RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD1300433
BRANCH OF SERVICE:  Army	BOARD DATE:  20131231
SEPARATION DATE:  20070716

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty PFC/E-3 (11B/Infantryman) medically separated for status post (s/p), through and through gunshot wound to the left posterior thigh group.  The CI suffered a gunshot wound during a deployment on March 2006 to Iraq.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty or satisfy physical fitness standards.  He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The gunshot wound condition, characterized as “medically unacceptable” from MEB was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded 3 other conditions, see rating chart below for Physical Evaluation Board (PEB) adjudication.  The Informal PEB adjudicated the gunshot wound to left posterior thigh group as unfitting, rated 10%.  The Ehlers-Danlos syndrome was rated as existing prior to separation and not rated.  The remaining conditions were determined to be not unfitting.  The CI made no appeals and was medically separated.

CI CONTENTION:  “VA gave me a rating of 90%.  The highest of individual ratings being PTSD.  Also, I don’t believe Elners-Danlos Syndrome was very well understood disorder at the time of my discharge.  I have Type 3 Elners-Dalos Syndrome, which has significantly compromised all of my joints.  Because of my injuries sustained in Iraq.  I have extensive issues with my jaw, knee, and ankle, which were all injured while I toured in Iraq.  Thank you for your consideration!”  [sic]

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 those conditions identified but not determined to be unfitting by the PEB when specifically requested by the CI.  The ratings for the unfitting gunshot wound of left posterior thigh group, the existed prior to service (EPTS) Ehlers-Danlos condition, and not unfitting conditions of multiple joint arthralgias and situational depression are addressed below; no additional conditions are within the DoDI 6040.44 defined purview of the Board.  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 Military Records.

RATING COMPARISON:

Service IPEB – Dated 20070518	VA - (6 Mos. Post-Separation) 	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Status Post, Through & Through Gunshot Wound to the Left Posterior Thigh	5313	10%	 Residuals of a Through & Through Gunshot Wound, Left Thigh, Muscle Group VIII	5313	10%	20080117 	
			Scars of the Left Thigh, Residuals of Gunshot Wound	7804	10%	20080117	
Ehlers-Danlos Syndrome	5099-5002	EPTS	Ehlers-Danlos Syndrome	5009	40%	20080117 	
Multiple Joint Arthralgias	Not Unfitting	Temporomandibular Joint Dyscrasia	9905	40%	20080117 	
Mild Hearing Loss, Right Ear	Not Unfitting	NSC	
Situational Depression	Not Unfitting	Posttraumatic Stress Disorder	9411	50%	20080117	
No Additional MEB/PEB Entries	Other x 4	20080117  	
Combined:  10%	Combined:  90%	
Derived from VA Rating Decision (VARD) dated 20080314 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Status Post, Through & Through Gunshot Wound of the Left Posterior Thigh Condition:  The CI received a gunshot wound in combat on 10 March 2006 to the left thigh with no vascular or neurologic injury.  He was treated in Baghdad, then Landstuhl, and no neuro-vascular damage or significant tissue loss was noted.  He was flown back to CONUS expeditiously because his wife was having intra-uterine surgery for his yet to be born son’s congenital deformities.  The left thigh posterolateral bullet tract showed no significant tissue loss.  The injury was thru and thru muscle Group 12 (posterior thing group, the biceps femoris, semitendinosus and semimembranosus).  Upon examination at the deployment health clinic, it was noticed that the CI had symptoms and findings of Ehlers-Danlos Type III with hyperextensibility of the joints.  The gunshot wound was healing well and there was left leg pain with ambulation.  The narrative summary (NARSUM) noted bilateral knee and bilateral shoulder pain, popping of knees, hips and shoulders, constant mild to moderate pain, stiffness in the mornings, activity makes it better, no swollen joints, no photosensitivity, no chronic infection, no lymphadenopathy and no weight loss.  Physical exam showed a normal gait, normal peripheral pulses, all joints had full range-of-motion, with hyperextension and a positive thumb sign (for hyperextensibility).  The diagnoses were (#1) Ehlers-Danlos Syndrome (medically unacceptable, (#2) multiple joint arthralgias – medically acceptable (#3) status post gunshot wound to the left thigh – medically acceptable, (#4) mild hearing loss in right ear – medically acceptable, (#4) situational depression – medically acceptable.  The VA Compensation and Pension (C&P) exams performed on 17 January 2008, noted the CI reported he was very fit and denied problems with endurance or strength, able to walk half a mile a day and 2-3 flights of stairs.  Physical examination revealed a linear entrance wound 1.0 by 0.5 cm above the knee on the posteromedial aspect and an exit wound that is circular 2.5 cm in diameter on the lateral aspect of the left thigh, both hyper-pigmented, mild tenderness and non-adherent.  On the bones exam, the CI additionally reported he used ankle and knee braces for sporting activities, he was steady on his feet, a history of multiple right shoulder dislocations and subluxations, left shoulder instability and bilateral knee instability.  After his gunshot injury and surgical washouts he had no continued significant functional or pain problems with the left thigh and only a bruised-type feeling proximal to the lateral thigh exit wound.  Physical exam revealed hypermobility of all joints with cutaneous changes consistent with Ehlers-Danlos syndrome.

