RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD–2014-02076		
BRANCH OF SERVICE:  Army	BOARD DATE:  20150602
Separation Date:  20031209

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-3 (Food Service Specialist) medically separated for constipation.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS).  He was issued a permanent P3 profile referred for a Medical Evaluation Board (MEB).  The “chronic constipation” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other condition was submitted by the MEB.  The Informal PEB adjudicated “history of constipation” as unfitting, rated 0%, citing application of the US Army Physical Disability Agency (USAPDA) pain policy.  The CI made no appeals and was medically separated.  

CI CONTENTION:  The CI requested that the Board review all of his conditions.  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:  

IPEB – Dated 20031029	VA* - (~1 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
History of Constipation	5099-5003	0%	Levator Ani Syndrome	7399-7336	20%	20040126	
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 1 (equals SC, NSC & deferred)	
RATING:  0%	RATING:  20%	
*Derived from VA Rating Decision (VARD) dated 20040430 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY:

History of Constipation Condition.  The CI developed severe constipation after he ate MRE’s during a training exercise in November 2001, February 2002 and April 2002 and developed rectal bleeding.  In July 2002, he was noted to a large chronic anal fissure (cut or tear in the anus) and underwent rectal surgery (lateral partial sphincterotomy - cutting the internal muscle).  The CI reinjured the surgical site by heavy lifting and underwent a second rectal surgery.  The CI had continued symptoms of abdominal pain and complaints of difficulty walking and rectal bleeding and underwent extensive gastrointestinal (GI) evaluations (including colonoscopy esophagogastroduodenoscopy (EGD), rectal manometry, X-rays, etc.).  The CI continued to be followed by surgery for abdominal pain, constipation and a recurrent anal fissure without symptom resolution.  In April 2003, the CI was diagnosed with levator ani syndrome (recurrent muscle spasm in the anus).  Abdominal symptoms were not relieved by medications or pelvic physical therapy.  

The MEB Narrative Summary (NARSUM) exam approximately 6 months prior to separation documented complaints of extreme pain with continued muscle spasm; muscle weakness in the lower abdomen and a history of recurrent rectal bleeding.  The NARSUM summarized the GI specialty exams including abnormal studies consistent with levator spasm and noted recurrent episodes of bleeding with emergency room visits; the most recent being the month of the NARSUM.  The examiner stated “the degree of severity is mild overall.”  The commander’s statement approximately 5 months prior to separation indicated that the CI’s constipation and abdominal pain prevented him from standing or walking for long periods of time and prevented him from meeting minimum passing standards on the APFT.  A treatment note from approximately 4 months prior to separation documented a recurrent anal fissure.  

The VA Compensation and Pension (C&P) exam approximately a month after separation documented that the CI required continuous medication, had recurrent anal fissures, spasm of the pelvic floor muscles and that constipation caused lower abdominal cramps which lasted up to two days.  There were physical exam findings of a normal rectal exam with no fissures, hemorrhoids or bleeding.  The examiner diagnosed recurrent hematochezia (fresh blood from the anus) likely to be secondary to recurrent anal fissures.  The complete blood count did not show any anemia.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB coded the history of constipation condition as 5099 analogous to 5003 (Arthritis, degenerative [hypertrophic or osteoarthritis]) and rated at 10% with application of the USAPDA pain policy.  The VA coded the Levator Ani Syndrome condition as 7399 analogous to 7336 Hemorrhoids, external or internal and rated at 20% (with persistent bleeding and with secondary anemia, or with fissures).  

The PEB disability description noted the CI’s constipation complicated by eating MRE’s with surgically repaired anal fissure and stated “(the CI) continues to have intermittent episodes of abdominal pain, constipation and rectal bleeding precipitated by strenuous activities.”  The CI’s disability condition was clearly a gastrointestinal issue and VASRD coding would be under §4.114—Schedule of ratings–digestive system.  There is no exact code for the CI’s condition and the Board considered VASRD §4.20 (analogous ratings) for selecting appropriate coding for a “closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous.”  The Board deliberated on analogous coding under 7319 (Irritable colon syndrome), 7332 (Rectum and anus, impairment of sphincter control), 7333 (Rectum and anus, stricture), and 7336 (Hemorrhoids, external or internal) and adjudged that coding under 7336 was predominate.  The CI had well documented abdominal pain, with chronic constipation which caused recurrent bleeding and anal fissures.  The Board adjudged that the CI’s disability picture proximate to separation most closely aligned with that of the 20% criteria under code 7336.  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 history of constipation condition coded 7399-7226.  

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 (635-40) for rating the history of constipation condition was operant in this case and the condition was adjudicated independently of that policy by the Board. In the matter of the history of constipation condition, the Board unanimously recommends a disability rating of 20%, coded 7399-7336 IAW VASRD §4.114a.  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	
History of Constipation	7399-7336	20%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140416, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

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, AR20160004489 (PD201402076)

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, accept the Board's recommendation to modify the individual's disability rating to 20% without re-characterization 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:

CF:
( ) DoD PDBR
( ) DVA