RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00802
BRANCH OF SERVICE:  Army	date of SEPARATION:  20091111

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E6, Health Care Specialist, medically for “left foot injury,” “paroxysmal atrial fibrillation” and “hemochromatosis with slight liver enlargement,” rated 20%, 0% and 0%, respectively; with a combined disability rating of 20%.

CI CONTENTION:  He was given higher ratings for his conditions by the VA.  The applicants complete submission is at Exhibit A.

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44.  It is limited to those conditions determined by the Physical Evaluation Board (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 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 PEB - 20090806	VARD - 20091130   	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Foot Injury	5284	20%	Left Ankle Residuals Status Post Surgery	5271	0%	20091002 	
Paroxysmal Atrial Fibrillation	7010	0%	Paroxysmal Atrial Fibrillation Status Post Ablation	7010	0%		
Hemochromatosis with Slight Liver Enlargement	7345	0%	Hemochromatosis	7799-7700	NSC		
Cardiomyopathy Class Mild I	Not Unfitting	Cardiomyopathy	7020	0%		
Hypertension		Hypertension	7101	0%		
Obstructive Sleep Apnea		Sleep Apnea	6847	50%		
Gastroesophageal		Gastroesophageal Reflux Disease	7399-7346	10%		
Headache Syndrome		Headache Syndrome	8199-8100	0%		
Intermittent Right Knee Pain		Right Knee Status Post Surgery	5260	0%		
Intermittent Low Back Pain		Lumbar Spine Degenerative Joint Disease and
Degenerative Disc Disease	5242-5243	40%		
High Cholesterol / Triglycerides		No VA Placement	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  70%	

ANALYSIS SUMMARY:  

Paroxysmal Atrial Fibrillation (PAF).  The service treatment record supports and substantiates the MEB narrative summary (NARSUM) dated 18 June 2009, which indicated the CI awakened with a pounding heart in March 2007.  Work-up revealed atrial fibrillation (an irregular heartbeat) and a structurally normal heart.  Within 30 hours he converted to a normal rhythm. Treatment consisted of Lovenox (an anticoagulant) initially followed by aspirin.  A second episode of atrial fibrillation occurred in July 2007, which also converted to normal within 30 hours and treatment was again with Lovenox; and, metoprolol (a beta blocker) was introduced.  In January 2008 he had an episode of chest pain and an episode of dyspnea (shortness of breath).  Workup was normal and the symptoms were suggested to be related to paroxysmal atrial fibrillation (PAF) and hypertension.  Additional studies including a brain scan (encephalomalacia of the frontal lobe favored a contusion) and echocardiogram (ejection fraction about 55% and all chambers were at the upper limit of normal size consistent with his height of 76 inches) were normal as was a Holter monitor study (to document arrhythmias) and a follow-up electrocardiogram (ECG or EKG).  In June 2008 the CI was treated with flecainide (an anti-arrhythmic medication) and the metoprolol was changed to diltiazem (a calcium channel blocker).  He did well with the combination of medications, but an ablation procedure was recommended in lieu of taking the flecainide in March 2009.  In April 2009 the ablation procedure was performed; postoperatively, the CI took Coumadin (warfarin, an anticoagulant) for 6 weeks and the flecainide was discontinued.  In May 2009 continuous ECG monitoring indicated no atrial fibrillation and no symptoms.  At the time of the NARSUM, the CI had no recurrence of atrial fibrillation based on two additional 24 hour Holter monitor studies, but he was advised there was a lifelong risk of recurrence.  A P4, L3 profile was issued in June 2009 that included several conditions (see below), including cardiomyopathy with the PAF, which limited all military functional activities, except wearing a protective mask and all chemical defense equipment as well as no running and no sit-ups.   The commander’s statement dated 5 June 2009 was not specific relating to the PAF, but indicated the CI was unable to manage the physical requirements within his MOS.  The CI indicated on DD Form 5 June 2009 for the Medical Evaluation Board “I go in and out of A-fib, but had ablation procedure in April 08.”  Examination noted on DD Form 2808 “RRR” (regular rate and rhythm).  At the VA Compensation and Pension (C&P) examinations dated 2 October 2009 and 8 October 2009 the CI complained of chest pain that occurred once each week and lasted for 2 to 3 minutes when present; however, it returned if he performed any vigorous activity such as physical training.  The examiner noted the CI was mostly in sinus rhythm, but did get occasional palpitations associated with chest pain and shortness of breath.  The CI did not have a pacemaker or have a history of sustained ventricular arrhythmias.  The examiner opined the CI was probably able perform to 5 to 6 METS of exercise at the time of examination, but could not definitively say exercise capacity until the CI had a stress test, but did note the radiofrequency ablation seemed to have been successful in terminating the atrial fibrillation.  Additional tests were required for diagnostic confirmation.  An EKG was normal.  During an exercise stress testing on 22 October 2009 the CI achieved a work load of 10.10 METS, but the test was stopped due to leg discomfort and back pain (see below).  His resting EKG was normal; functional aerobic capacity was fairly normal; heart rate response to exercise was appropriate as was his blood pressure and there was no chest pain, no arrhythmias, and no ST segment changes (indicating cardiac ischemia). 

