RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXX	CASE:  PD-2013-02007
BRANCH OF SERVICE:  Army	BOARD DATE:  20140617
SEPARATION DATE:  20050822

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty PV2/E-2 (91W/Health Care Specialist) medically separated for lower extremity (feet) stress fractures and a digestive disorder.  The conditions could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty or satisfy physical fitness standards.  She was issued a permanent P3/L3 profile and referred for a Medical Evaluation Board (MEB).  Alkaline bile reflux gastritis status post Billroth I gastrostomy, right second metatarsal stress fracture and right distal fibula stress fracture, characterized as not meeting retention standards, were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded one other condition.  The Informal PEB (IPEB) adjudicated stress fractures, lower extremities (right second metatarsal and distal fibula) as unfitting, rated 0% with application of VA Schedule for Rating Disabilities (VASRD).  The persistent vomiting due to gastritis was determined to have existed prior to service (EPTS) and therefore, not ratable.  The remaining condition was determined to be not unfitting.  The CI made no appeals and was medically separated.

CI CONTENTION:  “…I feel it should be changed because I was hurt on the job.  So now I’m discharged from the Army.  I’m 39 years old.  I can’t get a job.  My feet, knees and stomach problems bother me and affect me daily.  I live in constant fear.  I’ve tried to kill myself on several occasions.  I’m now living in a VA homeless program house.  I have 3 kids in college.  I can’t afford a home and help them.  And no one wants to really hire a broken down veteran.  Despite what they say.  I’m just really tired.” 

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 IPEB to be unfitting for continued military service and those conditions identified but not determined to be unfitting by the IPEB when specifically requested by the CI.  The ratings for the unfitting digestive and feet conditions are addressed below.  The knee and stomach conditions, as per the contention, were not identified by the MEB or PEB; and, thus are not within the DoDI 6040.44 defined purview of the Board.  These, and any condition 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.

The Board acknowledges the CI’s information regarding the significant impairment with which her medical conditions continue to burden her and suggests the ratings should have been conferred for other conditions documented at the time of separation.  The Board wishes to clarify that it is subject to the same laws for service disability entitlements as those under which the Disability Evaluation System (DES) operates.  While the DES considers all of the member's medical conditions, compensation can only be offered for those medical conditions that cut short a member’s career, and then only to the degree of severity present at the time of final disposition.  However the Department of Veterans Affairs, operating under a different set of laws (Title 38, United States Code), is empowered to compensate all service-connected conditions and to periodically reevaluate said conditions for the purpose of adjusting the Veteran’s disability rating should the degree of impairment vary over time.
RATING COMPARISON:

Service IPEB – Dated 20050808	VA* - (3 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Stress Fractures (Right Second Metatarsal and Distal Fibula)	5099 5003	0%	Residuals Stress Fracture, Right Foot	5299 5284	0%	20051117	
Gastritis	7399 7307	---%	Gastroesophageal Reflux Disorder	7399 7346	10%	20051117	
			Gastritis	7307	NSC	20051117	
Left Calcaneal Stress Fracture	Not Unfitting	Residuals Stress Fracture, Left Foot	5299 5284	0%	20051117	
Other x 0 (Not in Scope)	Other x 6	20051117	
Combined:  0%	Combined:  30%	
* Derived from VA Rating Decision (VARD) dated 20060112 (most proximate to date of separation (DOS))

ANALYSIS SUMMARY: The facts of the right and left foot conditions will be discussed together for economies of clinical scale, but separated for fitness and rating consideration and recommendations.

Bilateral Foot Conditions.  The narrative summary (NARSUM) notes the CI developed bilateral foot pain, left worse than right, in 2005.  Routine X-rays of the left foot in February 2005 were normal.  A bone scan also performed in February 2005 revealed a left severe calcaneal (heal bone) stress fracture and a suspected focal stress fracture in the right distal fibula and heal bone.  Despite physical therapy and foot orthotics, the pain persisted.  An X-ray of the right foot in July 2005 revealed a “possibly healing fracture of the second metatarsal (mid-foot) bone.”  At the MEB/NARSUM evaluation on 18 July 2005, a month prior to separation, the CI reported pain in both feet and swelling in the left ankle.  The MEB physical exam noted a normal gait.  Mild tenderness to palpation was present in the right heel bone without swelling.  Examination of the left foot and ankle was described as “normal without tenderness.”  Full range-of-motion (ROM), with normal strength and sensation was present in both feet and ankles.  At the VA Compensation and Pension (C&P) exam performed 3 months after separation, the CI reported pain, weakness and stiffness in both feet.  On physical exam gait was normal, without limitation to standing or walking.  Examination of both feet and ankles was normal without tenderness, weakness, edema, atrophy or disturbance in circulation.  X-rays of both feet and ankles obtained at this time were reported as normal.

The Board directs attention to its rating recommendation based on the above evidence.  The PEB rated the right foot condition 0%, code 5003.  The PEB adjudicated the left foot condition to be not unfitting and not ratable.  The VA rated the right and left foot conditions each at 0%, coded 5284 (foot injury-mild) IAW §4.31 (0% rating).  The next higher rating of 10% under this code requires the condition to be “moderate.”

