RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01788
BRANCH OF SERVICE:  Army	BOARD DATE:  20141203
SEPARATION DATE:  20060525

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an Active Guard/Reserve (AGR) SGT/E-5 (42A20/Administration Specialist) medically separated for irritable bowel syndrome (IBS) and bilateral snapping hip syndrome.  These 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).  The bowel and hip conditions, characterized as “irritable bowel syndrome [IBS] with chronic pain and bloating” and “snapping hip syndrome,” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded one other condition (gastroesophageal reflux disease [GERD]) for PEB adjudication.  The Informal PEB (IPEB) adjudicated the IBS and hip conditions as unfitting, rated 0% and ---% respectively, stating the hip condition was related to an Ehlers-Danlos syndrome (congenital connective tissue disorder) diagnosis and existed prior to service (EPTS) with no evidence of permanent service aggravation.  The remaining condition was determined to be not unfitting.  The CI non-concurred with the IPEB findings, hence, she requested and was granted a Formal PEB (FPEB).  The FPEB reviewed the IPEB proceedings, adjudicating the IBS condition unfitting, rated at 10%, as well as reaffirming the original IPEB’s findings for the bilateral hip conditions as EPTS.  The CI non-concurred with the FPEB findings, the case file was forward to the US Army Physical Disability Agency (USAPDA) for finial disposition determination, whom up held the FPEB’s findings and recommendations.  The CI made no further appeals and medically separated.

CI CONTENTION:  “Please consider all conditions.”

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 those conditions identified but not determined to be unfitting by the PEB when specifically requested by the CI.  The ratings for the unfitting IBS and hip conditions are addressed below; the requested GERD condition, which was determined to be not unfitting by the PEB, is likewise addressed below; and no additional conditions are within the DoDI 6040.44 defined purview of the Board.  Any conditions 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.

RATING COMPARISON:

Service FPEB – Dated 20060329	VA - (12 Mos. Post-Separation) 	
Condition	Code	Rating	Condition	Code	Rating	Exam	
IBS	7319	10%	IBS	7319	10%	20070228	
Bilat Snapping Hip Syndrome (EPTS)	5099-5003	--	Snapping Hip Syndrome, Ehler Danlos, Left Hip	5253	0%	20070228	
			Bursitis Left Hip	5019	0%	20070228	
			Snapping Hip Syndrome, Ehler Danlos, Rt Hip	5253	0%	20070228	
			Bursitis Rt Hip	5019	0%	20070228	
GERD	Not Unfitting	GERD	7307	NSC*	20070228	
Other x 0 (Not in Scope)	Other x 3	20070228	
Combined:  10%	Combined:  10%	
Derived from VA Rating Decision (VARD) dated 20070522 (most proximate to date of separation)
GERD corrected to 0% in VARD dated 20081216.  

ANALYSIS SUMMARY:  IBS and GERD are both abdominal conditions that produce a common disability picture, and both conditions are discussed together.  With regards to fitness the tenants of DODI 1332.38 are applicable, and for rating the Veterans Affairs Schedule for Rating Disabilities (VASRD) sections §4.114 (schedule of ratings–digestive system) and §4.113 (coexisting abdominal conditions) were considered.

Irritable Bowel Syndrome and GERD.  The record indicated a history of gastrointestinal (GI) symptoms including pain, reflux, abdominal cramping, diarrhea and constipation, vomiting and weight loss.  She was hospitalized in Kuwait and evacuated from theater.  The CI had recurrent and continued bouts of gastroenteritis, abdominal symptoms, and weight loss.  Specialty testing including normal colonoscopy, CT scan without significant GI lesions, and abnormal upper GI testing (EGD, esophageal pressure testing) led to a diagnosis of GERD with a hiatal hernia.  She underwent abdominal surgery (Nissen Fundoplication-stomach and hiatal hernia areas) in July 2005.  Following surgery, the CI had continued abdominal and epigastric complaints on medications, and reported “up to five bowel movements a day” without blood.  She was evaluated for diarrhea and bloating, difficulty swallowing (dysphagia), nausea and heartburn and was diagnosed with IBS.

