RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XX		BRANCH OF SERVICE: marine corps
CASE NUMBER:  PD1100703			SEPARATION DATE:  20030115
BOARD DATE:  20130320

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, SGT/E-5, (2847/Computer Technician), medically separated for possible mild inflammatory bowel disease (IBD) and complex regional pain syndrome (CRPS).  He did not respond adequately to treatment and was unable to perform within his Military Occupational Specialty (MOS) or meet physical fitness standards.  He was placed on limited duty and underwent a Medical Evaluation Board (MEB).  (Original MEB terminated for insufficient information)  CRPS, possible IBD, possible irritable bowel syndrome (IBS), pulmonary embolism secondary to immobilization, chronic pain disorder, history of (h/o) reflex sympathetic dystrophy, rule out (r/o) somatoform disorder, h/o Crohn’s disease, pain disorder with psychological features, personality feature impacted RSD were forwarded to the Physical Evaluation Board (PEB) as medically unacceptable IAW SECNAVINST 1850.4E.  No other conditions appeared on the MEB’s submission.  The Informal PEB (IPEB) adjudicated the possible mild IBD and CRPS as unfitting, rated 10% and 10% respectively; additionally possible IBS, edematous and erythematous of the distal rectum, possible IBD, personality features impacting reflex sympathetic dystrophy (RSD), pain disorder with psychological features, chronic pain disorder-h/o reflex sympathetic dystrophy, chronic pain disorder-r/o somatoform disorder conditions were determined to be Category II conditions (related to the unfitting conditions but not separately ratable), and pulmonary embolism secondary to immobility was determined to be not unfitting (Category III), and histrionic and obsessive traits were determined to be a Category IV (not disabilities under rules of Disability Evaluation System [DES]); with application of SECNAVINST 1850.4E and Veterans Administration Schedule for Rating Disabilities (VASRD).  The CI made no appeals, and was medically separated with a 20% combined disability rating.

CI CONTENTION: As evidenced by the VA rating subsequently awarded, the conditions referenced in the PEB rating were more involved, and deserved a higher disability rating, as the involved ankle was a causal agent of the accompanying nerve condition (identified as reflex sympathetic dystrophy, involving all four extremities. including the right lower extremity, and as such was integral and inseparable to the general conditions bodily present at the time, and was therefore not fully referenced in the PEB decision. It should be noted that the original claim for disability was filed in-service under a pilot program for faster induction to VA entitlements post-service, at Naval Medical Center Balboa, reflected by the difference in date of application for service-connected disability and actual date of separation.  SNM ended up being held past the original end of enlistment contract date on medical hold (and two years after initial application for VA disability was made in-service) due to attempts to stabilize medical conditions of SNM.  The difference in dates is relevant to this case, as the actual VA rating decision was made only 7 months after separation from USMC and said VA rating was made after the appropriate VA medical was undertaken soon after SNM was separated from USMC, as is directed by VA regulations.  The range and severity of bodily conditions found at the VA medical were present when SNM was discharged from service, and the PEB did not seem to fully acknowledge the actual condition of SNM at the time of separation, of which said separation was a lengthy amount of time after the initial PEB was undertaken, and during which SNM's medical condition, both overall and concerning the PEB filings had changed markedly for the worse. 
SCOPE OF REVIEW:  The Board wishes to clarify that the scope of its review as defined in DoDI 6040.44, Enclosure 3, paragraph 5.e. (2) is limited to those conditions which were determined by the PEB to be specifically unfitting for continued military service; or, when requested by the CI, those condition(s) “identified but not determined to be unfitting by the PEB.”  The ratings for unfitting conditions will be reviewed in all cases.  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 20021028	VA (3 Mo. After Separation) – All Effective Date 20030116	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Possible mild inflammatory bowel disease	7399-7323	10%	Crohn’s Disease	7399-7323	30%	20030416	
Complex Regional Pain Syndrome	8523	10%	RSD LLE	8599-8520	60%	20030416	
			RSD RLE	8599-8520	60%	20030416	
			RSD LUE	8599-8515	50%	20030416	
			RSD RUE	8599-8515	40%	20030416	
Possible IBS	CAT II	See Crohn’s Disease above	
Edematous & Erythematous Mucosa of the Distal Rectum	CAT II	No Corresponding VA Entry	
Possible Inflammatory Bowel Disease	CAT II	See Crohn’s Disease above	
Personality Features Impacting RSD	CAT II	No Corresponding VA Entry	
Pain Disorder w/Psychological Features	CAT II	No Corresponding VA Entry	
Chronic Pain D/O – HO Reflex Sympathetic	CAT II	See RSDs above	
Chronic Pain D/O-R/O Somatoform D/O	CAT II	See RSDs above	
Pulmonary Embolism Secondary to Immobility	CAT III	No Corresponding VA Entry	
Histrionic and Obsessive Traits	CAT IV	No Corresponding VA Entry	
↓No Additional MEB/PEB Entries↓	R Ankle s/p anterior tibiotalar joint debridement/open peroneal tendon debridement	5271	20%	20030416	
	Insomnia associated w/RSD	9499-9410	10%	20030416	
	0% x 1/Not Service Connected x 9	20030416	
Combined:  20%	Combined:  100%	

