RECORD OF PROCEEDINGS
AIR FORCE BOARD FOR CORRECTION OF MILITARY RECORDS

IN THE MATTER OF:	DOCKET NUMBER:  BC-2007-04028
		INDEX CODE:  108.00
		COUNSEL:  NONE
		HEARING DESIRED:  NO

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APPLICANT REQUESTS THAT:

Her disability rating be increased from 10% to 70%-80% with a permanent disability retirement.

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APPLICANT CONTENDS THAT:

An artificially low disability rating was reached as her condition was not fully characterized and full treatment benefits had not been obtained.  Had the board process been handled appropriately these errors would have been addressed.  She is now confined to a wheelchair.  This is a direct result of the surgery performed and the aftercare provided by the Air Force.  Her retirement should be processed under Reflex Sympathetic Dystrophy (RSD) or Neuralgia or the Femoral, Peronal and Tibial Nerves (final diagnosis while in the Air Force) at a total rating of 70% - 80%.  Private practitioners discovered the symptoms had spread to both legs and both hands.  Additionally, she experiences myoclonus (8104) as a result of the neurological problems.

Once the Medical Evaluation Board (MEB) progressed there were multiple points at which the packet should have been returned.  A packet must be recalled for clarification, updating, deficient information/evidence missing, change in status, errors, omissions, inconsistencies, and non-compliance with the regulations governing the Disability Evaluation System (DES) process.  Individuals responsible for this action include the preparing physician, the board president reviewing officer, the hospital commander, AFPC/DPPD, the Informal Physical Evaluation Board (IPEB) president, the Formal Physical Evaluation Board (FPEB) president, and the Secretary of the Air Force Personnel Council (SAF/PC).  None of these individuals acted to recall the packet despite multiple problems.  Therefore, the MEB and PEB could not carry out their primary roles to confirm the medical diagnosis and to determine the nature, origin and degree of the disability.

The narrative serves as the summary of all of the information the boards receive.  Therefore, this document is very important to any disability case.  The narrative, in this case; however, was missing information and contained inaccurate information.  Both oversights are violations of the regulations governing the narrative's preparation.

Whether she left the Air Force through force shaping or through the MEB, it is clear that her career was cut short by this disability.  Dramatic though it may sound, she was scared for her life.  A plethora of medications were prescribed, some of which were wholly inappropriate.  Care was often unacceptably delayed or denied.  She attempted to remedy the situation through a number of channels and unfortunately, all remedies were unsuitable.  She was ultimately forced to request to leave the Air Force in order to protect her health and to pursue medical treatment elsewhere.

In support of her request, the applicant provided a personal statement and documentation extracted from her medical records.

Applicant’s complete submission, with attachments, is at Exhibit A.

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STATEMENT OF FACTS:

The applicant entered active duty on 17 June 2002 in the grade of second lieutenant.  She was progressively promoted to the grade of first lieutenant having assumed that grade effective and with a date of rank of 29 May 2004.

An MEB convened on 12 April 2005 and referred her case to an IPEB with a diagnosis of chronic regional pain syndrome, mild, after injury to left anterior cruciate ligament.  On 11 May 2005, the IPEB found her unfit for further military service.  The IPEB recommended discharge with a combined compensable rating of 10%.  The applicant disagreed with the findings and recommended disposition of the IPEB and requested an FPEB.  On 29 June 2005, the FPEB found her unfit for further military service based on a compensable diagnosis of chronic regional pain syndrome.  The FPEB further recommended discharge with severance pay with a disability rating of 10%.  She appealed the FPEB decision to SAF/PC.  SAF/PC concurred with the findings and recommendation of the FPEB and directed discharge with severance pay effective 11 October 2005.  She served 3 years, 3 months, and 25 days on active duty.

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AIR FORCE EVALUATION:

AFPC/DPSD recommends denial.  DPSD states the applicant was released from active service on 11 October 2005 for diagnoses of chronic regional pain syndrome (Reflex Sympathetic Dystrophy), mild, after injury to left anterior cruciate ligament.  The IPEB reviewed her case on 11 May 2005 and recommended discharge with severance pay at a disability rating of 10%.  She requested a hearing with the FPEB and appeared with counsel before the FPEB on 29 June 2005.  The FPEB examined the evidence presented at the hearing and also recommended discharge with severance pay with a disability rating of 10%.  The FPEB noted the applicant had received a diagnosis of chronic regional pain syndrome and agreed that a change in the Veterans Administration Schedule for Rating Disabilities (VASRD) code to reflect sympathetic dystrophy was appropriate.  The FPEB noted she had missed minimal duty time and was able to perform her military duties without significant impairment or modifications of her duty environment.  They also noted the imaging study of 18 June 2004 showed no evidence of reflex sympathetic dystrophy, her anterior cruciate ligament reconstruction with graft had healed, and she had no mechanical limitations to her rehab or activities.  The FPEB also recommended discharge with severance pay at a disability rating of 10%.  In the applicant's rebuttal she requested her disability rating be increased to 50%.  On 29 August 2005, SAF/PC reviewed the entire case file with applicant's additional documentation.  The board found no compelling evidence to justify overturning previous board decisions.  They noted that during a follow-up clinical assessment conducted on 7 July 2005, the applicant demonstrated no impairment of gait and had essentially normal strength in the involved left knee.  Electrodiagnostic studies of the applicant's lower extremities also failed to demonstrate the presence of a peripheral neuropathy or radiculopathy to explain her symptoms.  SAF/PC found no errors with the adjudication procedure of her case and concurred with the dispositions of both boards upholding the recommendation of discharge with severance pay with a disability rating of 10%.

