RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02247
BRANCH OF SERVICE:  NAVY	 SEPARATION DATE:  20050809

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5, Cryptologic Technician, medically separated for the overall effect of endometriosis, posttraumatic stress disorder, depressive disorder, myofascial pain syndrome, and interstitial cystitis” with a disability rating of 0%. 

CI CONTENTION:  “Please review all conditions.”  The CI’s 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 – 20050428	VARD - 20070418  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Endometriosis	7629**	0%	Endometriosis	7629	30%	20061212	
Posttraumatic Stress Disorder	9411		Post-Traumatic Stress Disorder and Major Depression	9411	30%	20061211	
Depressive Disorder	9434						
Myofascial Pain Syndrome	5021-5319		Myofascial Pain Syndrome	5021-5319	0%	20061212	
Interstitial Cystitis	7512		Interstitial Cystitis	7512	60%	20061212	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  90%	

ANALYSIS SUMMARY:  

Endometriosis Condition.  The PEB combined the endometriosis, PTSD, depressive disorder NOS, myofascial pain syndrome, and interstitial cystitis together as unfitting; “The overall effect of the following diagnoses contribute to the unfit finding”; and provided an overall zero percent rating.  Not uncommonly this approach by the PEB reflected its judgment that the constellation of conditions was unfitting, but that individually each condition alone was not considered unfitting, hence the “combined effect”.  

The CI did not have a physical profile recorded until May 2005 (MEB H&P-DD2808), approximately 3 months prior to separation.  The profile documented a rating of “1” for each category (consistent with no physical or mental conditions limiting ability to perform in assigned MOS).  Accordingly, the CI was never profiled for any condition; however, she was working out of her specialty due to medical condition.  The NMA dated 24 November 2004, 9 months prior to separation, noted that the CI’s medical condition required her to be away from her duties for medical care about 20 hours a week, and she was not worldwide assignable.  The NMA also noted that she was in need of constant supervision and was unable to remain a viable watch stander due to medication.  She was able to perform random low priority task.  It was noted that she had to be removed from her position, and her clearance temporarily suspended due to medication.  The Board considered each condition separately as discussed below. 

The PEB determined the endometriosis condition alone was not independently unfitting but when combined with the other listed conditions, contributed to overall unfitness.  The Board considered whether the endometriosis considered alone was unfitting for continued military service.  If the Board determines the condition was unfitting for military service, it must then consider applicable codes and rating recommendation.  

According to the service treatment records (STR) and the MEB narrative summary (NARSUM), the CI had a long-standing history of chronic pelvic pain and endometriosis.  Upon entry to the service, the CI began undergoing evaluation for her chronic pelvic pain.  Her condition was initially treated with hormone medication and the response was positive.  However, she continued to have pain.  In 2004, she underwent a surgical procedure with diagnostic laparoscopy and was diagnosed with endometriosis.  Surgery did not improve her pain.   Since that time she had been followed in the chronic pelvic pain clinic and was restarted on hormone therapy and prescribed narcotic pain medication.  In March 2004, the CI presented to the emergency room for menstrual related abdominal pain.  There were no additional recorded visits to the ER related to endometriosis.

The NARSUM was conducted in January 2005, approximately 8 months prior to separation.  The examiner noted the CI had a 4 year history of endometriosis and interstitial cystitis (IC), and the history of treatment for both conditions.  The physical examination recorded tenderness to palpation of the bladder, and in both adnexa of the pelvis, otherwise, the examination was unremarkable.  It was noted that because the CI was taking large amounts of pain medication, her ability to function close to a regular schedule was inhibited.  According to the STR the CI did not have a profiled condition.  Clinic follow-up for pelvic pain in March 2005 noted the CI was doing very well.  It was noted that her pelvic pain had improved significantly although there had been a significant exacerbation the previous 2 weeks.  The VA compensation and pension (C&P) examination was accomplished 16 months post separation.  

The Board first considered whether the endometriosis condition was unfitting for continued military service.  The CI reported symptoms of excessive bleeding and pelvic pain.  Her treatment included hormone therapy which she responded well and pain medication which had to be adjusted on several occasions.  However, there was no duty restrictions imposed secondary to this condition.  The physical examination at the NARSUM recorded tenderness as the single finding.  There was no mention of medication side effects, and the CI was alert and oriented during the examination.  There was no evidence that the CI’s condition required quarters in the 12 months before separation.

The commander noted the CI was unable to perform her duties because of her medication; however, no specific condition was implicated, and therefore, it was not possible to ascribe that this condition had interfered with duty performance since the CI took multiple medications for multiple conditions.  The VA C&P examination offered no probative value since it was too remote from date of separation.  Board members agreed there was insufficient evidence to support that the endometriosis condition cut short the CI’s military career.  After due deliberation and consideration of the totality of evidence, there is not reasonable doubt in the CI’s favor supporting addition of endometriosis as an unfitting condition for separation rating.