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 0% rating using code 7010 (supraventricular arrhythmias) for the PAF status post atrial pulmonary vein isolation ablation.  The VA likewise assigned a 0% rating using code 7010 for the PAF status post ablation.  The Board sought a route to a higher rating cognizant that at the time of separation, the ablation was successful in eliminating the PAF and/or any recurrence of it for at least 7 months; and a combination of medications had controlled the PAF prior to the procedure, although it would be speculative to place an exact date when it was initially achieved, but it was likely more than a year prior to separation.  Therefore, the CI’s condition at separation did not rise to a 10% rating using code 7010, which states “Permanent atrial fibrillation (lone atrial fibrillation), or; one to four episodes per year of paroxysmal atrial fibrillation or other supraventricular tachycardia documented by ECG or Holter monitor.”  Similarly a 30% rating is not applicable as well since it requires “paroxysmal atrial fibrillation or other supraventricular tachycardia, with more than four episodes per year . . .”   The Board did note that during the VA C&P examination the CI related a history of palpitations, which were neither sustained nor documented by ECG or Holter monitor; and, during the stress test he had no arrhythmias and achieved a workload of 10.10 METs.  Therefore, use of code 7011 (Ventricular arrhythmias [sustained]) is inapplicable.  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 paroxysmal atrial fibrillation condition.

Left Foot Injury.  The CI injured his left ankle and heel after landing wrong after a routine night jump.  On the march back to the barracks, the CI twisted his ankle again.  Treatment consisted of ice and ibuprofen (an NSAID) and the next morning X-rays revealed 3rd and 4th metatarsal fractures.  Placement in a CAM [controlled ankle movement] walker for 2 weeks did not resolve the pain whereupon he was placed in a cast for 10 weeks.  Repeat X-rays were suspicious for a “coalition of the subtalar joint” (ossification of the joint with limited motion).  CAM walker placement, physical therapy, and two steroid injections did not resolve the pain.  Surgery was recommended, but was postponed for deployment even while the CI was in a CAM walker, which was removed on patrol.  He rolled his ankle on the rocky terrain; and, the ankle was marked by intermittent swelling and bruising with a worsening of the pain.  As a result, the CI was medically evacuated.  Surgery (left subtalar joint arthroscopy to shrink chronic scar tissue and synovitis) was performed in September 2003 followed by postoperative physical therapy.  Despite lack of improvement, the CI was deployed for 3 months.  He had a MMRB [MOS/Medical Retention Board], which found him fit for duty and he reclassified as a Health Care Specialist and was transferred overseas where he was able to perform, albeit with an alternate aerobic event.  However, pain persisted and was worse in the morning.  His condition at the time of the NARSUM was marked by daily pain in his ankle on the inside and the center of his heel with a severity of 6-7/10 (10 being the worst pain) and flares reached 10/10 pain.  He often limped and could not run.  The commander’s statement did not explicitly address the left ankle pain, but noted the CI could not manage the physical requirements in his MOS.  For the MEB examination the CI reported on DD Form 2807-1 dated 5 June 2009 he had arthritis in the left ankle postoperatively.  The MEB examiner noted on DD Form 2808 dated 18 June 2009 the CI was tender over the left anterior talofibular area without instability, bruising, or edema.  Range-of-motion (ROM) measurements were dorsiflexion 16 degrees, plantar flexion 22 degrees, eversion 8 degrees and inversion 24 degrees.  A permanent L3 profile was issued for left ankle on 18 June 2009 with restrictions noted above.  At the VA C&P examination the ROM of the left ankle was dorsiflexion 0-20 degrees and plantar flexion 0-45 degrees with no pain on motion.  There was tenderness to palpation over the dorsal aspect of the 4th metatarsal.  The CI walked on the toes and heels without difficulty and without pain or guarding and with a normal gait.  There was not a decrease in the ROM or function with repetitive bilateral foot rocking and heel and toe walking.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 20% rating using code 5284 (Foot injuries, moderately severe) for left foot injury, while the VA assigned a 0% rating using code 5271 (Ankle, limited motion) for left ankle residuals status post surgery.  The Board sought a route for a higher rating, but was unable to find one in the absence of ankylosis of the ankle and a severe foot injury or malunion of the tarsal or metatarsal bones at the time of separation.  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 left foot injury condition.