Per AFI 36-3212, section 2.61, if major change in the diagnosis or in a member's condition is discovered, the referring MTF commander must recall the case for further medical evaluation and new medical board or addendum as appropriate.  The commander sends a report of circumstances and request for recall to HQ AFPC/DPSD.  At no time was a request for recall received by their office.  Any new medical documentation regarding the member's condition was submitted with each new appeal of her case.

The preponderance of evidence reflects that no error or injustice occurred during the disability process.

The complete DPSD evaluation is at Exhibit C.

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APPLICANT'S REVIEW OF AIR FORCE EVALUATION:

On 1 February 2008, the evaluation was forwarded to the applicant for review and comment within 30 days (Exhibit D).  As of this date, this office has received no response.

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ADDITIONAL AIR FORCE EVALUATION:

The AFBCMR Medical Consultant recommends changing the record to reflect the applicant was retired from military service with a 40% disability rating, due to her "moderately severe" Complex Regional Pain Syndrome (CRPS).

The AFBCMR Medical Consultant states the applicant was given a 10% disability rating for her condition.  The record reflects numerous evaluations by different physician specialists (sports medicine, neurology, and orthopedics) some finding inconclusive evidence of CRPS and others confirming the diagnosis.  In assessing the severity of the applicant's medical condition, the Medical Consultant noted that the rationale of the FPEB for awarding a 10% disability rating was based collectively upon the applicant's use of "non-narcotic medications and her ability to perform her military duties without significant impairment or modifications of her duty environment."  The FPEB also noted that the applicant had reportedly "missed minimal duty time" and that she "[had] no limitations in activities of daily living."  The applicant's commanding officer also provided the following description of the applicant's duty performance in a letter dated 23 February 2005, which reads: "XXXXXXXXXX supervisor says that her duty performance has not diminished significantly and suggested that her standards are perhaps much higher than most people's.  Although she has missed several days of work for medical appointments, [her supervisor] does not deem them excessive.  He also has seen no significant negative impact from her condition to his work center or the unit's overall mission."  

Additionally, electrodiagnostic studies (EMG and nerve conduction velocity) of the applicant's lower extremities failed to demonstrate a quantifiable neurological deficit.  Nonetheless, the applicant had been under an extended treatment plan utilizing a broad range of pain modulating measures both during military service and following her discharge, to include lumbar sympathetic blocks, a saphenous nerve block, use of a transcutaneous electrical nerve stimulation (TENS) device, and a variety of oral medications; none of which eliminated the applicant's symptoms.

Although the applicant's medical condition may have progressed since leaving military service, to the extent that she is now reportedly wheelchair-dependent, the Military Disability Evaluation System (MDES) can only rate her medical condition based upon its level of severity at the "snap-shot" in time in which the final case disposition was reached.  The AFBCMR Medical Consultant acknowledges the applicant's concerns that a 10% disability rating does not accurately reflect the actual level of functional impairment she experiences on a given day, particularly when taking into account her reported daily fatigue and the adverse effects of her medications.  Therefore, in justifying a recommended Board action, attention is directed to special rating guidelines for Neuralgia, or pain, as provided under the Veterans Administration Schedule for Rating Disabilities (VASRD).  Neuralgia, cranial or peripheral, characterized usually by a dull and intermittent pain, of typical distribution so as to identify the nerve, is to be rated on the same scale, with a maximum equal to moderate incomplete paralysis.

