RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXXX		CASE:  PD-2014-02526
BRANCH OF SERVICE:  Army		SEPARATION DATE:  20040626

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reserve E4, Motor Transport Operator, medically separated for a “chronic atypical chest pain” and “osteoarthritis, thoracic spine and knees” rated 10% and not rated rather existed prior to service (EPTS) and not service aggravated, respectfully, with a combined disability rating of 10%.

CI CONTENTION:  “Consider all conditions found unfitting and not unfitting by the Physical Evaluation Board.”  The CI’s 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 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 - 20040524	VARD - 20050708	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Atypical Chest Pain	5099-5003	10%	Heart Condition	7005	NSC	STR	
Osteoarthritis, Thoracic Spine and Knees	5003	---%	Arthritis Thoracic Spine	5242	0%	STR	
			Patellofemoral Pain Syndrome, Left Knee	5299-5260	10%	20050418	
			Patellofemoral Pain Syndrome, Left Knee	5299-5260	10%	20050418	
Hypertension, Controlled	Not Unfitting	Hypertension	7101	NSC	STR	
COMBINED RATING:  10%	COMBINED RATING FOR ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:

Atypical Chest Pain. The service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM) documented a March 2004 onset of chest pain and palpitations in Kuwait (2 months after activation for the deployment).  This resulted in medical evacuation and an extensive evaluation.  The latter included multiple specialty consultations with heart monitoring (Holter), imaging (cardiac ECHO), stress test (described as normal, no available documentation for METs [metabolic equivalents of task]), cardiac catheterization, and electrophysiologic studies (bilateral upper extremity EMGs) for associated arm pain.  No pathology or specific etiology was identified.  The symptoms persisted despite trials of various medications and continued to interfere with duties.  The outpatient STR evidence probative to rating was consistent with that related by the NARSUM.  The MEB NARSUM was conducted 3 May 2004 (7 weeks prior to separation) and documented daily episodes of chest pain “even at rest” which was “frequent ... and slight” with occasional palpitations.  No specific functional limitations were elaborated.  The NARSUM physical examination was normal, although the examiner mentioned a previous finding of chest wall tenderness.  

The CI failed to report for a scheduled VA Compensation and Pension (C&P) examination, and there is no probative post-separation evidence other than a stress test conducted by the VA on 16 December 2004 (6 months post-separation) which was normal with an exercise tolerance of 7 METs.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB coded the condition analogously to 5003 (degenerative arthritis) and conferred a 10% rating based on the USAPDA pain policy criterion of “slight/frequent” pain.  The VA coded the condition 7005 for coronary artery disease (not consistent with the findings at catheterization), and denied service connection, stating there was “no medical evidence showing a diagnosed heart condition related to active duty service.”  There is no precise clinical fit for undiagnosed chest pain under any VASRD code.  With the exam finding of tenderness from the service evidence, the PEB’s analogous application of 5003 was not unreasonable.  Given the lack of documentation for painful motion, however, there was no VASRD §4.71a criterion for the minimum 10% rating; and, concession to the PEB’s rating per the USAPDA pain policy was favorable under 5003.  There are a host of codes under VASRD §4.104 for the cardiovascular symptoms (from which the VA’s 7005 was taken) which could be considered as analogous substitutes for the condition; but, these are all based on stress test MET criteria; and, the only available such evidence (7 METs from the VA) does not satisfy 10% criteria for any of them.  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 of the atypical chest pain condition.

Chronic Osteoarthritis, Thoracic Spine and Knees.  Prior to his activation on 3 January 2004 (6 months prior to separation) for the Kuwait deployment, the CI had 3-month periods of active duty in 1984 (basic training) and again in 2003.  His entry physical in 1984 did not document any complaints or diagnosis referable to osteoarthritis (OA).  The administrative file documented a total of nine accredited years of reserve service.  There were several STR entries from the 2003 period of active duty which documented complaints and X-ray findings consistent with OA of both knees, sick slips for same, and a medical assessment from May 2003 which documented “worsening back and knee pain secondary to activity of load bearing equipment.”  There were STR entries from the 2004 mobilization (prior to medical evacuation from Kuwait) which documented complaints of back and knee pain, sick slips, and X-rays of 21 January 2004 (3 weeks after activation) demonstrating OA of the thoracic spine and knees.  There were no outpatient STR entries for OA complaints in the interval after medical evacuation prior to separation.  There was a temporary L2 profile for “degenerative joint disease” of the upper back and both knees issued February 2004 (2 weeks after activation).  The commander’s performance statement from May 2005 referenced only the chest pain complaints without mention of orthopedic conditions or limitations.  There was no STR evidence for significant range of motion (ROM) limitation (spine or knees), gait disturbance or other significant functional limitations, associated radicular symptoms or positive neurological findings, or significant knee joint findings other than tenderness (no effusions, instability, or meniscal impingement).