PTSD and Depressive Disorder Conditions.  According to the service treatment records the CI had a preservice history of sexual molestation during childhood.  The NARSUM recorded a previous medical history of PTSD and depression.  In March 2002, the CI underwent psychological evaluation where she reported that she had been sexually assaulted by a civilian beautician in 1999 and was seeking help with issues related to the assault.  The CI noted that she had received counseling after the assault and was currently in counseling.  The mental status examination (MSE) was unremarkable; however, the psychologist assessed the conditions of MDD and PTSD.  Specific diagnostic criteria were not addressed.  In April 2002, she was prescribed antidepressant by the primary care provider.  There was no indication from the record that any mental health (MH) condition was profiled and no MH condition was implicated in the NMA.  There was no indication from the NARSUM that any MH condition failed retention standards.  

The Board noted that over the 4-year history of treatment, the CI engaged minimally in MH treatment, although she took psychotropic medications consistently for 2 years prescribed by her primary care physician.  The CI did not have psychiatric consultation prior to the 2 months before separation.  The record clearly documented the challenges of formulating a treatment diagnosis, as well as the transient nature of her symptoms.  The record showed that under multiple personal stressors, the CI decompensated briefly, but recovered after resolution or stability of the inciting stressor.

The VA C&P examination was considered too remote from date of separation for probative value.
Board members concluded at the time of separation, her MH conditions were chronic, and symptoms were transient but stable; however, there was not a preponderance of evidence that her MH conditions cut short the CI’s military career.  After due deliberation and consideration of the totality of evidence, there is not reasonable doubt in the CI’s favor supporting addition of PTSD and depressive disorder NOS as unfitting conditions for separation rating.  

Myofascial Pain Syndrome Condition.  According to the STR, the CI was diagnosed with myofascial pain syndrome in 2004 related to her complaint of pelvic pain.  She was treated with narcotic medication, a medication for neuropathic pain, and prescribed physical therapy.  It should be noted that this condition encompassed both the pain related to endometriosis and interstitial cystitis (IC).  At the last OB/GYN clinic visit, 5 months before separation, the examiner noted that the CI “demonstrated a lot of excessive pain behaviors during the examination as she has previously.”  The pelvic examination was unremarkable.  The NARSUM did not list or discuss this diagnosis and the MEB did not forward myofascial pain syndrome condition to the PEB.  It is more likely than not that this diagnosis was separated out in the diagnoses of IC and endometriosis.

The Board first considered whether the myofascial pain syndrome condition was unfitting for continued military service.  The evidence demonstrated that this condition did not constitute a separate pathology from the endometriosis and the IC conditions, and therefore, is addressed in the context of those conditions.  This condition was not profiled, or judged to fail retention standards.  After due deliberation and consideration of the totality of evidence, there is not reasonable doubt in the CI’s favor supporting addition of myofascial pain syndrome as a separately unfitting condition for separation rating.

Interstitial Cystitis Condition.  The STR noted that the CI was diagnosed with IC after reporting urinary incontinence and frequent urgency with discomfort when voiding.  She experienced burning sensation throughout her pelvis.  The initial diagnostic impression was of overactive bladder and stress incontinence.  Treatment recommendation included increase water intake and discontinue caffeine use.  The CI later underwent diagnostic cystoscopy which was unremarkable.  The diagnosis of IC was made.  The CI was treated with patches and later electrical bladder stimulation therapy with good results.  As noted above, physical examination at the NARSUM showed bladder tenderness to palpation.  

The Board first considered whether the IC condition was unfitting for continued military service.  The CI reported symptoms of pain on voiding, excessive voiding, and urgency, which was treated aggressively and improved with treatment.  This condition was not profiled, and there was no documented duty restrictions associated with the condition.  There was no evidence that the CI’s condition required quarters in the 12 months before separation.  Therefore, there was not a preponderance of evidence that the interstitial cystitis condition cut short the CI’s military career.  Therefore, the Board concluded there were no separately unfit condition that rendered the CI unfit; however, the overall effect of these conditions contributed to the unfit finding.

BOARD FINDINGS:  In the matter of the endometriosis, post-traumatic stress disorder, depressive disorder, NOS, myofascial pain syndrome, interstitial cystitis conditions and IAW VASRD § 4.117, 4.130, the Board recommends no change in the PEB adjudication.  There were no other conditions within the Board’s scope of review for consideration.  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 20140508, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR DIRECTOR, SECRETARY OF THE NAVY COUNCIL OF REVIEW
               BOARDS 

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS
 
Ref:   (a) DoDI 6040.44
       (b) CORB ltr dtd 21 Sep 16

      In accordance with reference (a), I have reviewed the cases forwarded by reference (b), and, for the reasons provided in their forwarding memorandums, approve the recommendations of the PDBR that the following individual’s records not be corrected to reflect a change in either characterization of separation or in the disability rating previously assigned by the Department of the Navy’s Physical Evaluation Board:

		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN

						  
XXXXXXXXXXXXXXXXXXXX
Assistant General Counsel
					(Manpower & Reserve Affairs)