The Board directs attention to its rating recommendation based on the above evidence.  The PEB used VASRD code 5313 for s/p through and through gunshot wound to the left posterior thigh rated 10%, and the VA used the same code 5313 for residuals of a through and through gunshot wound, left thigh muscle Group VIII for the same 10% rating (moderate).  The Board did not find evidence in the record of a moderately severe disability of muscles for a higher 30% adjudication under VASRD §4.56 (evaluation of muscle disabilities, such as: through and through or deep penetrating wound by small high velocity missile or large low-velocity missile, with debridement, prolonged infection, or sloughing of soft parts and intermuscular scarring, or service department record or other evidence showing hospitalization for a prolonged period for treatment of wound, or record of consistent complaint of cardinal signs and symptoms of muscle disability, and, if present, evidence of inability to keep up with work requirements, or objective findings. entrance and [if present] exit scars indicating track of missile through one or more muscle groups, indications on palpation of loss of deep fascia, muscle substance, or normal firm resistance of muscles compared with sound side., or tests of strength and endurance compared with sound side demonstrate positive evidence of impairment).  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 s/p through and through gunshot wound of the left posterior thigh condition.

Ehlers-Danlos Syndrome:  The Board considered the evidence in the record.  There was no indication of any permanent unfitting service aggravation of the Ehlers-Danlos (congenital joint hypermobility) syndrome.  The CI had a long history of injuries, and surgeries prior to entering active duty with a waiver for the injuries and subsequent surgeries.  Although examiners did not identify the Ehlers-Danlos syndrome at any time prior to the diagnosis while on active duty, he had a right shoulder labrum reconstruction in 2004, anterior cruciate ligament reconstruction of the left knee in 2003, prior to active duty service, with very good recoveries and high functioning in athletics.  However, once diagnosed his profiled restrictions for Ehlers-Danlos syndrome hypermobility of joints and left thigh pain, included: not moving with a fighting load, unable to construct an individual fighting position, unable to do 3-5 second rushes, no 2-mile run, no sit-ups, no push-ups and no unlimited running, walking biking or swimming.  The remarks were to avoid activities that require vigorous exertion, heavy lifting, or excessive strain on joints and ligaments.  The Board determined that these restrictions were preventive in nature since extra caution and special practices are commonly advised to prevent permanent joint damage.  The Board did not find evidence in the record that besides the grave and unfortunate combat injury, routine performance of military duties and training were compromised prior to the injury.  There was no evidence that permanent service aggravation or joint damage, such as a requirement for surgery, or prolonged periods of incapacitation due to joint dislocations, pain, or injuries above the natural progression of the condition.  The Board concluded that the condition was a genetic and congenital condition that was EPTS and was not permanently aggravated by service beyond the natural progression of the disease.  The Board further wishes to clarify that it is bound by Title 10, United States Code (Sec. 1207a) which stipulates that a military member must have accrued 8 years of active duty time in order to receive disability for a pre-existing condition not aggravated by service.  The Board concluded therefore that this condition could not be recommended for additional disability rating.

Multiple Joint Arthralgias:  The multiple joint arthralgias condition is subsumed under the diagnosis of Ehlers-Danlos syndrome.  The left ankle sprain and temporomandibular joint injuries were not profiled or mentioned in the commander’s statement and were determined to be medically acceptable by the MEB and the PEB.  The CI was physically functional in athletics prior to service and able to fulfill his military duties with this condition up to the point of his gunshot injury.  He was preventively profiled for any possible joint injuries as is commonly done with the diagnosis of Ehlers-Danlos syndrome.  The Board could not find evidence in the commander’s statement or elsewhere in the file that documented any interference of the multiple joint arthralgias condition with performance of duties.  Upon consideration of the evidence by the Board, without preponderance of evidence to be considered unfitting, the Board concluded that this condition could not be recommended for an additional disability rating.
Situational depression:  The CI stated that he had psychiatric attention once or twice while on medical hold.  The medication record showed the antidepressants citalopram (Celexa) prescribed on 6 June 2006, Bupropion (Wellbutrin) on 9 November 2006, and sertraline (Zoloft) on 11 December 2006.  The NARSUM examination on 2 October 2006, documented the CI was taking Celexa for the diagnosis of situational depression due to his son having several congenital abnormalities requiring extending hospitalizations and numerous surgeries.  The mental status examination revealed normal coherent responses, no abnormal emotional reaction and capable of managing any benefit payments.  There were no psychiatric profile limitations (S1), and the commander’s statement did not indicate any psychiatric impairments.  The Board could not find other evidence in the file that documented any interference of the situational depression condition with performance of duties, such as emergent need for psychiatric care, psychiatric hospitalization or frequent need of mental health (MH) counseling.  The Board concluded that there was no psychiatric symptomatology severe enough to indicate unfitness.  The Board discussed the later diagnosis of PTSD by the VA MH C&P examination on 17 January 2008, in which the CI stated he received psychiatric attention on perhaps one or two occasions, treated with sertraline and then citalopram antidepressant medications for about 3 months, which the CI thought were not effective.  There were no service MH records for that examiner to review, and the CI had not sought treatment after discharge.  The Board concluded that since no psychiatric symptomatology precluded the performance of his limited clerical duties; and the later diagnosis of PTSD had no effect on the fitness determination at the time of discharge.  The Board concluded therefore that this condition could not be recommended for an additional disability rating.

BOARD FINDINGS:  The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised.  In the matter of the s/p through and through gunshot wound of the left posterior thigh condition and IAW VASRD §4.56, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended Ehlers-Danlos syndrome the Board unanimously recommends no change from the PEB determination of EPTS without permanent service aggravation.  In the matter of the contended multiple joint arthralgias and situational depression conditions, the Board unanimously recommends no change from the PEB determination as not unfitting.

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	
S/P Through and Through Gunshot Wound of the Left Posterior Thigh	5313	10%	
Ehlers-Danlos Syndrome with Hypermobility of Joints	5099-5002	EPTS	
Multiple Joint Arthralgias	Not Unfitting	
Situational depression	Not Unfitting	
COMBINED	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20130514, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

		
SFMR-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 XXXXXXXXXXXXXXXXXX, AR20140006423 (PD201300433)

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