Hemochromatosis with Slight Liver Enlargement.  The NARSUM dated 18 June 2009 indicated while being evaluated for headaches and hypertension, slight liver enlargement and some laboratory abnormalities were noted.  An abdominal CT scan showed homogenous increased hepatic attenuation consistent with iron overload, but the liver was not obviously enlarged.  The ferritin level (the major iron storage protein) was greater than 1000 and liver function tests were very slightly elevated (ALT 80 U/L and 74 U/L (Normal 21-72) in December 2006 and May 2007 and normalized thereafter.  Genetic testing was performed and revealed a positive homozygous genetic defect for the C282Y mutation of the HFE gene, which was 60-90% specific for hemochromatosis (too much iron in the body).  A liver biopsy revealed pathology that confirmed and was consistent with hemochromatosis.  (The primary source liver biopsy report was not in the STR.  In 2009 the patient reported there was limited cirrhosis and significant iron overload.)  A weekly phlebotomy was initiated with a goal of keeping the hematocrit (volume percentage of red blood cells in blood) less than 50 percent.  The CI had no overt symptoms of hemochromatosis, although the NARSUM author raised the possibility that the atrial fibrillation (discussed above), which began in March 2007, although the cause was unknown, “could very likely be due to iron deposition in the myocardium” (heart muscle).  Other than the CI’s annotation of hemochromatosis on the DD Form 2807-1, there was no further mention of it at the MEB physical examination.  The permanent P4 profile discussed above did mention hemochromatosis, while the commander’s statement did not explicitly mention it.  The VA C&P examiner noted that the hemochromatosis was controlled with a maintenance phlebotomy once a month, the most recent of which was in September 2009, 2 months prior to separation.  Post-separation, the CI was seen in consultation on 14 January 2010 at which time he had no new symptoms; however, although his ferritin level was below 100, his serum iron and percent saturation were high.  As a result a phlebotomy was performed and follow-up was scheduled for 6 weeks.  Additional phlebotomies were performed in June 2010, August 2010, August 2012, and November 2012.

