RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX		CASE:  PD-2014-02546
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070930

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Firefighter) medically separated for an exertional rhabdomyolysis condition.  The condition could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty (MOS) or satisfy physical fitness standards.  She was issued a permanent P3L3 profile and referred for a Medical Evaluation Board (MEB).  The “exertional rhabdomyolysis” “heat intolerance” and “chronic compartment syndrome,” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded five other conditions (adjustment disorder, headaches, allergic rhinitis, iron deficiency anemia, and antiphospholipid syndrome) for PEB adjudication.  The Informal PEB (IPEB) adjudicated “exertional rhabdomyolysis” as unfitting, rated 0%, with application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).   The remaining five conditions were determined to be not unfitting and therefore not ratable.  The CI made no appeals and was medically separated.  

CI CONTENTION:  The CI contends that she was not evaluated for additional conditions.  Her 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 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 20070809	VA* - (~1 Mo. Pre-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Exertional Rhabdomyolysis	7999-7900	0%	Exertional Rhabdomyolysis	5099-5025	20%	20070908	
			Antiphospholipid Syndrome	7799-7714	10%	20070908	
Antiphospholipid Syndrome	Not Unfitting					
Adjustment Disorder	Not Unfitting 	Adjustment Disorder	9327	10%	20070908	
Other MEB/PEB Conditions x 6 (Not In Scope)	Other x 5	
RATING:  0%	RATING:  60%	
*Derived from VA Rating Decision (VARD) dated 20080417 (most proximate to date of separation [DOS]).  
ANALYSIS SUMMARY:  

Exertional Rhabdomyolysis Condition.  The narrative summary (NARSUM) noted the CI began to experience symptoms in June 2006 diagnosed as rhabdomyolysis.  Due to continued symptoms her diagnosis was revised to exertional rhabdomyolysis (rhabdo).  She had recurring weakness, heat intolerance, and generalized pain in upper and lower extremities.  Her symptoms recurred regularly with exertion, high temperature exposures and exercise.  Her legs developed swelling associated with numbness and an aching sensation lasting up to 30 minutes after exercise.  Service treatment records are scarce; however, available record suggests a history of three exercise related rhabdo episodes prior to mid-January 2007.  The record demonstrated elevated creatine kinase value of over 2,000 on three occasions (Nov 2005, Jan 2006, and Jan 2007) with rapid resolution within a few days.  All symptoms resolved after periods of rest and removal from hot environments.  Her condition was treated with Ibuprofen, cyclobenzaprine for spasms, and a muscle relaxant. The CI underwent consultation with Rheumatology to evaluate other causes of her symptoms; however, none were found.  The NARSUM was conducted 29 June 2007, 3 months prior to separation.  Physical examination documented normal range-of-motion (ROM) in all extremities, tenderness on palpation of the arms with normal appearance, absence of thigh deformity and absence of tenderness on palpation of the quadriceps muscle.  The physician documented three separate diagnoses: exertional rhabdomyolysis, heat intolerance, and chronic compartment syndrome.  Her profile allowed no PT training other than own pace and distances, no prolonged standing for greater than 3 minutes, no ACU in hot weather, and no alternate APFT.  

