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AF | PDBR | CY2014 | PD-2014-02669
Original file (PD-2014-02669.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXX    CASE: PD-2014-02669
BRANCH OF SERVICE: Army  BOARD DATE: 20150210
SEPARATION DATE: 20060121


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-1 (Basic Trainee) medically separated for a bilateral leg condition. The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty. He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB). The condition “bilateral tibia stress fractures, with chronic pain” was the only condition forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. The Informal PEB adjudicated “chronic bilateral leg pain, due to tibial stress fractures” unfitting, rated 10%, referencing the US Army Physical Disability Agency (USAPDA) pain policy. The CI made no appeals and was medically separated.


CI CONTENTION: “Please consider all 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 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 20051115
 VA* (2 Mo. Pre-Separation)
Condition
 Code Rating Condition Code Rating Exam

Chronic Bilateral Leg Pain…Tibial Stress Fractures
 5099-5003 10% Right Tibial Stress Fracture with Ankle Strain 5299-5262 10% 20051117
Left Tibial Stress Fracture 5299-5262 0% 20051117
Other x 0 (Not In Scope)
 Other x 0
RATING: 10%
 RATING: 10%
* Derived from VA Rating Decision (VA RD ) dated 200 60130 (most proximate to date of separation [ DOS ] ) .



ANALYSIS SUMMARY:

Bilateral Tibial Stress Fractures. The earliest entry in the available service treatment record (STR) is from 29 May 2005 (20 days after enlistment) and notes a complaint of right ankle pain from an injury the second week of training. That exam did note bilateral tenderness of both tibial shafts. The X-rays obtained on that visit noted a possible avulsion fracture of the right ankle (“tiny” off dorsum of talus; later demonstrated as cortical stress fracture) and bilateral cortical stress reactions (e.g., shin splints) of both tibias. Subsequent STR entries note persistent ankle and lower leg pain prohibiting training requirements. The CI was placed on 30 days convalescent leave (4 June – 5 July), reporting no pain on return. His pain recurred with a phased return to physical training, however, an orthopedic evaluation from 27 September 2005 (4 months prior to separation) noted “bilateral shin splints ... right ankle pain ... continuous ... still unable to stand in formation ... right worse than left.” Tenderness of the medial right ankle and both anterior tibias was noted, documenting full range-of-motion (ROM) of bilateral hips, knees, and ankles. A MEB was recommended at that juncture. Serial X-rays after the initial findings noted initial progression from the early studies (as above); but, the final reports noted “healing stress reactions” of the right ankle and tibia, and “healed cortical stress reaction” of the left tibia.

The narrative summary conducted on 25 October 2005 (3 months prior to separation); and, documented that the CI “continues to experience lower pretibial and ankle pain with standing for more than 30 minutes; with impact activities, i.e. running, jumping or squatting and bending acutely with onset of activity.” The pain was rated “constant” and “slight,” and no differentiation of right vs. left severity was provided. The physical exam noted bilateral pre-tibial tenderness and “2+ tenderness ... over right ankle in particular, worse than left”; and, recorded full ROM of both knees and ankles.

A VA Compensation and Pension examination was conducted on 17 November 2005 (2 months prior to separation), and addressed “bilateral shin splints” without right vs. left distinction. It noted only “pain and swelling” of the shins, interfering with running, without any work loss. The VA physical exam documented a normal gait and “normal findings” of the right and left tibias. Normal bilateral ankle and knee examinations with normal measured ROM were also recorded, although pain with repetitive motion of the right ankle (but not the left ankle) was noted. In addition to “bilateral tibial stress fractures” a diagnosis of “right ankle sprain” was entered, although the latter was not specifically addressed in the exam or rated by the VA.

The Board directed attention to its rating recommendation based on the above evidence. The PEB’s bilateral 10% rating analogous to 5003 (degenerative arthritis), although supported by the USAPDA pain policy, was compliant with the provisions of VASRD §4.71a for that code. The VA’s provided separate ratings under 5299-5262 (tibia and fibula, impairment of) which analogously provides for rating based on contiguous knee or ankle disability: 10% for “slight,” 20% for “moderate” and 30% for “marked.” The VA rater invoked the right ankle evidence to support a 10% rating, judging that compensable criteria were not met for the left leg (no contiguous joint involvement).

The Board considered whether separate ratings for each extremity under 5299-5262 (or any code available under §4.71a) could be supported; but, by firm precedence would need to satisfy itself that each extremity was reasonably justified as separately unfitting. Members agreed, however, that if evaluated separately for fitness, it was dubious that the pathology and disability confined to the left leg would have resulted in separation; and, furthermore, that a separate compensable rating for the left leg was not well supported (as per the VA rating determination) even if conceded as separately unfitting. Members further agreed that the evidence does not support a rating higher than 10% for the left leg under any applicable code.

Having concluded that separate ratings were not reasonably justified in this case, the consolidated 10% rating under criteria of 5003 is the only well supported path to a compensable rating. It is also noted that, although not applied by the PEB, the code 5022 (periostitis) is the closest clinical match for a diagnosis of shin splints available under §4.71a; a code which defaults to rating under criteria of 5003 (code change thus not indicated). 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 of the bilateral tibial stress fracture 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. As discussed above, PEB reliance on the USAPDA pain policy for rating was operant in this case and it was adjudicated independently of that policy by the Board. In the matter of the bilateral tibial stress fracture 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 re-characterization of the CI’s disability and separation determination.


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20140425 w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans Affairs Treatment Record





XXXXXXXXXXXXXXX
President
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, AR20150010994 (PD201402669)


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 and hereby deny the individual’s application.
This decision is final. The individual concerned, counsel (if any), and any Members of Congress who have shown interest in this application have been notified of this decision by mail.

BY ORDER OF THE SECRETARY OF THE ARMY:




Encl                       XXXXXXXXXXXXXXX
                                    Deputy Assistant Secretary of the Army
                                    (Review Boards)
                                                     
CF:
( ) DoD PDBR
( ) DVA

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