BOARD DATE: 12 December 2017 DOCKET NUMBER: AR20160004685 BOARD VOTE: _________ _______ ________ GRANT FULL RELIEF ________ ________ ________ GRANT PARTIAL RELIEF ________ ________ ________ GRANT FORMAL HEARING ____x____ ___x_____ ____x____ DENY APPLICATION 2 Enclosures 1. Board Determination/Recommendation 2. Evidence and Consideration BOARD DATE: 12 December 2017 DOCKET NUMBER: AR20160004685 BOARD DETERMINATION/RECOMMENDATION: The evidence presented does not demonstrate the existence of a probable error or injustice. Therefore, the Board determined the overall merits of this case are insufficient as a basis for correction of the records of the individual concerned. ______________x___________ CHAIRPERSON I certify that herein is recorded the true and complete record of the proceedings of the Army Board for Correction of Military Records in this case. BOARD DATE: 12 December 2017 DOCKET NUMBER: AR20160004685 THE BOARD CONSIDERED THE FOLLOWING EVIDENCE: 1. Application for correction of military records (with supporting documents provided, if any). 2. Military Personnel Records and advisory opinions (if any). THE APPLICANT'S REQUEST, STATEMENT, AND EVIDENCE: 1. The applicant requests reconsideration of her request to correct her military records to show she was medically discharged instead of being honorably discharged for weight control failure. 2. She states Army Regulation (AR) 635-200 (Active Duty Enlisted Administrative Separations) requires that the Soldier must be given a reasonable opportunity to comply with and meet the body fat standards if no medical condition exists. She offers that just because no one knew a medical condition existed, does not mean it did not. She adds it is difficult to meet the body fat standards if she is battling with multiple sclerosis (MS). a. She states the illness presented itself when she enlisted in the Army and became physically active. She maintains she could not perform the required physical fitness because her body would become fatigued, her back would hurt, and her ankle would go numb. When she overexerted her body it would shutdown. It was after her discharge that a civilian neurologist diagnosed her medical condition of MS. She asserts it was difficult for her to lose weight because of her undiagnosed condition. b. She did not share her health and pain issues because doing so could be seen as a sign of weakness. When she deployed, her physical conditions became worse and she experienced migraines, muscle pain, and fatigue. She performed her military duties the best she could. She now asks that her illness be recognized because it affected her duty performance. She would like to receive a medical discharge based on her undiagnosed illness. c. She concludes the Army (sic) (it appears she means the Department of Veterans Affairs (VA)) has recognized that she had MS while serving her country and awarded her a 60 percent disability rating for the MS. 3. She provides: * self-authored statement * DD Form 214 (Certificate of Release or Discharge from Active Duty) * letter from her neurologist, dated 1 May 2014 * VA letter, dated 16 November 2015 CONSIDERATION OF EVIDENCE: 1. Incorporated herein by reference are military records which were summarized in the previous consideration of the applicant's case by the Army Board for Correction of Military Records (ABCMR) in Docket Number AR20140021101 on 3 September 2015. 2. The applicant enlisted in the Regular Army on 20 October 2009 and trained as a network switching systems operator-maintainer. 3. Her record is void of any documentation concerning her enrollment in the Army Weight Control Program (AWCP) or the specific facts and circumstances surrounding her discharge. However, her Enlisted Record Brief (ERB) shows a Report to Suspend Favorable Personnel Actions (Flag) was initiated on 11 September 2011 for "enrollment" in the weight control program (code "KA"). It also shows on 14 March 2012, the flag was removed due to initiation of elimination procedures (code "BA"). 4. On 17 July 2012, the separation approval authority reviewed her separation packet and directed her separation from the Army in accordance with AR 635-200, chapter 18, for failure to meet body fat standards with the issuance of an Honorable Discharge Certificate. 5. The applicant’s ERB dated 25 July 2012 shows her physical profile (i.e., her PULHES ratings) as 111111, meaning she had no physical conditions that limited her ability to perform her military and specialty duties. 6. Her DD Form 214 shows she was honorably discharged on 3 September 2012 under the provisions of AR 635-200, chapter 18, for weight control failure. She completed 2 years, 10 months, and 14 days of creditable active service. Her foreign service was 10 months and 16 days, which was her service in Kuwait from 18 January to 3 December 2011. 