Unfitting Right Foot Condition:  The Board next undertook a rating of the right foot condition.  The Board noted the normal gait and unimpeded function of the right foot on all proximate examinations.  The Board agreed that the mild tenderness to palpation on the NARSUM exam did not rise to the level of 10% IAW §4.59 or §4.40.  The Board found no other codes for rating consideration.  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 right foot condition.

Contended Left Foot Condition:  The Board then undertook a review of the left foot condition, adjudicated as not unfitting by the PEB, but contested by the CI.  The Board’s main charge is to assess the fairness of the PEB’s determination that left foot condition was not unfitting.  The Board’s threshold for countering fitness determinations is higher than the VASRD §4.3 (reasonable doubt) standard used for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  The left foot condition was not profiled or implicated in the commander’s statement and was not judged to fail retention standards.  It was reviewed by the action officer and considered by the Board.  There was no performance based evidence from the record that this condition significantly interfered with satisfactory duty performance.  After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the left foot condition and so no additional disability rating is recommended.

Gastritis Condition.  The CI entered the military in December 2004.  On entry (Military Entrance Processing Station) examination the CI noted that she had never had an abdominal surgical procedure.  At this time the CI reported no GI symptoms and taking no medications.  On physical examination, a well healed 6-inch scar was noted in the upper abdominal area.  The CI reported falling from a tree and having sutures placed in her abdominal wall in an emergency room at age 6.  On 1 February 2005, the CI first presented with a 24-hour history of nausea, vomiting and diarrhea which responded to medication.  The CI was sent home on convalescent leave for her foot condition from 29 February to 30 March 2005.  Upon return, she presented on 10 April 2005 with a 3-day history of upper abdominal pain and vomiting to include possible blood.  On clinic evaluation, the CI again reported no surgical operations other than a tubal ligation after child birth, but noted continued vomiting after eating.  Abdominal examination was normal with no reported evidence of recent abdominal surgery.  On Barium swallow radiographic study on 15 April 2005, reflux of gastric contents into the esophagus was noted with abdominal straining.  This study was restricted to the esophagus and did not define the stomach.  On 18 April 2005, the CI reported vomiting bilious material after eating.  The CI was seen in the surgical clinic on 4 May 2005 reporting epigastric pain and vomiting after eating.  The examiner opined that the CI might have a gastric ulcer and requested an abdominal endoscopy for clarification upper abdominal endoscopy.  The procedure was performed on 2 May 2005.  The procedure revealed that the CI had undergone a major stomach operation to include removal of approximately 40% of the distal stomach (antrectomy) with a reconstruction of gastrointestinal (GI) continuity with a Billroth 1 procedure (a hookup procedure) and the presence of bile gastritis (irritation of the stomach lining from bile).  At the MEB/NARSUM evaluation on 18 July 2005, a month prior to separation, the CI again reported no hospitalizations for surgery and being “unaware” of having had removal of part of her stomach.  On examination a well healed 6-inch right upper quadrant abdominal scar was reported.  At the VA C&P exam, performed 3 months after separation, the CI reported nausea and vomiting as often as one time a day usually related to food.  On examination a six inch scar with previously unreported “keloid formation” was noted in the upper abdominal area.

The Board directs attention to its rating recommendation based on the above evidence.  The PEB adjudicated the stomach condition EPTS, to be not permanently service aggravated, and thus, not ratable.  The VA adjudicated the stomach condition as not service-connected; but rated the vomiting, 10%, coded 7346, analogous to hiatal hernia, for gastro-esophageal reflux.  The Board undertook to determine if the stomach condition was EPTS.  The Board noted the presence of a large, well healed abdominal scar consistent with an upper abdominal operative procedure at service entry.  The Board found no evidence in the record of any documented major abdominal operations, as would be required for gastric resection, during the duty period or the period of convalescent leave.  The Board unanimously agreed that the evidence in record was clear and convincing that the gastric operation occurred prior to service.

The Board then undertook to determine if the condition was permanently service aggravated.  Upon review, the Board, agreed by a consensus (2:1) that well-established medical principles document that upper abdominal pain, bile gastritis with reflux and vomiting are known consequences of gastric resection with reestablishment of GI continuity, to include the Billroth I Procedure, and that these may occur acutely or at distant interval after surgery unrelated to known stimuli.  The Board agreed by a consensus that, based on acceptable medical practice, the symptoms in this case were related to the gastric operation.  The Board agreed by a consensus that this condition and associated symptoms represent, with virtual medical certainty, the natural progression of known and established complications of gastric resection.  The Board by a consensus concluded there was no evidence of abdominal injury or GI illness while in military service that would have caused the symptoms or permanently service aggravated the pre-existing condition.  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 gastritis 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.  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 right foot stress fracture condition, IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended left calcaneal stress fracture, the Board unanimously recommends no change in the PEB’s adjudication as not unfitting.  In the matter of the gastritis condition, IAW §4.114, the Board, by a 2:1 vote, recommends no change in the PEB adjudication as EPTS.  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.

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20131104, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

		

SAMR-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 XXXXXXXXXXXXXXXXX, AR20140019330 (PD201302007)

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						     
CF: 
(  ) DoD PDBR
(  ) DVA