RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	 CASE:  PD-2014-00358
BRANCH OF SERVICE:  Army  	 BOARD DATE:  20150721
SEPARATION DATE:  20070222  

SUMMARY OF CASE:  The available evidence of record reflects that this covered individual (CI) was an active duty E-5 (Motor Transport Operator) medically separated for chronic costochondritis.  The condition could not be adequately rehabilitated to meet the requirements of his Military Occupational Specialty (MOS).  He was issued a permanent P3 profile and referred for a Medical Evaluation Board (MEB).  The “chronic costochondritis”, was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded one other condition (Wolff-Parkinson-White Syndrome) for PEB adjudication.  The informal PEB (IPEB) adjudicated the chronic costochondritis as unfitting, rated 10%, citing the US Army Physical Disability Agency (USAPDA) pain policy.  The remaining condition was determined to be not unfitting.  The CI made no appeals and was medically separated.  

CI CONTENTION:  The applicant makes no specific contention in his application.  His complete submission is at Exhibit A.  

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 20070118	VA* - (2 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Costochondritis	5099-5003	10%	Chronic Costochondritis	6899-6817	0%	20070425	
Other x 1 (Not in Scope)	Other x 4	20070425	
Rating:  10%	Combined:  20%	
* Derived from VA Rating Decision (VARD) dated 20070615.  

ANALYSIS SUMMARY:  

Chronic Costochondritis Condition.  The service treatment record detailed that the CI was referred to the cardiology clinic in March 2006 for complaints of chest pain and palpitations, and underwent an extensive cardiac and pulmonary evaluation.  He was diagnosed with Wolff-Parkinson-White (WPW) syndrome (in which there is an extra electrical pathway between the heart's upper chambers [atria] and the lower chambers [ventricles], which causes an intermittent rapid heartbeat).  He underwent radio-frequency catheter ablation of the WPW bypass tract in June 2006.  The CI showed no evidence of recurrent arrhythmia after his ablation, but he continued to report palpitations that were similar to those prior to the procedure, and continued to have significant chest pain.  He was evaluated with numerous non-invasive tests (including echocardiography and stress perfusion imaging) and Holter and event monitoring, which were all normal.  The pain was nearly constant; was focused at the left border of the sternum (breast bone); was reproducible with palpation; and worsened with activities like  prolonged sitting, running, jumping, lifting, wearing/carrying military gear, and bending/twisting activities.  His pain was variously identified as chronic chest pain syndrome, etiology unknown; atypical chest pain; and chronic costochondritis; but was clearly differentiated from the WPW and coexisting gastro-esophageal reflux disease.  The CI was unable to do his job without significant limitations secondary to this pain, and was referred to the MEB.  

At a cardiology evaluation on 11 October 2006 (4 months before separation), the CI’s pain was “reproducible with palpation and worsened with activities like head movement, etc.”  He continued to do limited physical training but these activities did not exacerbate his symptoms.  He did not have associated dyspnea (shortness of breath), presyncope (feeling like he was going to pass out), syncope (passing out), edema (swelling, especially of the ankles), or weight gain.  He could not put on his battle gear due to chest pain symptoms.  On examination, there was tenderness on palpation at the left sternal border.  A DD Form 2808, Report of Medical Examination, was also completed the month where the examiner reported the CI suffered constant chest pain after a 2-mile run several months earlier, and he could not tolerate pressure applied to the chest.   However, lungs and chest were described as “Normal.”  A DA Form 3349, Physical Profile, was generated and listed both WPW and non-cardiac chest pain as diagnoses of interest; although significant duty restrictions were listed, they could not be attributed solely to either condition.  In a performance statement to the PEB, the CI’s commander did not attribute any specific duty restrictions to either condition.  

At the narrative summary (NARSUM) on 18 December 2006 (2 months pre-separation), the CI reported that his symptoms got worse with activities such as prolonged sitting, running, jumping, wearing/carrying military gear, and bending/twisting activities.  On examination there was consistently reproducible tenderness to palpation over the costochondral junction on the left over ribs 3-6.  There was also tenderness to a lesser degree diffusely over the pectoralis major muscle.  He had full active range-of-motion and normal strength of all extremities, and normal light touch sensation throughout.  

At the VA Compensation and Pension (C&P) exam performed on 25 April 2007 (2 months after separation), the CI described no chest pain but confirmed tenderness in the morning or after resting on a couch, that improved with movement.  Cough or chest movements did not cause pain.  On examination, there was moderate tenderness over the costochondral joints of the upper sternum.  The examiner wrote, “Estimate to what extent, if any, per veteran, they affect functional impairment during the flare-up.  NONE.”  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the condition at 10%, analogously coded 5003 (degenerative arthritis), citing slight/constant pain and the USAPDA pain policy.  After additional review of the case, the VA rated the condition at 10%, analogously coded 5297 (removal of ribs), stating that the functions affected, and the anatomical localization and symptoms, were closely related to those of chronic costochondritis.  Review of the VASRD indicated that there was no specific code for costochondritis, so an analogous code had to be invoked.  A higher evaluation of 20% was not supported under code 5297 unless two ribs have been removed, or under code 5003 unless there was X-ray evidence of involvement of two or more major joints or minor joint groups, with occasional incapacitating exacerbations.  Rating under analogous code 5022 (periostitis) was not advantageous, as it is rated as arthritis, degenerative (code 5003).  The Board also considered analogous code 5321 (thoracic muscle group) but noted that a higher rating of 20% (associated with severe or moderately severe disability) was not supported, as detailed in §4.56.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), and finding no pathway to a higher rating, the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the chronic costochondritis 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.  As discussed above, PEB reliance on the USAPDA pain policy for rating the chronic costochondritis condition was operant in this case and the condition was adjudicated independently of that policy by the Board.  In the matter of the chronic costochondritis condition 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 re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140106, 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 XXXXXXXXXXXXXXXXXXXX, AR20150015848 (PD201400358)

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