7. On 8 June 2017, the ABCMR obtained an advisory opinion from the Army Review Boards Agency (ARBA) Senior Medical Advisor, who states the evidence provided does not support the applicant's request for a medical retirement. a. A DD Form 2807-2 (Medical Prescreen of Medical History Report), dated 9 September 2009, shows her height as 66" and weight 180 pounds (maximum allowable 160). A DD Form 2807-1 (Report of Medical History), dated 14 September 2009, indicated she was taking no medication and was in good health. A DD Form 2808 (Report of Medical Examination), dated 14 September 2009, with clinical evaluation cited her as having truncal obesity (moderate), exaggerated spine curvature mild asymptomatic, moles, tattoos, and pes planus mild asymptomatic. Her height was listed as 66" and weight 173 (maximum 160 with actual body fat (BF) 35 percent. The summary of defects/diagnosis was listed as overweight/excessive BF. She was qualified for service. b. A DA Form 5501 (BF Content Worksheet), dated 14 September 2009, shows her height as 66", neck 14", waist 33.5", and hips 41.5" with a 35 percent BF. The DA Form 5501, dated 20 October 2009, shows her height as 66", waist 33", hips 41", and neck 14" with a 34 percent BF. Based on the applicant's age (21-27), her maximum BF content was 32 percent. However, this form was checked that she met the standards. c. A review of the applicant’s electronic medical record (AHLTA) revealed the following clinical/treatment records: * 5 March 2010, right shoulder x-ray series for injured right shoulder while doing push-ups, no radiographic abnormality * 5 October 2010, operation report for symptomatic cholelithiasis with laparoscopic cholecystectomy, tissue examination of gallbladder for symptomatic cholelithiasis, chronic cholecystitis and cholelithiasis * 15 November 2010, behavioral health (BH) symptom screening (surgery clinic), no depressive symptoms * 26 May 2010, chest x-ray one view, no acute cardiopulmonary process detected by radiograph * 26 May 2010, three-dimensional computerized tomography (CT 3D) reconstruction of abdomen and pelvis for abdominal pain with oral and intravenous line (IV) contrast, unremarkable contrast enhanced CT scan of abdomen; probably an old inflammatory process or silent mass in the right adnexa region * 16 July 2010, ultrasound of bladder, extramural or intramural right-sided bladder wall mass or mass external to the urinary bladder, measuring at least 1/8 centimeters in diameter * 30 July 2010, right upper quadrant (RUQ) abdomen ultrasound with RUQ pain associated with eating fatty meals, normal gallbladder sonogram associated with cholelithiasis * 6 August 2010, CT abdomen/pelvis without contrast, no definite evidence of bladder mass although study is markedly limited by the lack of intravenous contrast; probable fundal and left uterine mass and/or left adnexal/ovarian mass is noted * 17 August 2010, cystoscopy with cystoscopy demonstrating mild chronic cystitis * 20 September 2010, ultrasound transvaginal normal side anteflexed uterus and bilateral ovaries; thickened endometrial echoes may represent secretory phase * 3 October 2010, left ankle x-ray series for falling down stairs after slipping on water, reports "pop" heard, soft tissue swelling of the left ankle without fracture * 10 February through 24 October 2011, Theater clinic (Kuwait) visits for patellofemoral syndrome right knee and gastroenteritis requiring antinausea treatment for oral rehydration * 15 December 2011, BH screening for post-deployment screening, unremarkable, does not desire any therapeutic supportive service at this time * 7 February 2012, magnetic resonance imaging (MRI) lumbar spine for 8-month history of non-resolved lower back pain, no evidence of herniated disc or spinal stenosis; mildly enlarged bilateral transverse process of the L5 * 21 February 2012, lumbar spine x-ray series for chronic back pain since basic training, negative lumbar spine * February to March 2012, several visits to physical therapy for low back pain d. A DD Form 2900 (Post-Deployment Health Reassessment (PDHRA)), dated 21 March 2012, shows she reported right knee pain, chronic low back pain (that became worse during deployment), left ankle pain, sleep issues, and a profile for back. She was referred to onsite BH at the Soldier Readiness Processing on 21 March 2012 for post-deployment screening. She reported that her best friend was raped in February 2011 downrange by a well-liked Soldier in her unit. The applicant herself was raped at age 11 by an adult family friend. She feels the Soldier got off with very light consequences because he was well-liked, whereas she was being chaptered out due to weight and physical training (PT) failure. Post-traumatic stress disorder (PTSD) is listed as a diagnosis. However, diagnostic criteria are not met based on encounter documentation. e. Follow-up BH visit on 29 and 30 March 2012 for mindfulness group training and command directed mental status evaluation in conjunction with chapter 18. She stated she was just recently diagnosed with PTSD and has been referred for treatment. She is currently involved in group therapy and will see her individual therapist for the first time on 12 April 2012. She is currently on no medications for this disorder. A DA Form 3822 (Report of Mental Status Evaluation), dated 30 March 2012, noted unremarkable mental status, but she was not cleared to continue to process for the chapter 18 (administrative discharge) until she is able to avail herself