RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2014-00034
BRANCH OF SERVICE:  army	BOARD DATE:  20150217
SEPARATION DATE:  20070613

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (Wheeled Vehicle Mechanic) medically separated for heat induced muscle inflammation.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty.  He was issued a permanent P3 and referred for a Medical Evaluation Board (MEB).  The MEB forwarded “myalgia and myositis” to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded three other conditions (see rating chart below) as medically acceptable.  The PEB adjudicated “heat induced myositis with elevated cpk levels” as unfitting, rated 20%.  The remaining conditions were determined to be not unfitting.  The CI made no appeals and was medically separated.

CI CONTENTION:  “The MMRB gave me a rating of 20% for myalgia, myositis, hypertension, broncho spasms, and gastro esophageal reflux disease.  I did not appeal the rating because Ms. S—A-- of Reynolds Army Community Hospital MEB (Reynolds ACH PEBLO) said a soldier appealed his rating decision and received a lower rating.  I feared a lower rating and did not appeal.  However VA gave me an initial rating of 70% approximately one month after I was discharged.  The VA also diagnosed me with PTSD currently rated at 50% and diabetes one month after discharge, which was service connected.  I loved being in the U.S. Army and planned on retiring.  It was an honor and pleasure to fight for the great country and I regret that I am no longer able to do so.  Also the people who made this decision couldn’t possibly know how I feel on a daily basis.”

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 when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting.  Any conditions outside the Board’s defined scope of review and any contention not requested in this application may remain eligible for future consideration by the Board for Correction of Military/Naval Records.  Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards to the unfitting medical condition at the time of separation.  The Board has neither the role nor the authority to compensate for post-separation progression or complications of service-connected conditions.  That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws.  The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation.

RATING COMPARISON:

Service IPEB – Dated 20070406	VA - (1 Mos. Pre-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Heat Induced Myositis	5021	20%	Myalgia and Myositis	5099-5025	40%	20070510	
Hypertension	Not Unfitting	Hypertension	7101	10%	20070510	
Exercise Induced Bronchospasms	Not Unfitting	Asthma	6602	30%	20070510	
GERD	Not Unfitting	GERD	7399-7346	10%	20070510	
Other x 0 (not in scope)	Other x 3	20070510	
Combined:  20%	Combined:  70%	
Derived from VA Rating Decision (VARD) dated 20070713 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Heat Induced Myositis.  The CI developed muscle pain and cramping with exertion when in the heat in the summer of 2005 (although later he noted some symptoms over the preceding 1 to 2 years).  Laboratory testing disclosed abnormally high levels of muscle enzymes.  Rheumatology evaluation on 1 March 2006 noted periodic episodes of muscle cramping after exertion particularly in hot environments.  The CI reported he could do his work as a mechanic without major problems and had been lifting weights without problems.  The physical examination was normal including muscle strength.  The rheumatologist concluded there was no evidence of an inflammatory myositis or other rheumatic disease and thought the CI’s muscle condition may be metabolic in nature and recommended evaluation by neurology.  Neurology evaluation performed on 10 March 2006 noted muscle cramping with exertion particularly in the summer months.  There was no specific muscle weakness.  On examination, muscle strength and tone were normal.  The neurologic examination was also normal showing no signs of associated neurologic abnormalities.  Except for elevated muscle enzymes, extensive laboratory testing (blood) was normal.  Electromyogram on 3 April 2006 and again on 22 May 2006 revealed the presence of abnormal myopathic findings.  Echocardiogram (ultrasound imaging of the heart) was normal showing no evidence of changes that would indicate a syndrome that also affected cardiac muscle.  A metabolic myopathy (disorders of energy metabolism in the muscles) was suspected and the CI was referred for skeletal muscle biopsy.  The muscle biopsy, obtained in October 2006, was reported as being non-diagnostic.  Regardless of the non-diagnostic muscle biopsy, the clinical diagnosis was consistent with a metabolic myopathy (although there are several well characterized metabolic myopathies, there are a large number of possible metabolic defects than can cause the condition and are difficult to identify).  At the time of the clinic appointment for initial MEB examination on 29 January 2007, the CI reported a recent episode of muscle cramping and fatigue when on leave in a hot environment.  The CI reported intermittent right arm muscle cramps when performing excess work with the right upper extremity.  At the time of that examination, pain was graded as 0/10 and lab testing on 29 January 2007 demonstrated muscle enzyme at a low level for the CI.  At a clinic appointment on 26 February 2007, to complete the MEB examination, pain was reported as 0/10 and the musculoskeletal examination was normal.  The MEB narrative summary (NARSUM) dated 27 February 2007, reported continued episodic bouts of muscle cramps and pain, particularly in hot environments.  The CI reported muscle cramps, muscle soreness, malaise and fatigue which interfered with performance of mechanic duties, particularly repetitive strenuous motions or maintaining a static position.  He reported he was able to walk up to one mile, perform 20 push-ups, 25 sit-ups and lift up to 180 pounds.  At the VA Compensation and Pension (C&P) examination on 10 May 2007, a month prior to separation, the CI reported muscle pain three times per week lasting 2 hours.  The muscle pain involved all muscles and was aggravated by activity and heat.  On examination, muscle strength was normal.  At a VA clinic examination on 12 October 2007, 4 months after separation, there was no weakness, muscle atrophy, with normal gait but persistent muscle pain.  At the time of the VA C&P examination on 24 November 2007, 6 months after separation, the CI endorsed muscle pain and fatigability.  On examination muscle strength was normal without spasm.  VA neurology examinations from 2009 reflected continued muscle cramps particularly in hot weather.  Examinations noted normal muscle bulk and tone with normal strength.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the heat induced myositis 20% coded 5021 (myositis).  The VA rated the myalgia and myositis analogously under the VASRD diagnostic code 5025 (fibromyalgia) and granted 40% for constant symptoms.  The myositis code (5021) used by the PEB is rated under diagnostic code 5003 for limitation of motion however there was no limitation of motion.  In addition, there was no muscle weakness for rating under codes for specific muscle groups.  Although the CI did not have fibromyalgia, the Board considered the 5025 diagnostic code provided a good approximation for considering its rating recommendation for the CI’s unusual condition.  The Board considered whether the CI’s condition more nearly approximated the constant or nearly so for 40% versus episodic with exacerbations often precipitated by environmental stress or overexertion and present more than a third of the time.  The Board noted that the treatment record consistently described episodic symptoms rather than constant symptoms which were typically triggered by overexertion and environmental heat.  Clinic examinations noted normal strength without evidence of muscle spasms.  Therefore the Board concluded that the 20% rating was best supported by the evidence of the service treatment record.  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 heat induced myositis condition.

