RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD1301104
BRANCH OF SERVICE:  Army	BOARD DATE:  20140218
SEPARATION DATE:  20020718

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SSGT/E-6 (97E/Interrogator) medically separated for chronic chest wall and abdominal pain.  The CI performed sit-ups after duty hours while at a temporary duty location in 1996, when he experienced a sharp left-sided chest pain lasting for approximately 20 minutes.  During this time he was unable to move or breathe deeply.  The pain resolved and he sought no medical care.  During the course of two permanent duty station changes, which affected follow-up on treatment plans, the pain recurred and became more frequent and severe.  The CI received multiple orthopedic evaluations and conservative treatment included steroid injections and physical therapy.  By 2001, the chest wall and abdominal pain condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS) or satisfy physical fitness standards.  He was issued a permanent P3 profile and referred for a Medical Evaluation Board (MEB).  The conditions, characterized as “costochondritis”, “aponeurotic neuritis”, and “diastasis of abdominal rectus,” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other conditions were submitted by the MEB.  The Informal PEB adjudicated the rib cage and upper abdominal condition as unfitting, rated 0%.  The CI made no appeal and was medically separated.

CI CONTENTION: The CI attached a 4-page statement to his application which was reviewed by the Board and considered in its recommendations.

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 rating for the unfitting rib cage and upper abdominal condition is addressed below; and, 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 20020404	VA - (6 Mos. Pre -Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Pain of Rib Cage and Upper Abdomen, of Uncertain Etiology, variously diagnosed as Costochondritis, Aponeurotic Neuritis, Diastasis of Abdominal
Rectus, which limits physical vigor.	5099 5003	0%	Costochondritis	5399-5319	10%	20020128	
			Diastasis of Rectus Abdominis
Rectus, with Aponeurotic Neuritis 	5319	0%	20020128	
No Additional MEB/PEB Entries	Other x 9	20020128	
Combined:  0%	Combined:  20%	
Derived from VA Rating Decision (VARD) dated 20020923.
ANALYSIS SUMMARY:  The PEB combined the costochondritis, aponeurotic neuritis and diastasis of abdominis rectus conditions under a single disability rating, coded analogously to 5003.  Although VASRD §4.71a permits combined ratings of two or more joints under 5003, it allows separate ratings for separately compensable joints.  IAW DoDI 6040.44 the Board must follow suit if the PEB combined adjudication is not compliant with the latter stipulation, provided that each “unbundled” condition can be reasonably justified as separately unfitting in order to remain eligible for rating.  If the members judge that separately ratable conditions are justified by performance based fitness criteria and indicated IAW VASRD §4.7 (higher of two evaluations), separate ratings are recommended; with the stipulation that the result may not be lower than the overall combined rating from the PEB.  The Board’s initial charge in this case was therefore directed at determining if the PEB’s combined adjudication was justified in lieu of separate ratings.

Pain of Rib Cage (costochondritis) and Upper Abdomen (aponeurotic neuritis/ diastasis of rectus abdominis).  The CI reported that his first episode of left chest pain begun in 1996.  An acute care note dated 30 August 1996 documented that the CI sustained a fall while playing sports.  The records were silent for chest pain until 5 August 1998 when the CI reported recurrence of his left chest pain with abdominal exercises.  The examination revealed tenderness to palpation at left 9th rib.  The CI was treated with conservative therapy, nerve block and steroid injection without relief.  At a pain management evaluation on 2 September 1999, the examiner noted a large diastasis between his the upper rectus abdominis muscles and recreation of his pain with deep palpation on the aponeurotic portion of the upper area of the left rectus abdominis.  The CI was permanently profiled and continued on conservative management and physical therapy.  Radiographic and cardiac evaluations were normal.  At the VA Compensation and Pension examination performed 6 months prior to separation the CI reported that twice a month he would have left chest pain that would result in cessation of the activity for about 15 minutes.  The use of pain medications reduced the frequency of the left chest pain.  The CI also reported episodic abdominal pain which responded to activity cessation.  The physical examination revealed significant anterior (front) chest tenderness to palpation.  The narrative summary 4 months prior to separation noted a history of left chest pain dating to 1996.  After multiple orthopedic consultation and persistent pain despite conservative management, the CI was diagnosed with chronic thoracic costochondritis and diastasis of the rectus abdominis.  The CI reported sharp, intense left chest flare-ups lasting 15-20 minutes.  The flare-ups occurred 2-3 times per week with minimal pain in between exacerbations.  Activity modification, rest and antiinflammatory medications relieved the pain.

The Board directs attention to its rating recommendation based on the above evidence.  The PEB adjudicated the pain of the rib cage and upper abdomen (costochondritis, aponeurotic neuritis, and diastasis of abdominal rectus) conditions under a single service disability rating for “overall effect” as permitted by DoDI 1332.38 (E3.P3.4.4).  This approach by the PEB reflects its judgment that the constellation of conditions was unfitting, but that each condition was not individually unfitting.  Since this is an intrinsic service prerogative outside the scope of the VASRD, the Board does not recommend separate codes and ratings in this circumstance unless members agree that one or more conditions were separately unfitting independently of overall effect.  In support of a recommendation for two or more separate service ratings derived from a PEB overall effect adjudication; members must be satisfied, based on a preponderance of the evidence, that each condition recommended for separate rating would have independently resulted in MEB referral and a PEB finding that the member was unfit due to physical disability.  The Board’s initial charge in this case was therefore directed at determining if the PEB’s single overall effect rating was justified in lieu of separate unfit determinations and ratings.

The preponderance of the treatment notes were directed toward treatment of his rib pain (costochondritis).  The rib pain was documented as greater than the abdominal pain (diastasis of the rectus abdominis).  Both conditions were profiled for pain which limited physical vigor.  The overall pain associated with both conditions was implicated in the commander’s statement.  Board members agreed that the overall pain of the rib cage and upper abdomen and the lack of response to multiple pain management modalities contributed to the CI’s inability to perform physical tasks related to military service.  The Board determined that it was speculative to separate the functional impact of the rib pain from that of the abdominal pain and that either would not have rendered the CI incapable of performing his MOS within his rating; but, that it was also reasonable to surmise that it was the overall effect of both the pain of the rib cage and upper abdomen (costochondritis, aponeurotic neuritis and diastasis of abdominal rectus) which rendered him unfit.  Members agreed, therefore, that the pain of the rib cage and upper abdomen (costochondritis, aponeurotic neuritis and diastasis of abdominal rectus) conditions were not reasonably justified as separately unfitting; and, accordingly, they cannot be recommended for separate disability rating.  Members agreed that the pain of the rib cage and upper abdomen (costochondritis, aponeurotic neuritis, and diastasis of abdominal rectus) condition met the VASRD criteria for application of §4.40, functional loss as demonstrated by the inability to perform physical tasks related to military service.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the rib cage and upper abdomen (costochondritis, aponeurotic neuritis and diastasis of abdominal rectus) pain 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 rib cage and upper abdomen (costochondritis, aponeurotic neuritis and diastasis of abdominal rectus) condition, the Board unanimously recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of his prior medical separation:

UNFITTING CONDITION	VASRD CODE	RATING	
Pain of Rib Cage and Upper Abdomen	5099-5003	10%	
COMBINED	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20130809, 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, AR20140012279 (PD201301104)

1.  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 to modify the individual’s disability rating to 10% without recharacterization of the individual’s separation.  This decision is final.  

2.  I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum.   

3.  I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures.

BY ORDER OF THE SECRETARY OF THE ARMY:

Encl						     

CF: 
(  ) DoD PDBR
(  ) DVA