of BH treatment. f. Follow-up BH on 5, 12 and 23 April 2012 with working diagnosis of PTSD based on past history of childhood sexual abuse at age 11 and a friend's rape during deployment to Kuwait. Group therapy on 26 April and 3 and 10 May 2012. Clinic visit on 14 May 2012 for back pain and ankle pain for results of MRI bone scan. Profile was extended for 30 days and she was instructed to continue with chiropractor treatment regimen and physical therapy. Follow-up BH on 17 and 21 May 2012 for group therapy and individual follow-up of her PTSD. g. Physical therapy evaluation of left ankle pain since January 2010 after onset while in basic training; since then no change. Pain now is 0/10, worst numbing after running and swelling reported. Reports had inversion sprain while driving in a motor vehicle accident on 7 May 2012 to swerve and is worse. Hit the curb and busted rim and she had to get an old ankle brace to use to walk. It was worse 8/10 days after accident and swelling 4 days later. She did not go to the Emergency Room (ER). h. Follow-up BH on 12 and 24 July 2012 and 10 August 2012 by social work services with record review for case closure. Date of initial appointment listed as 13 June 2012 and date of termination of care 24 July 2012. Final diagnosis: Axis I – PTSD; Axis II – deferred; Axis III – health concerns; Axis IV – grief; and Axis V: Global Assessment of Functioning - 65. i. On 6 September 2012 (post-service), the applicant was seen at the ER for "numbness and tingling all over entire abdomen" with onset the day before. There was no abdominal pain. Family medicine note, dated 27 September 2012, "applicant who presented to ER for pain and tingling, eventually presented to VA from where she was transferred at Scott and White, admitted, and diagnosed with multiple sclerosis." j. Clinic visit on 25 October 2012 requesting asthma medication. Notes state "recently began exercising again following new onset multiple sclerosis, and had some wheezing. She reports previous history that exercise induced asthma and had not been a problem for her for several years." k. Family medicine clinic visit on 11 January 2013 followed by a neurologist at Scott and White in Temple, TX. Notes: needs new MRI orders... obesity with body mass index (BMI) at or above 35 percent… needs a psych evaluation for upcoming weight loss surgery. Headache syndromes, sleep disorders – sleep apnea previously followed by Georgetown Sleep Center and still having issues with sleep. l. A VA medical statement, dated 1 May 2014, signed by a VA neurologist states, …she first developed neurologic symptoms during basic training in 2010. She had numbness in her left ankle while running, always at the 1.5 mile mark. Then it would go away once she stopped running. She complained of this and saw providers for it. She was worried that she may step in a pothole and hurt herself because she couldn't feel her foot striking the ground. She states that at first it was attributed to low back problems. She has this problem to this day if she runs 1.5 miles, even on a treadmill. She was later diagnosed with multiple sclerosis in September 2012. In retrospect, the first symptoms occurred in basic training. Those symptoms that come on with exercise and resolve after resting were typical for Uhthoff's phenomenon that occurs in multiple sclerosis. Therefore, her first symptoms of multiple sclerosis occurred in basic training in 2010. m. A limited review of VA records through the Joint Legacy Viewer shows 48 listed problems (16 VA entered) including insomnia, MS, personal history of traumatic brain injury, migraine, obstructive sleep apnea syndrome, asthma, traumatic arthropathy of the knee, allergic rhinitis, obesity, personal history of colonic polyps, and others. As of June 2014, the applicant was VA service connected at 90 percent overall (migraine headaches at 50 percent; neurogenic bladder at 40 percent; anxiety disorder at 30 percent; lumbosacral/cervical strain at 20 percent; limited flexion of knee at 10 percent; forearm muscle injury at 10 percent; traumatic brain disease at 10 percent; forearm muscle injury at 10 percent; inflammation of the gall bladder at 0 percent; and scars at 0 percent. n. ARBA medical review in the previous case, dated 5 February 2015, states the applicant’s medical history is more representative of chronic orthopedic injuries rather than symptoms of MS. Additionally, in ABCMR Docket Number AR20140021101, dated 3 September 2015, the applicant requested a medical discharge instead of a discharge for weight control failure. She said she could not lose weight or perform PT due to her illness, which was not known at the time. Her body could not take the stress of PT and would shut down automatically when it overheated. Her request was denied. o. The applicant met medical retention standards for PTSD, obstructive sleep apnea with continuous positive airway pressure, migraine headache, history of left ankle injury, cholelisthesis and cholecystitis (status post cholecystectomy/gall bladder removal), right shoulder pain, recurrent low back pain, heartburn and gastritis with history of helicobacter pylori (H. polori) infection, bronchitis/wheezing, history of exercise induced asthma, history of trichomonas infection, existed prior to service (EPTS) spinal curvature asymptomatic, EPTS truncal obesity, EPTS pes planus mild asymptomatic, and other physical, medical, and/or behavioral conditions in accordance with AR 40-501 (Standards of Medical Fitness) and AR 635-40 (Physical Evaluation for Retention, Retirement, or Separation) in effect at the time. Her medical conditions were duly considered during medical separation processing. There is no evidence of a medical disability or condition, which would support a change to the character or reason for the discharge in this case. 8. On 17 October 2017, the applicant responded to the advisory opinion. She reiterates the information contained in her application to the Board concerning her battling with MS while she was in the military. Additionally she provides three internet articles titled "Kyphosis, Stenosis and Multiple Sclerosis," "Recognize Multiple Sclerosis Symptoms," and "The Connection Between MS and Your Weight." The first article provides a picture of the vertebral column of the spine and states that kyphosis refers to the normal curves of the thoracic spine. The second article states that early symptom of MS include blurred or double vision, thinking problems, clumsiness or a lack of coordination, loss of balance, numbness, tingling, and weakness in the arm or leg. The last article explains the possibility of weight gain for people living with MS due to medications and/or depression. However, it states to keep the scale at a happy number, people with MS should adjust their diets with smart food choices and controlled portion sizes to reflect changes in their activity level. REFERENCES: 1. AR 600-9 (AWCP), in effect at the time, provides guidance on implementation of the program. a. Paragraph 3-2 states, in pertinent part, Active Army Soldiers exceeding body fat standards will be provided exercise guidance, dietary information or weight reduction counseling by health care personnel, and assistance in behavioral modification, as appropriate, to help them attain the requirements of the Army. Soldiers not meeting body fat standards after 1-year from date of entry into the Active Army will be entered in the AWCP and flagged under the provisions of AR 600–8–2 (Report to Suspend Favorable Personnel Actions) by the unit commander. Enrollment in a weight control program starts on the day that the Soldier is informed by the unit commander that he/she has been entered in a weight control program. b. Health care personnel will perform a medical evaluation when a Soldier has a medical limitation, is pregnant, or when requested by the unit commander. A medical evaluation is also required for Soldiers being considered for separation because of a failure to make satisfactory progress in the AWCP, or within 6 months of expiration term of service. The medical professional will conduct a thorough medical evaluation to rule out any underlying medical condition that may be a cause for significant weight gain: c. If the underlying medical condition does not require referral to a medical evaluation board (MEB)/physical evaluation board (PEB) and a Soldier is classified as overweight, these facts will be documented and the Soldier will be entered into the AWCP. d. Soldiers who have not made satisfactory progress in the AWCP after a 6-month period and for whom no medical reasons exist to cause the overweight condition, the unit commander will initiate a mandatory bar to reenlistment or administrative separation under AR 635-200, chapter 18. 2. AR 40-501 provides that for an individual to be found unfit by reason of physical disability, he/she must be unable to perform the duties of his/her office, grade, rank or rating. Performance of duty despite impairment would be considered presumptive evidence of physical fitness. 3. AR 635-40 establishes the Physical Disability Evaluation System (PDES) and sets forth policies, responsibilities, and procedures that apply in determining whether a Soldier is unfit because of physical disability to reasonably perform the duties of his or her office, grade, rank, or rating. It provides for a medical evaluation board that is convened to document a Soldier's medical status and duty limitations insofar as duty is affected by the Soldier's status. A decision is made as to the Soldier's medical qualifications for retention based on the criteria in AR 40-501, chapter 3. Disability compensation is not an entitlement acquired by reason of service-incurred illness or injury; rather, it is provided to Soldiers whose service is interrupted and who can no longer continue to reasonably perform because of a physical disability incurred or aggravated in service. a. Paragraph 3-1, in effect at the time, states the mere presence of impairment does not of itself justify a finding of unfitness because of physical disability. In each case, it is necessary to compare the nature and degree of physical disability present with the requirements of the duties the member reasonably may be expected to perform because of his or her office, rank, grade, or rating. The Army must