The NARSUM stated only, “He has generalized joint pains including back pains and takes Vioxx [anti-inflammatory] for this.”  There was no further elaboration or mention of the condition(s).  The only probative physical examination evidence was grossly normal neurological testing.  The diagnosis “degenerative arthritis (osteoarthritis) thoracic spine and knees,” however, was forwarded on the MEB’s DA Form 3947 as a medically unacceptable condition.

Although the CI did not present for his initially scheduled VA C&P examinations and there was no temporally probative post-separation evidence for the thoracic spine, a later VA examination for a claim of bilateral knee conditions was conducted 14 April 2005 (10 months after separation).  This documented an atraumatic onset in 2001 (a 2007 VA examination documented the same date of onset for the thoracic spine) which was attributed to “physical activity while in the Army” (the Board noting that the onset was not temporally correlated with a period of active duty).   The examiner noted near constant pain causing “difficulty in bending or stooping ... [which] ... did not result in any time lost from work.”  The physical examination recorded bilateral findings of “slight instability” in all planes with effusion (X-rays from the same day commented on the bilateral absence of effusion) and crepitus; although, gait was documented as normal, and bilateral measured ROM was normal (flexion to 140 degrees for each knee, with pain only at end-excursion).

The Board directed attention to its recommendation based on the above evidence.  The Board’s first charge is an assessment of the PEB’s determination that the condition(s) existed prior to service (EPTS) without permanent service aggravation (PSA), and were thereby not eligible for service rating.  The PEB’s DA Form 199 decision cited the pre-existence of positive X-ray findings prior to the 2004 activation for concluding that the OA condition was EPTS; and, both the VA histories of onset and the 2003 STR evidence are further support for a reliable conclusion that the OA was a chronic condition preceding either of the later periods of active duty.  The Board, however, must also assess the PEB’s conclusion that there was no PSA “beyond natural progression” as stated in the DA Form 199.  The Board’s assessment of PSA is derived from the DoDI 1332.38 (E3.P4.5.2.3) presumption of aggravation standard; a presumption that may only be overcome by a preponderance (defined as “greater than 50% probability”) of competent medical evidence and accepted medical principles that the natural progression of a pre-existing condition was unaltered by any consequence of military service.  Although it was conceded that the OA condition was exacerbated by the physical demands of the 2003 and 2004 activations (and logically by the physical requirements of drilling during the few years interspersed between onset and periods of active duty), member consensus was that significant speculation was required to conclude that this resulted in a permanent escalation of the natural progression of OA.  In this regard it was noted that the CI was shielded from persistent rigorous physical activities by both his cardiac and orthopedic profiles during his only protracted activation (2004), and that there was no significant clinical acuity documented in the STR after re-deployment.  The available post-separation VA evidence did not portray significant disability that could not be reasonably expected from the natural progression of chronic OA.  The members’ consensus conclusion therefore was that the presumption of aggravation was overcome by a preponderance of evidence in this case.  After due deliberation in consideration of the totality of the evidence under the above standard, therefore, member consensus was that there was insufficient cause to recommend a change in the PEB’s determination that the OA condition existed prior to service and was not permanently aggravated by service.

Contended Hypertension.  An STR entry from the 2003 activation indicated that the CI’s blood pressure was being monitored.  An entry early in the 2004 activation documented that the CI was being treated for hypertension (Lisinopril).  There were numerous listings of blood pressure throughout the STR with normal readings (sporadic mild elevations), and it was normal at the time of the MEB physical examination.  There was no documentation in the outpatient STR or the NARSUM of any complications or symptoms attributable to the condition.  It was judged to meet retention standards, was not profiled, and was not implicated by the commander.

The Board’s main charge is to assess the fairness of the PEB’s determination that the hypertension was not unfitting.  The Board’s threshold for countering service fitness determinations is higher than the VASRD §4.3 (reasonable doubt) standard used for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  Based on the above facts, members agreed that there was no performance based evidence suggesting that the condition significantly interfered with duty performance.  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 contended hypertension condition and so no additional disability rating is recommended.

BOARD FINDINGS:  In the matter of the atypical chest pain condition and favorably conceding the US Army Physical Disability Agency (USAPDA) pain policy, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the thoracic spine and bilateral knee osteoarthritis condition, the Board by a majority vote recommends no change in the PEB determination that it was not compensable because it existed prior to service and was not permanently aggravated by service.  The single voter for dissent recommended modification and did not elect to submit a minority opinion.  In the matter of the contended hypertension condition, the Board unanimously recommends no change from the PEB determination as not unfitting.  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 20140531, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR Commander

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation
for XXXXXXXXXXXXXXXXXXXXXXX AR20160007509 (PD201402526)

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 and hereby deny the individual's application.
This decision is final. The individual concerned, counsel (if any), and any Members of
Congress who have shown interest in this application have been notified of this decision
by mail.

BY ORDER OF THE SECRETARY OF THE ARMY:

Enclosure

CF:
( ) DoD PDBR
( ) DVA