At the narrative summary (NARSUM) and MEB exam, the CI reported weight loss of 35 pounds, stomach pain, nausea, vomiting, abdominal pain, bloating and diarrhea.  The MEB physical exam noted very small well-healed puncture marks (from surgery), normal bowel sounds and no palpable tenderness.  Weight was 96 pounds [109 pounds recorded on December 2004 fitness test] and height was 61 inches (pre-deployment weight was 125 pounds).  She was described as an alert, well developed, trim … (individual) in no acute distress.  There was no electrolyte or other lab test abnormalities.  “Present Status” indicated the CI was in medical hold, doing “CQ 2 days a week.  She says on a bad day she is in the bathroom all the time and no matter what day it is she tends to work or do things where there is a bathroom available.”

Repeat CT scan of the abdomen performed in January 2006 showed non-specific thickening of the duodenum (upper intestine at stomach outlet [akin to Barrett’s Esophagus]).  Barium enema (VA ~March 2006) was normal, EGD noted inflammation of the esophagus and sigmoidoscopy was unremarkable with the examiner commenting that “there was positive stool, so I do not believe that the patient has been having chronic diarrhea.”

At the VA Compensation and Pension (C&P) exam (performed 12 months after separation), the CI reported symptoms of daily diarrhea, moderate dyspepsia and dysphagia (swallowing and heartburn) intermittent with remissions on medication, nausea and vomiting related to meals, and having missed 5 weeks of work during the prior 12 months.  Weight was 125 pounds and there were no signs of significant weight loss or malnutrition.

A remote VA C&P exam in August 2008 (performed 27 months after separation), although the CI was 7 months pregnant, her pre-pregnancy symptoms of GERD including nausea that was treated with medication with positive results and taking IBS medication that was helpful with controlling her loose watery stools.  The CI stated that she averaged 5 bowel movements per day and on severe days, she could have up to 10 bowel movements.  “Her symptoms would be aggravated with stress or intake of any milk products.”  Symptoms were noted to have worsened and the exam was rated by the VA at 30% effective July 2008.

The Board directed attention to its rating recommendation based on the above evidence.  Both the service and VA rated the IBS at 10% using disability code 7319 (irritable colon syndrome).  The service found GERD as not unfitting, and the VA rated GERD with IBS (after initial not service-connected GERD rating was corrected).  Any possible alternative GI rating using the GERD criteria (analogous to 7346 [Hernia hiatal]) would not rise above 10% without symptoms which were “productive of considerable impairment of health” which was not in evidence proximate to separation.  Dual rating the IBS and the GERD conditions (if GERD rose to the level of being unfitting) is not permitted IAW VASRD §4.113 (Coexisting abdominal conditions).  The Board therefore did not specifically deliberate if the IBS and GERD symptoms could be separated or if the GERD rose to the level of being separately unfitting as it would not alter any rating determination.  The Board therefore focused on rating all digestive system disability.  The 10% criteria for IBS is for “Moderate; frequent episodes of bowel disturbance with abdominal distress” while the 30% criteria is for “severe; diarrhea, or alternating diarrhea and constipation, with more or less constant abdominal distress.”

All of the exams proximate to separation described frequent episodes of diarrhea, bowel disturbance and abdominal distress which were adjudged as moderate and best aligned with the 10% rating criteria.  The increased symptoms noted in the 2008 VA exam were adjudged post-separation worsening and not indicative of the CI’s disability level 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 adjudications for the combined IBS and GERD conditions.

