RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00582
BRANCH OF SERVICE:  MARINE CORPS	BOARD DATE:  20150326
SEPARATION DATE:  20051215

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (Aircraft Maintenance) medically separated for a Raynaud’s disease condition.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty.  He was referred for a Medical Evaluation Board (MEB).  The condition, “Raynaud’s disease,” was forwarded to the Physical Evaluation Board (PEB) IAW SECNAVINST 1850.4E.  Five other conditions (unspecified hypothyroidism, other and unspecified disorder of bone and cartilage, cervicalgia, lumbago and espohageal reflux) were submitted by the MEB.  The Informal PEB adjudicated “Raynaud’s Disease,” as unfitting, rated 0%, with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The remaining conditions were determined to be Category III (not separately unfitting and does not contribute to unfitting condition).  The CI made no appeals and was medically separated.

CI CONTENTION:  “I was rated 0% on my disability and found unfit for service. I immediately file with the VA and received a 70% rating for disabilities.”

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 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 20051017	VA - (~4 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Raynaud’s Disease	7117	0%	Raynaud’s Disease	7117	10%	20060413	
Left Wrist Articular Cartilage Disease	Not Unfitting	Left Wrist, Status Post Tear of Triangular Fibrocartilage Complex	5215	10%		
Chronic Neck Pain		Degenerative Disc Disease, C4-5	5243	10%		
Chronic Back Pain		No VA Entry	
Gastroesophageal Reflux Disease		Hiatal Hernia and Gastroesophageal Reflux Disease	7346	0%	20060413	
Hypothyroidism		Hypothyroidism	7903	10%		
Other x 0 (Not In Scope)	Other x 7	
Combined:  0%	Combined:  70%	
Derived from VA Rating Decision (VARD) dated 20060512 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Raynaud’s Disease Condition.  Treatment records evidence that the CI presented in 2002 with reports of continuous redness, stiffness, numbness, tingling, and cold sensitivity in both hands and feet.  A diagnosis of Raynaud’s phenomenon was rendered.  An internal medicine note dated 17 May 2004 documented reports of loss of grip in the hands with purplish color changes, discomfort and aching.  The physical examination was normal except for “mild coolness perceived in the fingers.”  A treatment note dated 23 March 3005 documented a 3-year history of continuous redness, stiffness, numbness, tingling, and cold sensitivity in both hands and feet occurring most days.  The examiner noted that cold protection was not helpful and that the CI still had issues with his hands in the summer particularly with air conditioning.  The physical examination demonstrated red discoloration (hyperemic) of the hands and feet with diffuse tenderness to full range-of-motion (ROM) of most joints.  A diagnosis of Raynaud’s disease was rendered.  The narrative summary (NARSUM) dated 8 August 2005 noted reports of continuous redness, stiffness, numbness, tingling, and cold sensitivity in both hands and feet.  The frequency of attacks was described as most days with loss of grip strength nearly every day of the week.  The physical examination documented both hands as diffusely red discoloration, diffusely tender joints, purplish mottling, cool to touch, and full ROM.  A diagnosis of Raynaud’s disease was rendered.

At the VA Compensation and Pension (C&P) examination performed 4 months after separation, the CI reported burning and tingling in his hands all of the time, a reddish blue or purple discoloration with moderately cold weather, and occasional white spots in his hands.  He described flare-ups in the winter and summer characterized by an inability to hold objects in his hands and pain with bending his fingers.  He noted very frequent spells in the winter, but he also had spells in the summer in damp or cool settings.  The physical examination showed no Raynaud’s phenomenon skin changes of the hands.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB adjudicated the Raynaud’s disease as unfitting with a disability rating of 0%; coded 7177 (Raynaud’s syndrome).  The VA rated the Raynaud’s syndrome at 10% for characteristic attacks occurring one to three times a week.  The Board considered whether the evidence supported a higher than 0% rating.  The Board noted that multiple prior to separation treatment notes and the NARSUM documented the frequency of characteristic attacks (color changes of the digits of one or more extremities lasting minutes to hours, sometimes with pain and paresthesia’s, and precipitated by exposure to cold or by emotional upsets) daily, most days of the week, or nearly every day of the week.  Board members agreed that the frequency met criterion for a 20% rating.  There was no evidence of digital ulcers or auto-amputation for a higher rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 20 % for the Raynaud’s syndrome condition.

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that left wrist articular cartilage disease, chronic neck pain, chronic back pain, gastroesophageal reflux disease (GERD), and hypothyroidism were 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.