The Board directed attention to its rating recommendation based on the above evidence.  The Board assigned a 0% rating using coded 7345 (Chronic liver disease without cirrhosis (including hemochromatosis).  The VA assigned a NSC [Not Service Connected] rating using code 7799-7700 (Anemia, hypochromic-microcytic and megaloblastic, such as iron-deficiency and pernicious anemia):for the hemochromatosis and modified the rating to 0% using code 7345 in October 2010 citing that it was asymptomatic.  The Board sought a route to a higher rating and noted that the CI was rated for chronic liver disease without cirrhosis, albeit hemochromatosis can cause chronic liver disease.  He did initially have slight liver enlargement clinically, which was not confirmed on CT scan and he had transient elevation of one liver enzyme that resolved.  A liver biopsy was not available, but the CI reported he had limited cirrhosis, which raises the possibility of code 7312 that likewise provides a 0% rating.  The CI did he have anemia; therefore, code 7700 is not applicable.  However, the CI had hemochromatosis, a disease of excess iron that can involve not only the liver, but is also associated with, but not limited to, skin bronzing or hyperpigmentation, diabetes, arthropathy, hypogonadism, and cardiomyopathy.  Therefore, use of analogous code 7799-7704 (Polycythemia vera--an elevated red blood cell mass) IAW VASRD §4.20 (Analogous ratings) is reasonable because both polycythemia vera and hemochromatosis are conditions of excess that involve symptoms and/or clinical finding in some of the same organs.  Furthermore, a 40% rating is warranted since the CI’s hemochromatosis was not stable based on elevated iron levels, but was treated with regular phlebotomies and continued to be so within 12 months post-separation and beyond.  A higher rating is not indicated since myelosuppressants (medication to lower the total red blood cell mass) are not part of the hemochromatosis treatment regimen nor is a low rating indicated since the hemochromatosis was not stable based on elevated iron levels.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 40% for the hemochromatosis condition.  

Contended PEB Conditions

The Board’s main charge is to assess the fairness of the PEB’s determination that cardiomyopathy Class mild I, hypertension, high cholesterol/triglycerides, obstructive sleep apnea, gastroesophageal reflux, headache syndrome, intermittent right knee pain, and intermittent low back pain were not unfitting.  The Board’s threshold for countering fitness determinations requires a preponderance of evidence, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  The cardiomyopathy (with paroxysmal atrial fibrillation) was profiled although it was not clear what portion of the permanent P4 profile it encompassed since it included the PAT, which was subsequently ablated as noted above.  Additionally, the obstructive sleep apnea was profiled P2 with the limitation that access to CPAP/electricity was required.  None of the contended conditions were explicitly implicated in the commander’s statement, which indicated the CI was unable to manage the physical requirements of his MOS and none of the conditions were judged to fail retention standards.  There was no performance based evidence from the record that any of the conditions significantly interfered with satisfactory duty performance.  In particular the Board members discussed the intermittent back pain condition and noted that despite the limitation of motion noted on a physical therapy examination, the CI still performed his duties in an outstanding manner and even with the decreased ROM measurements during the VA examination, the CI used no assistive devices and was able to walk greater than 2 miles.  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: In the matter of the left foot injury condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the hemochromatosis condition, the Board unanimously recommends a disability rating of 40%, coded 7799-7704 IAW VASRD §4.117.  In the matter of the contended cardiomyopathy class I, hypertension, hyperlipidemia (high cholesterol/triglycerides), obstructive sleep apnea, gastroesophageal reflux headache syndrome, intermittent right knee pain, and intermittent low back pain 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.  The Board recommends that the CI’s prior determination be modified as follows; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective as of the date of his prior medical separation:    

CONDITION	VASRD CODE	RATING	
Paroxysmal atrial fibrillation	7010	0%	
Left foot injury	5284	20%	
Hemochromatosis with slight liver enlargement	7799-7704	40%	
RATING	50%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140218, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB							
MEMORANDUM FOR Commander

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXXX, AR20160005606 (PD201400802)

1.  Under the authority of Title 10, United States Code, section 1554(a), I approve the enclosed recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) pertaining to the individual named in the subject line above to re-characterize the individual’s separation as a permanent disability retirement with the combined disability rating of 50% effective the date of the individual’s original medical separation for disability with severance pay.

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:

	a.  Providing a correction to the individual’s separation document showing that the individual was separated by reason of permanent disability retirement effective the date of the original medical separation for disability with severance pay.

	b.  Providing orders showing that the individual was retired with permanent disability effective the date of the original medical separation for disability with severance pay.

	c.  Adjusting pay and allowances accordingly.  Pay and allowance adjustment will account for recoupment of severance pay, and payment of permanent retired pay at 50% effective the date of the original medical separation for disability with severance pay.

	d.  Affording the individual the opportunity to elect Survivor Benefit Plan (SBP) and medical TRICARE retiree options.

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:
						      					
Enclosure
					
CF: 
(  ) DoD PDBR
(  ) DVA