ANALYSIS SUMMARY:

Possible Mild Inflammatory Bowel Disease.  The CI was evaluated for abdominal pain with diarrhea, and nausea and vomiting beginning 24 September 2001.  Colonoscopy with biopsies in October 2001 demonstrated inflammation of the ascending colon and superficial ulcers of the rectum.  Biopsies of the cecum demonstrated mild chronic inflammation while the rectal biopsies showed no significant abnormalities.  Gastroenterology evaluation in November 2001 noted mild diffuse abdominal tenderness.  The CI’s weight was recorded as 159.4 pounds (five pounds lower than at the initial presentation for care).  Laboratory studies were negative for evidence of acute or chronic inflammation.  Imaging by CT scan and ultrasound were normal.  An upper endoscopy was also normal.  The CI was thought to have mild Crohn’s disease based on the colonoscopy and biopsy reports.  Repeat laboratory testing in March 2002 was again normal (negative for evidence of acute or chronic inflammation) and the gastroenterologist was not certain whether symptoms were due to Crohn’s disease or medication side effects from pain medication.  The CI had lost additional weight to 146 pounds by February and March 2002.  A repeat colonoscopy 8 April 2002 was completely normal without evidence of inflammatory bowel disease, and biopsies were negative for abnormalities.  Laboratory testing was also negative for evidence of acute or chronic inflammation.  The CI had been on medications for IBD prior to this examination.  On 13 June 2002, the gastroenterologist raised doubts about the diagnosis.  The 22 August 2002 gastroenterologyn narrative summary (NARSUM) noted that a previous small bowel follow through barium study showed changes in the terminal ileum suggestive of Crohn’s disease.  In July 2002, the CI had constipation requiring “aggressive” laxative treatment after which he had done well with “some” abdominal pain, “some” early satiety, “some” loose bowel movements, and occasional scant hematochezia (that was also attributed to hemorrhoids).  The GI clinic noted three loose bowel movements per day and the CI weighed 160 pounds.  Diagnoses of possible IBD and possible IBS were introduced.  The gastroenterologist planned continued reduction in medication.  At the time of the MEB history and physical examination on 14 August 2002, the CI weighed 163 pounds.  At the time of the VA Compensation and Pension (C&P) examination on 16 April 2003, the CI reported there had been no blood in his stools for several months.  Abdominal examination recorded no abnormalities.  The Board considered rating analogously under the VASRD diagnostic code for ulcerative colitis, also an IBD, as there is not a specific code for Crohn’s disease.  At the time of initial diagnosis in October 2001, the colonoscopy and biopsies indicated mild inflammation.  Repeat colonoscopy in April 2002, while on treatment, was normal without evidence of active disease.  Repeat laboratory testing showed no evidence for acute or chronic inflammation.  Following the April 2002 colonoscopy, the CI regained lost weight.  At the time of the gastroenterology MEB NARSUM, mild chronic symptoms were described without exacerbations or flares of IBD (Crohn’s).  The additional related PEB diagnosis of edematous and erythematous mucosa of the distal rectum is an examination finding that was present at the time of initial colonoscopy that had resolved by the time of the colonoscopy examination in April 2002 and is not itself a disability subject to rating.  The related PEB diagnosis of possible IBS as a cause of the symptoms attributed to possible mild IBD is not separately ratable in accordance with VASRD §4.14 (avoidance of pyramiding).  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’s adjudication for the possible mild inflammatory bowel disease condition.