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that hypertension, GERD, and exercise induced bronchospasm were not unfitting.  The Board’s threshold for countering PEB fitness determinations is “preponderance of evidence,” but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  According to treatment records and the MEB NARSUM, hypertension and GERD were controlled with medication.  The CI developed exercise induced bronchospasm in approximately May 2004 and was treated with inhaler medications.  A temporary profile for asthma from 9 February 2005 to 9 March 2005 is noted, however no further profiles for asthma or exercise induced bronchospasm is in the available records.  Follow up in clinic on 23 May 2005 noted mild intermittent symptoms and use of inhaler less than once per week.  Medications were refilled and he was released from the clinic with no recommended limitations.  Spirometry in August 2005 was normal.  Follow-up in clinic 27 October 2005 also noted mild intermittent symptoms and use of inhaler less than once per week and he was released from the clinic with no recommended limitations.  Treatment records through 2006 to the time of the MEB examination reflected refill of medications but otherwise no concerns.  Spirometry on 30 January 2007 was normal.  The MEB examination noted the exercise induced bronchospasm condition to be stable and the MEB referred the condition as meeting retention standards.  The hypertension, GERD, and exercise induced bronchospasm conditions were not profiled or implicated in the commander’s statement and were not judged to fail retention standards.  All were reviewed and considered by the Board.  There was no performance based evidence from the record that any of these conditions 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 any of the contended conditions and so no additional disability ratings are recommended.

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 heat induced myositis condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended hypertension, gastroesophageal reflux, and exercise induced bronchospasm conditions, the Board unanimously recommends no change from the PEB determinations as not unfitting.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  The Board, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination.

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20131218, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

XXXXXXXXXXXXXXX
President
DoD Physical Disability Board of Review

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 
XXXXXXXXXXXXXXX, AR20150011021 (PD201400034)

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		     XXXXXXXXXXXXXXX		
		     Deputy Assistant Secretary of the Army
		          (Review Boards)
						         
CF: 
(  ) DoD PDBR
(  ) DVA