Snapping Hip Syndrome.  The bilateral snapping hip syndrome with pain was found to be unfitting by the service and that was considered administratively final.  The PEB disability description stated the CI had been “diagnosed with ‘Ehlers-Danlos Syndrome’ (hyper-flexibility at joints and elsewhere),” and the condition was not compensable due to EPTS without evidence of permanent service aggravation.  The DA Form 2173 (Statement of Medical Examination and Duty Status), dated 14 December 2005, noted complaints of bilateral hip pain during mobilization training in August 2004, with increasing hip pain due to the weight of gear and weight loss.  The CI was treated with medication for left hip “bursitis versus tendonitis” and had findings of tenderness with full range-of-motion (ROM) and discomfort with abduction of the left leg.  A note later that month indicated the left hip condition was resolved and she was cleared for duty without restrictions.  She passed her fitness test in December 2004.  The NARSUM in December 2005 noted the CI complained that both hips bothered her and snapped which she attributed to weight loss.  She had been on profile restriction to include her hips.  “She says if she just walks it pops or if she bends over to grab something it pops.  She says it got worse when she lost weight.  The pain is not constant but the pressure feeling is constant.”  Physical exam documented full ROM at the hips with hyper-flexibility.  “The areas that tend to snap run right through the groin close to the pubic bone.  It is only certain actions such as extension of the leg as well as certain flexion or external rotation that brings that on.”

At the VA C&P exam (performed 12 months after separation), the CI reported diagnoses of bilateral hip pain, "snapping tendons," and “Ehlers-Danlos.”  The course was noted as intermittent with remissions, and on no treatment.  The examiner stated “Mention of ‘Ehlers-Danlos’, though has none of the findings.”  Exam documented a normal gait.  Hips had “cracking” with full painless active and passive ROM bilaterally.

The Board directed attention to its rating recommendation based on the above evidence.  The record had no evidence of painful hips prior to 2004.  There were scant treatment notes relating to the hip condition and there was no source treatment note or consult making a diagnosis of Ehlers-Danlos os syndrome.  Aside from hyper-flexibility at the hips, there was no evidence of skin or vascular findings or other joint hypermobility to fully support the diagnosis of Ehlers-Danlos syndrome.  Snapping hip syndrome bilaterally was well supported by the examinations and only the left hip had an additional diagnosis of bursitis which was considered resolved.

The Board considered that both snapping hip syndrome and Ehlers-Danlos syndrome are not typically associated with painful hips.  Given the question of the actual diagnosis of Ehlers-Danlos, and the late onset of painful hips in the face of increased activities and weight loss, the Board adjudged that the EPTS and lack of permanent aggravation as determined by the FPEB was not to the level as to create a virtual certainty (IAW DoDI 1332.38).  The Board therefore adjudged that the hip conditions were compensable.  There was scant evidence to separate the left hip from the right hip in terms of severity and both hips were considered reasonably unfitting.  With regards to rating the hips, however, there was no objective evidence of painful motion for either hip and no periods of incapacitation due to the hips.  Each hip if rated separately would warrant a 0% rating each, under the specific hip codes or general joint codes since VASRD §4.59 for painful motion were not adjudged to have been met.  The Board considered that only the left hip had had a diagnosis of bursitis, but that each hip “snapping” could be analogized to 5024 (tenosynovitis) and considered as two major joints with pathology as code 5099-5024, rated 10%, using the criteria of code 5003.  There were no incapacitating episodes 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 10% for the bilateral hip 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 IBS (and GERD) condition and IAW VASRD §4.114, the Board unanimously recommends no change in the PEB adjudication.  The GERD condition is considered within the IBS rating as discussed above.  In the matter of the bilateral hip condition, the Board unanimously recommends a disability rating of 10%, coded 5099-5024 IAW VASRD §4.71a.  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 her prior medical separation:

UNFITTING CONDITION	VASRD CODE	RATING	
Irritable Bowel Syndrome (with GERD)	7319	10%	
Bilateral Snapping Hip Syndrome	5099-5024	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140414, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

XXXXXXXXXXXXXXX
President 
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 XXXXXXXXXXXXXXXXXX, AR20150008243 (PD201401788)

1.  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 to modify the individual’s disability rating to 20% without recharacterization of the individual’s separation.  This decision is final.  

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.   

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:

Encl		     XXXXXXXXXXXXXXXXXX
		     Deputy Assistant Secretary of the Army
		         (Review Boards)

CF: 
(  ) DoD PDBR
(  ) DVA