RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03282
BRANCH OF SERVICE:  Army  	SEPARATION DATE:  20051215

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an activated Reserve E-5 (Military Police) medically separated for a neck condition, rated at 10%. 

CI CONTENTION:  The applicant requests the Board consider all conditions.  Her 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 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 20051123	VA* - (~1 day Pre-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Neck	5237	10%	Cervical Spine Herniated Disc	5243	20%	20051214	
Bilateral Knee Pain	5003	EPTS	Chondromalacia w/Mild Arthritis, Right Knee	5010	10%	20051214	
			Chondromalacia w/Mild Arthritis, Left Knee s/p Arthroscopic Surgery	5010	10%	20051214	
Left Foot Pain	5099-5003	EPTS	Non Union 5th Metatarsal s/p Bunionectomy w/Osteotomy	5283	10%	20051214	
Hypothyroidism	Not Unfitting	Hypothyroidism	7903	10%	20051214	
Migraine Headaches	Not Unfitting	Migraine Headaches	8100	30%	20051214	
Positive Rheumatoid Factor	Not Unfitting	Positive Rheumatoid Factor	5002	NSC	20051214	
Endometriosis/Abdominal Pain	Not Unfitting	Endometriosis/Abdominal Pain 	7629	NSC	20051214	
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 2 	
RATING:  10%	RATING:  80%	
*Derived from VA Rating Decision (VARD) dated 20060821 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY:  The Physical Evaluation Board (PEB) combined the right and left knee conditions under a single disability rating, coded 5003.  Although VASRD §4.71a permits combined ratings of two or more joints under 5003, it allows separate ratings for separately compensable joints.  The Board must follow suit (IAW DoDI 6040.44) if the PEB combined adjudication is not compliant with the latter stipulation, provided that each ‘unbundled’ condition can be reasonably justified as separately unfitting in order to remain eligible for Service rating.  If the members judge that separately ratable conditions are justified by performance based fitness criteria and indicated IAW VASRD §4.7 (higher of two evaluations), separate ratings are recommended; with the stipulation that the result may not be lower than the overall combined rating from the PEB.  The Board’s initial charge in this case was therefore directed at determining if the PEB’s combined adjudication was justified in lieu of separate ratings.

Neck Condition.  The service treatment record (STR) documents that the CI sustained a neck injury in a self-defense class prior to unit deployment.  A cervical spine X-ray was unremarkable.  A physical therapy (PT) encounter recorded that a prior cervical MRI showed a C5-C6 disc bulge without neural impingement.  The neurological exam documented slightly diminished sensation in the left C7 distribution.  The assessment listed discogenic cervical pain with a C7 radiculopathy (irritation or injury of a nerve root) and the CI was treated with manual cervical traction.  At a PT follow-up, the CI complained of a right neck pain aggravation while carrying her ruck and work equipment.  The physical exam revealed tenderness and spasm of the right levator scapulae muscle.  There was good cervical segmental movement and range-of-motion (ROM) was WNL (within normal limits) for flexion and extension.  There was pain with ROM and right rotation and left side bending were both decreased by 25%.  Bilateral upper extremity strength was normal.  A cervical spine MRI showed a broad based disc bulge at C5-C6 resulting in mild to moderate left nerve root opening (neural foramen) and central spinal canal stenosis (narrowing).  The narrative summary (NARSUM) referred to the orthopedic surgery addendum for the MEB regarding musculoskeletal complaints.  The orthopedic surgery MEB addendum for the neck recounted the history and interventions.  The CI complained of neck pain with associated bilateral posterior arm pain (L>R) and bilateral fingers tingling (L>R).  She had not had symptomatic relief from PT (6 weeks) and the epidural steroid injections (two of three scheduled complete) provided only minimal and transient relief.  The CI took Naprosyn, a nonsteroidal anti-inflammatory drug (NSAID) for pain relief.  The MEB addendum documented the findings from the orthopedic exam performed 5 weeks earlier.  The neck exam revealed diffuse cervical spine tenderness.  The goniometer measured ROM was flexion to 40 degrees (45 normal) and the balance listed “There was full bending and extension of the neck.”  The Spurling’s test (assesses cervical nerve root compression by a herniated disc) and Waddell’s (0/5) signs (psychogenic, or nonorganic, manifestations of pain) were negative.  Strength, sensation, and deep tendon reflexes (DTRs) were normal.  The diagnosis listed C5-C6 disc herniation.  The compensation and pension (C&P) exam, 1 day before separation, recounted the history and interventions.  The CI complained of constant neck pain with associated stiffness, neck spasms, upper extremity weakness (L>R), and radicular symptoms (paresthesias in both upper arms with a tingling sensation in the last three fingers on both hands).  Her daily medications included NSAIDs (Toradol and Relafen) and a muscle relaxant (Robaxin).  She reported flare-ups with 7/10 pain which made it difficult to turn her head.  Flare-ups occurred upon awakening, were exacerbated by movement and jerking motions, and were relieved with heat and a combination opioid/acetaminophen analgesic (Darvocet).  The CI reported incapacitating episodes 5 times over the past 12 months requiring bed rest as a result of her neck condition.  She did not use a cervical collar.  The physical exam revealed a normal posture, her gait favoring the left leg, and no upper extremity atrophy.  The neck exam revealed left cervical paraspinal and bilateral upper trapezius tenderness.  There was no warmth, erythema (redness), swelling, effusion (fluid collection), or discoloration.  The pain limited cervical spine ROM was flexion to 15 (normal=45), extension to 25 (normal=45), bilateral lateral flexion to 30 (normal=45) and bilateral rotation to 60 degrees (normal=80).  The ROM was not additionally limited by pain, fatigability, weakness, or lack of endurance following repetitive use.  The strength, sensation, and DTRs were normal and there were no pathologic reflexes.  A cervical spine X-ray showed mild degenerative disease.  The diagnosis listed C5-C6 broad based disc bulge with mild to moderate left neural foraminal narrowing.  A C&P exam, 18 months after separation, documented full cervical spine ROM of flexion to 45, extension to 45, bilateral lateral flexion to 40, and bilateral rotation to 80 degrees.  