Complex Regional Pain Syndrome.  The CI was evaluated for right ankle pain after an inversion injury in 1999.  The CI underwent two ankle surgeries for his painful right ankle; an arthroscopic evaluation January 2000 which demonstrated no bony or ligamentous abnormalities and arthroscopic surgery in January 2001 for right ankle anterior impingement and peroneal tendonosis.  The CI reinjured the right ankle in February 2001.  In the weeks following, the CI developed increasing pain in the right lower extremity with vascular, skin and sensory changes consistent with CRPS; (previously called reflex sympathetic dystrophy).  By June 2001, the CI reported similar pain complaints in both upper extremities with objective findings of edema and discoloration of the left and right upper extremities.  Between March and August of 2001, the CI underwent several sympathetic blocks with transient relief of pain.  In August of 2001, the CI was hospitalized for epidural pain management of his CRPS which also provided transient relief of his symptoms.  The NARSUM in October 2001, 15 months prior to separation, noted the use of a wheelchair for ambulation and guarding of his left arm with reluctance to move either the left arm or right leg.  The physical examination demonstrated objective findings of edema of the right leg with skin mottling and sensory hypersensitivity of the left arm and right leg.  In July 2002, 6 months prior to separation, the CI was hospitalized for an acute exacerbation of his total body pain with relief of his pain “only at concentrations of local anesthetics that produced profound motor block.”  Physical therapy notes stated that he was not able to and frequently refused therapy.  While hospitalized, examiners noted a distractible examination and unusual anatomical distribution of pain.  He was observed to frequently rub his feet on his sheets or move his arms when he was concentrating on answering unrelated questions when he would otherwise claim rubbing was too painful and movement not possible.  Evaluation in the pain clinic included administration of a medication that was not analgesic in people with normal pain responses.  With this medication, there was relief of pain and immobility consistent with the ability to be distracted.  He was able to move all of his extremities with ease.  The pain specialist concluded the response indicated CRPS was limited to the right leg and the remainder of the pain complaint was not explained by CRPS.  At the 9 August 2002 NARSUM, 5 months prior to separation, the CI reported CRPS symptoms throughout his entire body with continued use of a wheelchair due to pain.  Physical findings demonstrated resolution of his left arm and right leg edema and skin mottling.  There was full upper and lower extremity strength, and normal muscle tone and bulk.  Sensory evaluation demonstrated allodynia and hyperesthesia (exaggerated pain response) of extremities, trunk and face.  Psychiatric and pain management evaluations were requested to evaluate for somatoform disorder and psychogenic pain.  The psychiatric consultant made Axis I diagnoses of pain disorder with psychological features and personality features impacting RSD; Axis II diagnosis of histrionic and obsessive traits.  The psychiatric examiner noted that the CI’s histrionic, obsessive, and controlling traits may contribute to his medical condition.  The pain psychology consultant stated “I am convinced that this young man’s pain syndrome and disability is greatly effected by secondary gain issues, whether they are psychological, social, monetary or some combination of these remains undetermined.”  Without any intervention other than extensive multidisciplinary diagnostic evaluations, the CI’s pain and functioning improved.  The psychiatry NARSUM dated 21 August 2002 stated, “Of note is that the patient’s functional status improved remarkably following the discussion of psychiatric diagnoses.”  By the time of a gastroenterology clinic follow up examination in October 2002, “Pt’s pain syndrome dramatically improved on no pain meds”; “Able to walk with slight limp.”  At the C&P examination in April 2003, 3 months after separation, the CI reported burning sensation in all joints, right greater than left.  The CI also reported sleep disturbance and the inability to walk secondary to pain.  The physical examination was significant for painful motion bilaterally of the upper and lower extremities.  The neurologic evaluation was significant for hypersensitivity to touch with normal vibration, coordination and reflexes.  The psychiatry C&P examiner noted the CI denied any significant degree of worry about his chronic pain condition and was functioning psychologically at a high level Global Assessment of Functioning of 95 without any psychiatric disorder.

The Board directs attention to its rating recommendation based on the above evidence.  The PEB rated the CRPS condition at 10%, coded 8523 for moderate anterior peroneal nerve incomplete paralysis.  The VA rated the CRPS condition at 60% each for the left and right lower extremities, 50% for the left upper extremity (dominant), and 40% for the right upper extremity (nondominant), coded 8599-8520 for the lower extremities and 8599-8515 for the upper extremities.  The Board considered all evidence relating to the CRPS condition.  The Board placed high probative value on the objective findings associated with CRPS including the results of pain clinic evaluation demonstrating normal pain response restricted to the right leg, X-ray findings of right leg, and resolved skin mottling and edema.  The Board noted that examiners observed that despite over a year of reported severe pain and impairment, inability to use the extremities and use of a wheel chair, the CI’s muscle bulk, tone and strength were normal on distracted examinations.  The presence of normal muscle bulk, absence of atrophy is inconsistent with the lack of use suggested by recorded symptoms.  The Board also noted the October 2002 clinic encounter indicating the CI was walking and had dramatically reduced pain on no medication.  Although his pain syndrome is classified as CRPS, there is no dedicated VASRD code for rating CRPS and this group of pain syndromes is rated by analogy to neuralgia of the affected peripheral nerve distribution in this case the anterior peroneal nerve as identified by the PEB.  All Board members agreed that the right lower extremity CRPS was the unfitting condition and that based on the October 2002 examination, the 10% rating adjudicated by the PEB was appropriate.  The Board discussed the apparent worsening at the post separation C&P examination, but concluded this was not consistent with the evidence of the extensive evaluations performed prior to separation.  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 for the CRPS 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 mild inflammatory bowel condition and IAW VASRD §4.114, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the CRPS conditions 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 recharacterization of the CI’s disability and separation determination, as follows: 

UNFITTING CONDITION	VASRD CODE	RATING	
Possible mild inflammatory bowel disease	7399-7323	10%	
Complex Regional Pain Syndrome	8523	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20110822, w/atchs.
Exhibit B.  Service Treatment Record.
Exhibit C.  Department of Veterans Affairs Treatment Record.

		

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 23 Apr 13

      In accordance with reference (a), I have reviewed the cases forwarded by reference (b), and, for the reasons provided in their forwarding memorandum, 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:

		-  former USMC
		-  former USN 
		-  former USMC
		-  former USN 
		-  former USN 
-  former USN 
-  former USN 
-  former USMC
-  former USMC 
-  former USMC
-  former USMC
-  former USMC
-  former USN