Chronic Neck and Back Pain:  The CI initially presented with neck and left upper back pain on 23 April 2002.  The CI denied a history of trauma.  He was diagnosed with and treated for left shoulder muscle spasms.  The records were silent for neck and upper back pain until February 2005 when the CI presented with muscle spasms in the right mid and upper back pain.  A primary care note dated 7 February 2005 revealed normal lumbosacral motion, trunk rotation, and gait.  The examiner noted right rhomboid and trapezius muscle group trigger points.  The CI was treated with opiate and anti-inflammatory pain medications and 24 hours sick leave (quarters) was issued.  A sports medicine note dated 14 February 2005 noted a diagnosis of thoracic dysfunction with myofascial pain with decreased lumbar flexion to 45 degrees and thoracolumbar spine tenderness to palpation (TTP) along the right scapula.  The CI was issued temporary activity restriction (no running, physical fitness testing, daily physical therapy or forced marches) and referred to chiropractic care.  A chiropractic care note dated 18 February 2005 documented a one-year history of upper back pain.  The CI described as right neck pain, muscle tightness, and cracking sensation.  The upper back pain was described as right trapezius muscle burning sensation which extends to the tip of the right shoulder.  The mid-back pain was worse with most activities.  The physical examination was significant for muscles spasms and tenderness to palpation of the cervical paraspinous muscles with normal cervical motion; thoracic spine asymmetry (right shoulder dropped), and right thoracic spine tenderness to palpation without muscle spasms.  Cervical and thoracic X-rays performed on 18 February 2005 were normal.  Diagnoses of inflammatory myopathy (myositis) and cervical spondylosis were rendered.  The CI continued with chiropractic care and pain medications with intermittent relief of his cervical and thoracic back pain.  He was released without activity limitations from chiropractic care in June 2005.  The NARSUM examination noted chronic neck and lumbar spine pain bilaterally.  The physical examination noted diffuse neck, shoulder girdle, and lumbar muscles TTP with limitation of motion due to pain.  The examiner referenced cervical X-rays results which demonstrated vertebral spurs and a nerve conduction study which was normal except for irritability of the left biceps muscle.  The examiner rendered diagnoses of chronic neck and back pain.  The examiner did not recommend or implicate these diagnoses as impacting the CI’s ability to perform his duties.  At the VA C&P examination dated 13 April 2006, the CI reported intermittent locking and pain in the neck with occasional pain radiation to the left shoulder.  He reported frequency of once a month locking and two incapacitating neck pain episodes since 2005.  The CI reported that he had been working as a truck mechanic since January 2006.  The physical examination demonstrated normal posture, gait, and cervical range of motion; except for slightly decreased cervical lateral flexion.  A diagnosis of cervical degenerative disc disease was rendered.

Gastroesophageal Reflux Disease:  Treatment records evidence that the CI was diagnosed with GERD in 2000.  An endoscopy dated 24 September 2001 noted a small hiatal hernia.  The CI was treated with Aciphex with good control.

Left Wrist Articular Cartilage Disease:  The CI presented with new onset left wrist pain on 7 April 2005.  A magnetic resonance imaging study dated 5 July 2002 revealed a tear in the triangular fibrocartilage complex.  The NARSUM noted that the left wrist was treated by orthopedics and that the CI was unable to do pull-ups and push-ups due to hand and wrist pain.  The VA C&P examiner noted a history of steroid injections to the left wrist with 6 weeks of pain relief.  At the time of the VA C&P examination the CI reported bilateral, left greater than right, wrist pain; rated 7/10; and worse with picking up things, driving, and bending the wrist.  The physical examination demonstrated a somewhat weak and hypermobile left wrist.

Hypothyroidism:  Treatment records evidence that the CI was evaluated for hypothyroidism in late 2004, due to headaches and weight gain, with negative thyroid laboratory results.  A treatment note dated 10 March 2005 documented continued weight gain despite regular exercise.  The CI was diagnosed with hypothyroidism subclinical and noted to have “initial success with Synthroid…”  The NARSUM noted that the CI was treated for Hypothyroidism by an outside medical facility endocrinologist.  The VA C&P examination noted that the CI was without symptoms while on his medication.

The conditions left wrist articular cartilage disease, chronic neck pain, chronic back pain, GERD, and hypothyroidism conditions were not profiled or implicated in the commander’s statement and were not judged to fail retention standards.  All were reviewed by the action officer 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.  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 Raynaud’s disease condition, the Board unanimously recommends a disability rating of 20%, coded 7117 IAW VASRD §4.104.  In the matter of the contended left wrist articular cartilage disease, chronic neck pain, chronic back pain, GERD, and hypothyroidism 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 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	
Raynaud’s Disease	7117	20%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 201340114, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR COMMANDER, NAVY PERSONNEL COMMAND
		   DEPUTY COMMANDANT, MANPOWER & RESERVE AFFAIRS
	                          
Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS          

Ref:   (a) DoDI 6040.44
       (b) PDBR ltr dtd	31 Jul 15 ICO XXXXXXXXXXXXXXX
       (c) PDBR ltr dtd 31 Jul 15 ICO XXXXXXXXXXXXXXX
       (d) PDBR ltr dtd 27 Jul 15 ICO XXXXXXXXXXXXXXX
	 (e) PDBR ltr dtd 24 Jul 15 ICO XXXXXXXXXXXXXXX
	 (f) PDBR ltr dtd 25 Jul 15 ICO XXXXXXXXXXXXXXX

1.  Pursuant to reference (a) I approve the recommendations of the Physical Disability Board of Review set forth in references (b) through (f).

2.  The official records of the following individuals are to be corrected to reflect the stated disposition:

     a. XXXXXXXXXXXXXXX, former USN:  Entitlement to disability severance pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge.

     b. XXXXXXXXXXXXXXX, former USMC:  Entitlement to disability severance pay with a 20 percent disability rating (increased from 0 percent) effective date of discharge. 

     c. XXXXXXXXXXXXXXX, former USN: Entitlement to disability severance pay with a 10 percent disability rating (increased from 0 percent) effective date of discharge. 

     d. XXXXXXXXXXXXXXX, former USN: Entitlement to disability severance pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge.

     e. XXXXXXXXXXXXXXX, former USMC: Entitlement to disability severance pay with a 20 percent disability rating (increased from 0 percent) effective date of discharge. 
     
3.  Please ensure all necessary actions are taken to implement these decisions, including the recoupment of disability severance pay, if warranted, and notification to the subject members once those actions are complete.