The Board directed attention to its rating recommendation based on the above evidence.  The Informal PEB rated the neck condition 10%, coded 5237 (cervical strain).  The PEB cited neck injury, multi-level degenerative disc disease by imaging, continued pain despite epidural steroids, paraspinal muscle tenderness, no muscular spasm, no loss of spinal motion, and no radiculopathy.  The VA rating decision (VARD), citing the C&P exam 1 day before separation, rated the neck condition 20% coded 5243 (intervertebral disc syndrome).  The VARD cited neck pain following self-defense class, broad C5-C6 disc bulge with mild to moderate left neural foraminal narrowing by imaging, mild degenerative disc disease by X-ray, neck pain, pain with ROM, reduced ROM, and no additional loss of ROM on repetitive use.  The ROM in the MEB exam was consistent with a 10% rating.  The ROM in the second C&P exam did not attain the minimum 10% rating based upon the general rating formula for diseases and injuries of the spine.  The higher 10% rating would require flexion of greater than 30 degrees but not greater than 40 degrees; or a combined ROM of greater than 170 degrees but not greater than 335 degrees of the cervical spine.  While the ROM in the first C&P exam was at the threshold of the 30% rating with flexion of 15 degrees (flexion of 15 degrees or less; or favorable ankylosis of the cervical spine), the combined ROM was consistent with the 10% rating.  With this exam cited in evidence, the VA assigned a 20% rating.  However, the Board assigned more probative value to the orthopedic surgery MEB exam because it documented ROM measurements with a goniometer and recognized that the normal second C&P exam followed a period of convalescence.  While the CI may have suffered additional pain from the nerve involvement, this is subsumed under the general spine rating criteria, which specifically states “with or without symptoms such as pain (whether or not it radiates).”  The critical decision is whether or not there was significant motor weakness which would impact military occupation specific activities.  There was no evidence that motor weakness or sensory loss existed to any degree that could be described as functionally impairing.  The Board therefore concluded that an additional disability rating was not justified on this basis.  Other routes to a rating higher than a 10% were considered, but there was no evidence of incapacitating episodes that would justify a minimum rating under the alternative formula for rating intervertebral disk disease.  While the CI claimed five incapacitating episodes requiring bed rest, and there were multiple individual sick slips for quarters, only two were related to neck pain.  While the first C&P exam documented a gait favoring the left leg, this was secondary to knee and foot pathology.  While the exams documented cervical spine tenderness, they did not document muscle spasms.  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 neck condition. 

