RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX	CASE: PD-2014-02353
BRANCH OF SERVICE:  Army	BOARD DATE:  20150630
SEPARATION DATE: 20011128

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-3 (Military Police) medically separated for right foot and abdominal wall pain conditions.  These conditions could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty.  She was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  Myofascial pain of the abdominal wall, right navicular osteochondral defect and right talus stress fracture, and psychological factors were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other condition was submitted by the MEB.  The Informal PEB adjudicated the right foot pain, and myofascial abdominal wall pain with psychological factors as unfitting, rated 10% and 0% respectfully with likely application of Veterans Affairs Schedule for Rating Disabilities (VASRD).  The CI appealed to the Formal PEB but retracted the appeal, and was 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 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:

IPEB – Dated 20010806	VA* - Service Treatment Records (STR)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Foot Pain	5284	10%	Right Foot, Ostialchondral…	5299-5284	NSC	STR	
Myofascial Abdominal Pain with Psychological Factors	5099-5021	0%	Chronic Pancreatitis	7347	NSC	STR	
			Borderline Personality…	9299-9211	NSC	STR	
			PTSD	9411	NSC	STR	
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 0	
RATING:  10%	RATING:  None	
*Derived from VA Rating Decision (VARD) dated 20050831 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Right Foot (Right lower extremity [RLE] Pain).  In August 1999, this CI stepped in a pothole and injured her RLE.  Nine months later, in May 2000, she suffered a re-injury while playing basketball.  Magnetic resonance imaging showed an osteochondral lesion at the base of the navicular bone, and a flattened dome of the talus.  The flattened talar dome was felt to possibly suggest a stress fracture.  It was determined that she was not a surgical candidate.  She was treated with activity modification and other conservative measures.  However, in spite of all treatment efforts, her pain persisted.

On 8 March 2001, the CI was evaluated by orthopedics.  She reported that her RLE pain was constant, and was worse with activity.  She had pain with walking, and the pain limited her activity.  On physical exam of the right foot and ankle, there were some areas of tenderness to palpation (TTP).  She was able to raise up on her right toes.  Anterior and posterior drawer sign was negative, and talar tilt was negative.  There was full active range-of-motion (ROM) at the ankle, muscle strength was normal and mild spurring at the talo-navicular joint.  The examiner’s diagnostic assessment was:  “Right talo-navicular joint pain.”  He instructed her to follow-up as needed.

The Board carefully reviewed all available evidence.  The CI had a VA Compensation and Pension (C&P) exam on 9 February 2010 (8 years after separation).  However, the Board did not find evidence of a C&P exam that was temporally proximal to the CI’s separation from service in November 2001.

The Board directed attention to its rating recommendation based on the evidence.  As noted above, there was no VA C&P exam that was temporally proximal to the CI’s separation.  The March 2001 orthopedic exam was 8 months prior to separation.  At that exam, right ankle ROM was normal.  However, she had pain with walking, and the pain limited her activity.  IAW the VASRD §4.10 (functional impairment), §4.40 (functional loss), §4.45 (the joints), and §4.59 (painful motion), when part of the musculoskeletal system becomes painful on use, it must be regarded as seriously disabled.  A 10% rating is warranted when there is satisfactory evidence of functional loss due to painful motion.  There was no path to a higher rating, since there was insufficient evidence of a seriously crippling bone or joint abnormality that would justify a higher rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board found insufficient cause to recommend a change in the PEB adjudication of the right foot pain (right lower extremity pain).

Myofascial Abdominal Pain with Psychological Factors.  In September 2000, this CI developed abdominal pain, after being kicked in the abdomen during a military training event.  She was suspected of having pancreatitis, but testing showed negative results.  After extensive medical evaluation and testing, there was no intra-abdominal pathology to explain her pain.  It was determined that her pain was myofascial pain of the abdominal wall.  She was treated with medication, physical therapy, and electro acupuncture.  In spite of all treatment efforts, her pain persisted and an MEB was initiated.  The MEB narrative summary (NARSUM) was dated 2 March 2001.  The CI reported that her pain was constant, and was averaging 7/10 in severity.  She was independent in all activities of daily living, but lifting of heavy objects was limited by abdominal pain.  On physical examination (PE), she was in no acute distress.  PE of the abdomen showed some TTP of the right abdominal wall.  This pain increased with abdominal muscle contraction or abdominal stretching.  The NARSUM examiner wrote, “It is expected that this patient’s abdominal pain situation will not improve so as to allow her to return to full unrestricted duty in the United States Army.”

