All Effective Date 20020716 Condition Code Rating Condition Code Rating Exam Bilateral Inferior Pubic Ramus Stress Fractures, X- Ray Verified with Other Lower Extremity Stress Reactions on Bone Scan 5299-5010 0% Stress Fracture Left Tibia 5299-5262 0% 20021217 Stress Fracture Right Tibia 5299-5262 0% 20021217 Bilateral Pelvic Stress Fractures 5299-5255 Non Service Connected (NSC) 20021217 .No Additional MEB/PEB Entries. The PEB combined the bilateral inferior pubic ramus...

  • AF | PDBR | CY2013 | PD-2013-01355

    Original file (PD-2013-01355.rtf) Auto-classification: Approved

    RATING COMPARISON : ServiceIPEB – Dated 20040107VA* -based on Service Treatment Records(STR)ConditionCodeRatingConditionCodeRatingExam Bilateral Lower Extremity Stress Fractures/Reaction50220%Left Tibial Stress Fractures5299-526010%STRRight Tibial Stress Fractures5299-526010%STROther x 0 (Not In Scope)Other x 0 Combined: 0%Combined: 20% *Derived from VA Rating Decision (VARD)dated 20040210 (most proximate to the date of separation (DOS)) Bilateral Stress Fractures . When the Board...

  • AF | PDBR | CY2012 | PD-2012-00728

    Original file (PD-2012-00728.txt) Auto-classification: Approved

    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. Left tibial stress fracture with bilateral femoral stress reactions.” The L3 profile listed “bilateral lower leg stress fractures.” The commander’s statement indicated complaints of leg pains, noted “stress fractures in both lower legs” without improvement following being “sent...

  • AF | PDBR | CY2014 | PD-2014-02669

    Original file (PD-2014-02669.rtf) Auto-classification: Denied

    The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of theVeterans Affairs Schedule for Rating Disabilities (VASRD) standards to the unfitting medical condition at the time of separation. Pre-Separation) ConditionCodeRatingConditionCodeRatingExam Chronic Bilateral Leg Pain…Tibial Stress Fractures5099-500310%Right Tibial Stress Fracture with Ankle Strain5299-526210%20051117Left Tibial Stress...

  • AF | PDBR | CY2012 | PD2012-00882

    Original file (PD2012-00882.pdf) Auto-classification: Denied

    See attached/enclosed letter and VA records.” In the letter the CI cites his bilateral tibial stress fractures as well as a panic disorder and painful knees, back and hands. Post-Separation) – All Effective Date 20031001 Condition Stress Fracture, Left Tibia Stress Fracture, Right Tibia Bursitis Left Hip Panic Disorder w/o Agoraphobia 0% X 1 / Not Service-Connected x 2 Combined: 50% Rating 10% 10% 10% 30%* Code 5022 5022 5019 9412 Exam 20030828 20030828 20030828 20030902 ANALYSIS...

  • AF | PDBR | CY2011 | PD2011-00492

    Original file (PD2011-00492.docx) Auto-classification: Denied

    The ratings for unfitting conditions will be reviewed in all cases. Bilateral Lower Leg Condition. Service Treatment Record.

  • AF | PDBR | CY2012 | PD2012 01005

    Original file (PD2012 01005.rtf) Auto-classification: Approved

    Service IPEB – Dated 20020313VA - based on Service Treatment Records (STR)ConditionCodeRatingConditionCodeRatingExam Chronic Bilateral Leg Pain due to Recurrent Tibial Stress Fractures5099-50030%Tibial Stress Fracture, Left Leg5299-50100%Service Treatment Record (STR)Tibial Stress Fracture, Right Leg5299-50100%STR Rating: 0%Combined Rating: 0%Derived from VA Rating Decision (VARD) dated 20050105 ( most proximate to date of separation [DOS]). The Board must therefore apply separate codes and...