Bilateral Knee Condition (See analysis above).  The STR documents that the CI fell from a tree and injured her right anterior cruciate ligament (ACL) 3 years before mobilization.  She underwent a right ACL reconstruction with an allograft (cadaver tissue transplant).  The following year she had a subsequent right knee arthroscopy.  Five months after mobilization, the CI presented to primary care complaining of 2 weeks of right knee pain.  She reported she “was mopping when felt pop in R knee & has pain since that time.”  The CI complained that her right knee had “given out” twice since she felt the pop.  The right knee exam revealed no effusion (fluid collection), crepitus (grating sound or sensation), or deformity.  The drawer (assesses anterior/posterior cruciate ligaments [ACL/PCL]) and McMurray (assesses menisci) tests were negative.  An orthopedic surgery exam documented that the left knee was unremarkable.  The right knee exam revealed tenderness on the undersurface of the patella and diffusely in the posteromedial knee.  There was no effusion and ROM was 0-130 degrees (0-140 normal).  The drawer, Lachman (assesses ACL), pivot shift (assesses ACL), and valgus/varus stress (assesses medial/lateral collateral ligaments [MCL/LCL]) tests were negative.  The diagnosis listed chronic right knee pain status post ACL repair.  At an aid station encounter the CI complained of insidious onset of posterior 8/10 right knee pain.  The physical exam revealed a normal gait.  The right knee exam revealed edema (swelling), effusion, erythema (redness), and warmth without deformity.  There was tenderness at the medial joint line, MCL, and patella tendon.  The ROM was full.  Patella grind (assesses abnormal patellar movement and painful crepitation), Lachman (soft endpoints), and McMurray tests were positive.  Patella apprehension (apprehension or pain on quadriceps contraction with patella displaced), posterior sag (assesses PCL), Obers (assesses iliotibial band), drawer, and pivot shift tests were negative.  The assessment listed retropatellar pain syndrome ([RPPS] symptom complex of anterior knee pain involving the patella) with prior history of ACL repair and degenerative joint disease (DJD).  The Orthopedic surgery MEB addendum for the knees documented the pre-mobilization right knee surgeries.  It also documented bilateral knee arthroscopies, 8 to 9 months prior to the addendum, which revealed significant chondromalacia (abnormal cartilage softening or degeneration).  The CI complained of bilateral knee pain that was equal, marked, and constant.  She reported associated swelling and some symptoms of giving way.  The CI denied using bracing, infections, or locking.  The right knee exam revealed a well healed incision with no effusion.  There was medial and lateral joint line tenderness and mild patellofemoral crepitus.  The goniometer measured ROM was flexion to 130 (140 normal) and extension to 0 degrees (0 normal).  Patella grind was positive and Lachman was 1+ (Grade 1: < 5 mm).  McMurray and valgus/varus stress tests were negative.  The left knee exam revealed medial and lateral joint line tenderness and mild crepitus with no effusion.  The goniometer measured ROM was flexion to 130 and extension to 0 degrees.  Lachman, McMurray, and valgus/varus stress tests were negative.  Strength, sensation, and DTRs were normal.  The bilateral knee X-rays showed mild DJD with right knee surgical hardware in place.  The diagnosis listed early DJD of the bilateral knees.  The Orthopedic surgeon planned to inject Synvisc (synthetic synovial [joint] fluid) into the bilateral knees to help relieve the pain.  The examiner opined that the CI had received maximal medical care from the orthopedic standpoint, no further treatment (except Synvisc) was warranted and the prognosis for further recovery as a civilian was equivocal.  The C&P exam recounted the history and interventions.  The CI complained of constant knee pain with associated stiffness, cracking, popping and giveaway.  She denied dislocation or recurrent subluxation of either knee.  Her daily medications included NSAIDs (Toradol and Relafen) which helped with the swelling and made the pain tolerable.  She reported flare-ups with 7-8/10 pain.  Pain was exacerbated by prolonged standing and relieved by staying off her feet and medications.  The CI was able to tolerate and function with the pain.  She reported the use of braces on both knees at night or with increased swelling.  The physical exam revealed a normal posture with her gait favoring the left leg.  She had a normal heel walk and tandem walk, but limped with the left leg on toe walk.  The CI used no mechanical aids for ambulation and there was no atrophy of the lower extremities.  The bilateral knee exam revealed medial, lateral, and patellar tendon tenderness and crepitus.  There was no warmth, erythema, swelling, effusion, or discoloration.  The bilateral knee ROM was flexion to 140 and extension to 0 degrees with pain.  The ROM was not additionally limited by pain, fatigability, weakness, or lack of endurance following repetitive use.  The strength, sensation, and DTRs were normal and there were no pathologic reflexes.  The right knee X-ray showed mild secondary DJD status post ACL repair and the left knee X-ray was normal.  The diagnosis listed bilateral knee early osteoarthritis.