Noting that the applicant's functional impairment has been predominantly due to pain, strict adherence to the aforementioned VASRD guidelines for rating Neuralgia, would result in a disability rating not exceeding 20% under this scheme.  However, noting that the applicant has also demonstrated additional physical signs and symptoms, characterized by organic changes related to her disorder, to include muscle atrophy, tremors, myochlonus, in addition to an altered tactile sensory response, the AFBCMR Medical Consultant finds justification for rating her medical condition, utilizing the same overarching disability rating scheme under the analogous code for the Sciatic Nerve code (8799-8720), but applying it to the more accurate rating criteria for Neuritis, instead, which reads: Neuritis, cranial or peripheral, characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, is to be rated on the scale provided for injury of the nerve involved, with a maximum equal to severe, incomplete paralysis.  The maximum rating which may be assigned for neuritis not characterized by organic changes referred to in this section will be that for moderate, or with sciatic nerve involvement, for moderately severe, incomplete paralysis.

Considering the applicant's self-reported and witnessed functional impairment, the medical records documentation, and the demonstrable "sciatic nerve involvement" of her disease process, a consideration for rating her condition as moderately severe, as above, at the time of her discharge is a reasonable course of action.  Nonetheless, operating under a different set of laws (Title 38, United States Code), the Department of Veterans Affairs is authorized to offer the applicant a higher disability rating based upon her current level of impairment and may adjust her disability rating due to any fluctuations in her condition that may occur over time.  Therefore, the two systems represent a continuum of medical care and disability compensation that starts with entry on to active duty and extends for the life of the veteran.  

The complete AFBCMR Medical Consultant's evaluation is at Exhibit E.

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APPLICANT'S REVIEW OF ADDITIONAL AIR FORCE EVALUATION:

On 24 March 2008, the AFBCMR Medical Consultant's evaluation was forwarded to the applicant for review and comment within 30 days (Exhibit F).  As of this date, this office has received no response.

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THE BOARD CONCLUDES THAT:

1.  The applicant has exhausted all remedies provided by existing law or regulations.

2.  The application was timely filed.

3.  Sufficient relevant evidence has been presented to demonstrate the existence of an injustice warranting partial relief.  After carefully reviewing the evidence of record, we agree with the AFBCMR Medical Consultant that it appears the applicant’s condition was not properly adjudicated according to standards in place during the contested time period.  Therefore, we believe that a change in her records is warranted to reflect a 40% disability rating at the time of final disposition of her case.  We considered her request that her condition be rated at 70%-80%; however, other than her own assertions, insufficient evidence has been provided showing that at the time of final disposition her condition had reached the level of severity warranting a 70%-80% rating.  Accordingly, we recommend her records be corrected to the extent indicated below.

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THE BOARD DETERMINES THAT:

The pertinent military records of the Department of the Air Force relating to APPLICANT be corrected to show that:

	a.  On 10 October 2005, she was found unfit to perform the duties of her office, rank, grade, or rating by reason of physical disability, incurred while she was entitled to receive basic pay; that the diagnosis in her case was Complex Regional Pain Syndrome, VASRD code 8799-8720, rated at 40%; that the degree of impairment was permanent; that the disability was not due to intentional misconduct or willful neglect; that the disability was not incurred during a period of unauthorized absence; and that the disability was not received in the line of duty as a direct result of armed conflict or caused by an instrumentality of war.

	b.  On 11 October 2005, she was retired by reason of physical disability under the provisions of AFI 36-3212.

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The following members of the Board considered AFBCMR Docket Number BC-2007-04028 in Executive Session on 6 August 2008, under the provisions of AFI 36-2603:

All members voted to correct the records as recommended.  The following documentary evidence pertaining to was considered:

   Exhibit A.  DD Form 149, dated 30 November 2007, w/atchs.
   Exhibit B.  Applicant's Master Personnel Records.
   Exhibit C.  Letter, AFPC/DPSD, dated 28 January 2008.
   Exhibit D.  Letter, SAF/MRBR, dated 1 February 2008.
   Exhibit E.  Letter, BCMR Medical Consultant, dated 19 March 2008.
   Exhibit F.  Letter, SAF/MRBR, dated 24 March 2008.

				

AFBCMR BC-2007-04028

MEMORANDUM FOR THE CHIEF OF STAFF

	Having received and considered the recommendation of the Air Force Board for Correction of Military Records and under the authority of Section 1552, Title 10, United States Code (70A Stat 116), it is directed that:

	The pertinent military records of the Department of the Air Force relating to APPLICANT, be corrected to show that:

		a.  On 10 October 2005, she was found unfit to perform the duties of her office, rank, grade, or rating by reason of physical disability, incurred while she was entitled to receive basic pay; that the diagnosis in her case was Complex Regional Pain Syndrome, VASRD code 8799-8720, rated at 40%; that the degree of impairment was permanent; that the disability was not due to intentional misconduct or willful neglect; that the disability was not incurred during a period of unauthorized absence; and that the disability was not received in the line of duty as a direct result of armed conflict or caused by an instrumentality of war.

		b.  On 11 October 2005, she was retired by reason of physical disability under the provisions of AFI 36-3212.