The VA Compensation and Pension (C&P) exam was accomplished 3 weeks prior to separation.  That exam noted the CI was diagnosed with chronic rhabdomyolysis prior to the initiation of the MEB, and that the condition of heat intolerance was “in combination with” her rhabdo.  The examiner documented whenever the CI is exposed to extreme sunlight, she develops problems with generalized aches and pain, especially in the shoulder and the leg.  Physical examination noted absence of pain or stiffness in the extremities; however, muscle tone and strength were not documented.  The examiner recorded diagnoses of exertional rhabdomyolysis and heat intolerance, resolved.  The Board directed attention to its rating recommendation based on the above evidence.  The PEB used the analogous 7900 code (hyperthyroidism) and rated the condition at 0%, citing the “symptoms recur regularly with exertion, high environmental temperatures and military training, and are helped by rest and cooler environment.  No significant residual impairment.”  The PEB combined the conditions of heat intolerance and compartment syndrome with exertional rhabdomyolysis, noting the symptoms of each could not be separated and “doing so would result in pyramiding.”  The Board noted the orthopedic service indicated the condition of compartment syndrome presented symptoms only during time of exercise and heat exposure, and removal from exercise and hot environment relieved the symptoms.  While compartment syndrome in most circumstances could be considered as a separate condition, the Board opined the clinical expression in this case was not distinctly different from the typical presentation of rhabdomyolysis, and therefore, the Board could not find reasonable justification to support a finding that the compartment syndrome could be found separately unfitting.  The Board next discussed the VA’s application of the analogous coding of 5099-5025 (fibromyalgia) for rating the rhabdomyolysis condition.  As noted above, the VA granted a 20% rating.  A rating under this code requires evidence of widespread musculoskeletal pain and tender points, with or without associated fatigue, sleep disturbance, stiffness, paresthesias, headache, irritable bowel symptoms, depression, anxiety, or Raynaud’s-like symptoms.  The 20% rating is for widespread musculoskeletal pain and tender points accompanied by the symptoms such as stiffness, paresthesias, headache, etc., that are episodic and present more than one third of the time.  A 10% rating under the 7900 and 5025 codes requires continuous use of medication for control of the condition.   The Board undertook a careful review of the record in evidence.  The record documents three episodes of rhabdomyolysis, the first in November 2005, and last recorded episode in January 2007.  The CI’s episodes consists of weakness, heat intolerance and generalized muscle pains associated with exposure to heat and resolved after periods of rest and withdrawal from heat.  The rheumatologist opined that the condition was not consistent with a diagnosis of inflammatory myositis, and the physical examination (5 months prior to separation) documented the presence of 2 out of 18 fibromyalgia syndrome tender points.  Joint stiffness, swelling or tenderness was not documented, and ROM was full in the shoulder, neck, wrist, fingers, hips, and knees.  There was no documentation of frequent headaches, or evidence of significant mood and anxiety symptoms related to exertional rhabdomyolysis.   All Board members agreed there is no evidence to support the use of this code.  Furthermore, there is no benefit to the CI in rating the condition under this code since the record provided no evidence that the condition was refractory to therapy (symptoms resolved on removal from heat or with rest) or that the symptoms were present more than a third of the time.  The records indicated last prescribed pain medication occurred 5 months prior to separation (Ibuprophen, and flexeril).  The Board could not find justification for considering a rating under any of the muscle codes since there was no residual impairment.  There were no examination findings supporting a higher rating using this code.  There was no path to coding higher than a 0% rating level.  The Board opined that the heat intolerance and chronic compartment syndrome conditions were an integral component of the rhabdomyolysis and could not be recommended for additional rating IAW VASRD 4.14 (avoidance of pyramiding).  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 for the rhabdomyolysis condition.  

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the conditions of adjustment disorder with disturbance of emotions and antiphospholipid syndrome were not unfitting.  The Board’s threshold for countering fitness determinations requires a preponderance of evidence, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  The Board reviewed mental health records and agreed that evidence of the record reflected minimal mental health related symptoms during 2007 leading into the time of the MEB.  The mental status examination conducted 2 months prior to separation, was normal.  The CI attributed the majority of her psychological symptoms to her physical condition. There was no indication that any psychotropic medication was prescribed other than a one-month prescription for Ambien 6 months before separation.  The Board next considered the antiphospholipid syndrome condition of hypercoagulable state and noted the oncologist opined that there was insufficient evidence to support a recommendation for empiric lifelong anticoagulation, and implementation of anticoagulation therapy was not documented.  The record did not demonstrate any medical complications related to this condition.  The above noted conditions were not profiled or implicated in the commander’s statement and were not judged to fail retention standards.  There was no performance based evidence from the record that either condition, in and of itself, significantly interfered with satisfactory 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 any of the adjustment disorder and antiphospholipid syndrome conditions and so no additional disability ratings are recommended.

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 Rhabdomyolysis condition and IAW VASRD §4.104, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended adjustment disorder with disturbance of emotions, and antiphospholipid syndrome conditions, the Board unanimously recommends no change from the PEB determinations as not unfitting.  There were no other conditions within the Board’s scope of review for consideration.  

RECOMMENDATION:  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 20140528, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB

28 JUL 2016

MEMORANDUM FOR Commander

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation
for XXXXXXXXXXXXXXXXXXXX, AR20160003418 (PD201402546)

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