The Board directed attention to its rating recommendation based on the above evidence.  The Board does not challenge service EPTS determinations, but does exercise the prerogative of assessing the PSA element IAW DoDI 1332.38 (E3.P4.5.2.3 - Presumption of Aggravation).  As previously elaborated, the Board must first consider whether each knee condition remains separately unfitting, having been de-coupled from a combined PEB adjudication.  The Informal PEB determined the bilateral knee condition to be unfitting, coded 5003 (degenerative arthritis), but existed prior to service (EPTS) and was not permanently service aggravated (PSA) and therefore not compensable.  While the MEB and PEB implicated bilateral knees, the vast majority of complaints, pathology, and therapeutic interventions in the STR were related to the right knee.  The Board concluded that the evidence did not provide sufficient grounds for recommending separate knee disability ratings in this case.  The VARD, citing the C&P exam the day before separation rated the right knee 10%, coded 5010 (traumatic arthritis) and rated the left knee 10%, coded 5010.  For the right knee, the VARD cited EPTS, worsened as a result of military service, no deduction was necessary since the preservice percentage was zero, patellofemoral syndrome, the requirement of another surgery during active service, significant chondromalacia and early osteoarthritis diagnosed by arthroscopic surgery, full ROM, painful or limited ROM, and no additional loss of ROM due to pain, fatigue, weakness or incoordination on repetitive use.  For the left knee, the VARD cited patellofemoral syndrome, significant chondromalacia and early osteoarthritis diagnosed by arthroscopic surgery, full ROM, painful or limited ROM, and tenderness.  In accordance with DoDI 1332.38, E3.P4.5.6, (Treatment of Pre-Existing Conditions) “Generally recognized risks associated with treating preexisting conditions shall not be considered service aggravation.”  The board agreed that the surgical residuals, from the service-provided corrective procedures to the EPTS conditions, would not reasonably constitute service aggravation.  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 bilateral knee condition.