find that a service member is physically unfit to reasonably perform his or her duties and assign an appropriate disability rating before he or she can be medically retired or separated. b. When a member is being processed for separation for reasons other than physical disability (e.g., retirement, resignation, reduction in force, relief from active duty, administrative separation, discharge, etc.), his or her continued performance of duty (until he or she is referred to the PDES for evaluation for separation for reasons indicated above) creates a presumption that the member is fit for duty. c. When a member is being processed for separation for reasons other than physical disability, the presumption of fitness may be overcome if the evidence establishes that the member, in fact, was physically unable to adequately perform the duties of his or her office, grade, rank, or rating even though he or she was improperly retained in that office, grade, rank, or rating for a period of time and/or acute, grave illness or injury or other deterioration of physical condition that occurred immediately prior to or coincidentally with the member's separation for reasons other than physical disability rendered him or her unfit for further duty. 4. Title 38, U.S. Code, sections 1110 and 1131, permits the VA to award compensation for a medical condition which was incurred in or aggravated by active military service. DISCUSSION: 1. The applicant argues, in effect, that she should have entered the PDES process due to her medical condition of MS instead of being separated for weight control failure. 2. Although the applicant's record is void of documentation verifying her enrollment in the AWCP, her ERB confirms she was flagged for weight control on 11 September 2011 and the flag was removed on 14 March 2012 prior to her discharge on 3 September 2012. The flagging action suggests and her DD Form 214 confirms that she did not show progress in the AWCP after 6 months. Therefore, regulatory guidance authorized her separation for failure to comply with Army standards. 3. The ARBA senior medical advisor stated her medical conditions were duly considered during medical separation processing (separation physical exam). As she had no physical profile restrictions that limited her duty performance, it appears there was no reason for military doctors or her chain of command to enter her into the PDES. (The PDES determines if there is a medical condition that interferes with the duty performance of a Soldier. When physical restrictions limit a member's duty performance, they are normally issued a limiting physical profile restricting their duty. After the profile is issued, the Soldier could be referred into the PDES.) 4. Army medical providers documented all her medical conditions and associated treatment during her active duty service. At no point does the medical evidence support her entry into the PDES. It does support the fact she was overweight. In the process of her separation physical examination she was referred to the VA (as required by law). 5. The VA determined she had multiple service connected medical conditions warranting compensation under laws applicable to the VA. The ARBA senior medical advisor has access to VA records and noted the applicant has a combined service connected disability rating of 90 percent (migraine headaches, neurogenic bladder, anxiety disorder, lumbosacral/cervical strain, limited flexion of knee, forearm muscle injury, traumatic brain disease, and forearm muscle injury). The VA did not rate her MS condition as being service connected. 6. Nevertheless, the fact that the applicant was awarded a 90 percent disability rating from the VA is noted. The VA is not required by law to determine medical unfitness for further military service. The VA awards compensation solely on the basis that a medical condition exists and that said medical condition reduces or impairs the social or industrial adaptability of the individual concerned. Consequently, the applicant's medical conditions, although not considered medically unfitting for military service at the time of processing for discharge, qualify her for VA benefits based on an evaluation by that agency. 7. The VA evaluates a veteran throughout his or her lifetime, adjusting the percentage of disability based upon that agency's examinations and findings. The Army must find unfitness for duty at the time of discharge before a member may be medically retired or separated as determined by the PDES. 8. Additionally, it is noted the applicant provided several internet articles and one that suggests a correlation between MS and weight gain due to medications and/or depression. Her military records do not contain evidence supporting this suggested correlation. //NOTHING FOLLOWS// ABCMR Record of Proceedings AR20150000953 Enclosure 1 ARMY BOARD FOR CORRECTION OF MILITARY RECORDS RECORD OF PROCEEDINGS ABCMR Record of Proceedings (cont) AR20160004685 2 ARMY BOARD FOR CORRECTION OF MILITARY RECORDS RECORD OF PROCEEDINGS Enclosure 1 ABCMR Record of Proceedings (cont) AR20160004685 3 ARMY BOARD FOR CORRECTION OF MILITARY RECORDS RECORD OF PROCEEDINGS Enclosure 2