Due to abdominal pain, the CI’s sleep was disrupted.  She was referred to the psychiatric consultation-liaison service (PCLS) for help with relaxation techniques, self-hypnosis, pain management, and coping strategies.  Although she did not meet diagnostic criteria for any major Axis I psychiatric disorder, the PCLS diagnosed her with: “Psychological factors affecting medical condition.”  This diagnosis was listed on DA Form 3947 (MEB Proceedings), and was sent to the PEB for adjudication.  The PEB combined the mental health (MH) diagnosis (“Psychological factors affecting medical condition”) with the abdominal pain, and treated them together as a single unfitting condition.

The Board evaluated whether or not it was appropriate for these two conditions to be “bundled” together.  The Board must determine if the PEB’s approach of combining the two conditions under a single rating was reasonably justified in lieu of separate ratings.  The Board must apply separate ratings in its recommendation if compensable ratings for each condition are achieved IAW the VASRD.  If the Board judges that two or more separate ratings are warranted, however, it must satisfy the requirement that each ‘unbundled’ condition was separately unfitting.

After due deliberation, the Board agreed that the evidence does not support a conclusion that each of the two conditions, separately, would have rendered the CI unable to perform her required military duties.  Specifically, the Board determined that the MH condition did not constitute a separately unfitting condition, for disability rating purposes.  There was not sufficient evidence in the record that the MH condition caused significant interference with satisfactory duty performance.  Therefore, the Board does not recommend a separate disability rating for the psychological factors.  The Board determined that it is appropriate for the myofascial abdominal wall pain to be bundled with or subsumes the psychological factors, and treated as a single unfitting condition.

The CI was medically separated from service on 28 November 2001.  The unfitting abdominal wall pain with psychological factors was coded 5099-5021 (analogous to myositis), and rated at 0%.  After separation, the CI filed a VA disability claim that was received by the VA on 29 October 2004.  A VARD was issued on 31 August 2005.  Service-connection for abdominal pain due to chronic pancreatitis was denied.  The Board carefully reviewed all available evidence.  The CI had a VA C&P exam on 9 February 2010 (8 years after separation).  However, the Board did not find evidence of a C&P exam that was temporally proximal to the CI’s separation from service in November 2001 as noted above.

The Board directed attention to its rating recommendation based on the above evidence.  The Board determined that the abdominal wall pain was not insignificant.  It did cause loss of power and lack of usefulness of the abdominal muscles.  The pain was exacerbated by strenuous abdominal activity.  IAW VASRD §4.10 (functional impairment), §4.40 (functional loss), §4.56 (evaluation of muscle disabilities, and §4.73 (schedule of ratings – muscle injuries), the unfitting abdominal pain condition would best be described as “moderate.”  There was not sufficient evidence in the record to support classifying her muscle injury as “moderately severe.”  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 unfitting myofascial abdominal pain with the subsumed psychological factors.  It should be coded 5319 (Group XIX. function:  support and compression of abdominal wall…) and IAW VASRD §4.56 and §4.73, meets criteria for a 10% rating.

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 right foot pain and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the myofascial abdominal wall pain with psychological factors and IAW VASRD §4.56 and §4.73, the Board unanimously recommends a disability rating of 10%, coded 5319.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  The Board, therefore, recommends that the CI’s prior determination be modified as follows, effective as of the date of her prior medical separation:

CONDITION	VASRD CODE	RATING	
Right Foot Pain	5284	10%	
Myofascial Abdominal Pain with Psychological Factors	5319	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140521, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB									20 March 2020	

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 XXXXXXXXXXXXXXXXXXXX, AR20150018410 (PD201402353)

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:

CF: 
(  ) DoD PDBR
(  ) DVA