Left Foot Condition.  The STR documents a long standing history of bunions (inflammation and enlargement of joint at base of the big toe) and tailor's bunions (inflammation and enlargement of joint at base of the little toe).  Six years before mobilization, the CI underwent a left toe bunion surgery (bunionectomy).  Additionally, she underwent a right tailor’s bunionectomy.  Twenty one months after mobilization, the CI complained of left lateral foot pain along the 5th metatarsal head.  The foot was painful in all types of shoes, particularly in her military boots.  In the informed consent for surgery, the surgeon briefed the potential complications.  These included, but were not limited to, pain, swelling, numbness, loss of fixation, hardware removal, overcorrection, undercorrection, infection, and need for additional surgery.  The CI request operative intervention and consented to the surgery freely.  The physical exam revealed an increased 4th/5th inter-metatarsal angle with increased lateral prominence of the 5th metatarsal head.  A left tailor’s bunionectomy, with an oblique wedge osteotomy (correction of the angulation of the metatarsal by removal of a small wedge of bone), was performed.  A left foot X-ray showed internal fixation of the 5th metatarsal with two surgical screws.  The old fracture appeared to have healed primarily by fibrous union.  The podiatry MEB addendum for the left foot documented that 3 months following the surgery, the CI complained of increased left foot pain with activities.  The CI was placed back into a cast for 2 months and placed on a permanent profile for a left foot non-healing osteotomy (surgical procedure where bone is cut or excised to shorten, lengthen, or realign).  The CI continued to complain of 6/10 left lateral foot pain.  The left lower extremity exam revealed mild foot edema without erythema or cellulitis (inflammation of subcutaneous connective tissue).  The goniometer measured ankle ROM was dorsiflexion of 30 degrees (20 normal) and plantar flexion of 45 degrees (45 normal).  The left lower extremity neurovascular status and DTRs were normal and there were no pathologic reflexes.  A left foot X-ray showed an adducted fifth metatarsal with two screws across the osteotomy site which was slightly distracted at approximately 2mm.  There was no motion at the osteotomy site under fluoroscopy (continuous real-time X-ray imaging).  The diagnosis listed nonunion left 5th metatarsal.  The podiatrist opined that the CI had exhausted all conservative means of treatment and surgical treatment was not indicated.  The C&P exam recounted the history of a left first metatarsal bunionectomy and the left fifth metatarsal bunionectomy.  The CI complained of constant left lateral foot pain with associated swelling and spasms.  She reported intermittent flare-ups to 7/10 pain.  Pain was exacerbated by prolonged standing and walking and relieved by getting off her feet, elevation, use of a brace, and medication (Motrin and Darvocet).  The CI denied a history of osteomyelitis (infection/inflammation of bone or bone marrow) or current use of a foot brace or other external device.  The physical exam revealed a normal posture with her gait favoring the left leg.  She had a normal heel walk and tandem walk, but limped with the left leg on toe walk.  The CI used no mechanical aids for ambulation and there was no atrophy of the lower extremities.  The left lower extremity exam revealed full ankle ROM without pain.  The left foot ROM was not additionally limited by pain, fatigability, weakness, or lack of endurance following repetitive use.  The left foot exam revealed mild first metatarsophalangeal joint prominence and fifth metatarsal tenderness and guarding.  There was no warmth, erythema, swelling, effusion, or discoloration.  There was no callus on the foot and the longitudinal arch was normal.  There was slightly decreased strength on resistance to the 1st and 5th toes on the left compared with right.  A left foot X-ray showed nonunion of the fifth metatarsal, internal fixation screws, and a heel (calcaneal) spur.  The diagnosis listed nonunion of the left 5th metatarsal status post bunionectomy.

The Board directed attention to its rating recommendation based on the above evidence.  The Board does not challenge service EPTS determinations, but does exercise the prerogative of assessing the PSA element IAW DoDI 1332.38 (E3.P4.5.2.3 - Presumption of Aggravation).  The Informal PEB determined the left foot condition to be unfitting, coded 5099-5003 (rating by analogy-degenerative arthritis).  The PEB cited left foot pain due to nonunion of 5th metatarsal osteotomy, status post surgery for EPTS condition, natural progression of condition, existed prior to mobilization and was not permanently service aggravated.  The VARD rated the left foot condition 10%, coded 5283 (metatarsal bones malunion/nonunion of).  The VARD cited nonunion of 5th metatarsal by X-ray, status post bunionectomy with osteotomy, directly related to military service, continued pain, and no increased warmth, erythema, swelling or effusion.  In accordance with DoDI 1332.38, E3.P4.5.6, (Treatment of Pre-Existing Conditions) “Generally recognized risks associated with treating preexisting conditions shall not be considered service aggravation.”  The board agreed that the surgical residuals, from the service-provided corrective procedures to the EPTS condition, would not reasonably constitute service aggravation.  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 left foot condition.

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the endometriosis/abdominal pain, migraine headaches, hypothyroidism, and positive rheumatoid factor were not unfitting.  The Board’s threshold for countering 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.  

Contended Endometriosis/Abdominal Pain.  The STR documents that the CI had recurrent abdominal pain and a symptomatic left pelvic mass.  She underwent diagnostic laparoscopy which revealed peritoneal cysts and pelvic adhesive disease.  The gynecologist resected the approximately eight separate free-floating, fluid-filled, peritoneal cysts and performed a lysis of adhesions.  The left ovary had a small follicular cyst (normal) and the right ovary appeared normal.  The operative report contained no comments regarding endometriosis.  Fourteen months later, a transabdominal/transvaginal pelvic ultrasound showed bilateral ovarian cysts.  The radiologist opined these were most likely functional (normal) cysts in a pre-menopausal female.  The gynecology MEB addendum for ovarian cysts recounted a history of multiple ovarian cysts.  The CI complained of 5/10 abdominal pain and reported her premenstrual pain had significantly improved since beginning an oral contraceptive (Ortho-Evra) 9 months prior.  The pelvic and rectovaginal exams were unremarkable.  A pelvic ultrasound showed a moderate amount of fluid, a normal uterus, and normal ovaries without cysts.  The assessment listed resolved ovarian cyst.  They gynecologist opined that the pain was physiologic in etiology, her condition was stable, her prognosis was good, her gynecological condition should not impact her performance of duty and no further treatment was required from the gynecological standpoint.  The NARSUM referred to the consultation by gynecology.  The diagnosis listed endometriosis, abdominal pain, and ovarian cyst which met retention standards.  While the endometriosis/abdominal pain was profiled, it was not implicated in the commander’s statement, met retention standards by the MEB and was considered to be not unfitting by the PEB.

Contended Migraine Headaches.  The STR documents a history of recurrent headaches.  A neurology consultation reported the CI complained of occipital headaches beginning with a neck injury during training.  She had previously been treated by a civilian neurologist with a decrease in frequency from two headaches per week to two per month with a preventative medication (Topamax).  She reported an increase in headaches with associated nausea, vomiting, light, sound, and smell sensitivity.  The CI reported some relief with an abortive medication (Imitrex) but presented to the emergency room on many occasions when headaches persisted.  She was taking Topamax for preventing headaches, oral Imitrex for aborting headaches, Lexapro for depression and Trazodone for sleep.  The neurological exam was unremarkable.  The assessment listed common migraine complicated by likely analgesic (Imitrex) rebound headaches.  The examiner opined that the CI would benefit from a single preventive medication (Nortriptyline) that would address headaches, depression and sleep.  The Neurologist recommended a steroid burst with taper (prednisone 60/40/20/10 every 3 days), injectable Imitrex infrequently for severe headaches, and released the CI without limitations.  The NARSUM referred to the consultation by neurology and that the CI had been released without limitations.  It documented that a brain MRI was unremarkable except for left maxillary sinusitis.  The diagnosis listed migraine headaches which met retention standards.  The migraine condition was profiled P2 (met retention standards) and was not implicated in the commander’s statement and was considered to be not unfitting by the PEB.

Contended Hypothyroidism.  The STR documents that the CI was diagnosed with hypothyroidism and started on thyroid hormone (Synthroid) replacement.  The endocrinology consultation documented that the CI had thyroid labs consistent with hypothyroidism (elevated thyroid stimulating hormone [TSH] and low free thyroxine [FT4]) and chronic autoimmune (Hashimoto’s) thyroiditis (elevated thyroid peroxidase [TPO] antibodies).  The endocrinologist opined that there was no need for a MEB for hypothyroidism as the CI was on appropriate replacement treatment and surveillance and was clinically normal (euthyroid).  The NARSUM referred to the consultation by endocrinology.  The diagnosis listed hypothyroidism which met retention standards (P2 profile), was not implicated in the commander’s statement and was considered to be not unfitting by the PEB.

Contended Positive Rheumatoid Factor.  The Service treatment record (STR) documents an isolated finding of a slightly elevated rheumatoid factor (RF) lab with a value of 22 international units per milliliter (normal is less than 20).  The NARSUM listed the diagnosis of positive RF test which met retention standards.  

All contended conditions were reviewed and considered by the Board.  There was no performance based evidence from the record that any of these conditions significantly interfered with satisfactory duty performance.  The Board determined that the preponderance of evidence indicated that these conditions were not unfitting for continued military service.  After due deliberation, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determinations for the endometriosis/abdominal pain, migraine headaches, hypothyroidism, and positive rheumatoid factor conditions and so no additional disability ratings are recommended.

BOARD FINDINGS:  In the matter of the neck condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the bilateral knee condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the left foot condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended endometriosis/abdominal pain, migraine headaches, hypothyroidism, and positive rheumatoid factor 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.  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 20140604, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR Commander, US Army Physical Disability Agency (AHRC-00), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXXXXXXXX AR20160004511 (PD201403282)

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