RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03450
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20050925

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Communication/Navigation/Mission Systems Journeyman, medically separated for “chronic pelvic pain” and “migraine headaches,” rated 10% and 10% respectively, with a combined disability rating of 20%.  

CI CONTENTION:  “Please consider 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 based upon a 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 - 20050808	VARD - 20070104 & 20070421	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Pelvic Pain	7699-7629	10%	Chronic Pelvic Pain	7699-7612	NSC	20060104	
Migraine Headaches	8100	10%	Migraine Headaches	8100	0%	20060104	
Post-Traumatic Stress Disorder (PTSD)…	Cat II; EPTS	Posttraumatic Stress Disorder with Depression	9434-9411	10%	20060104	
Irritable Bowel Syndrome	Cat II; Not Unfitting	Irritable Bowel Syndrome with Gastritis and History of Gastric Ulcers	7307-7319	10%	20060104	
Tobacco Habituation	Cat III; Not Compensable	No VA Placement	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Chronic Pelvic Pain and Irritable Bowel Syndrome.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s pelvic pain condition began without trauma, and potentially following pelvic inflammatory disease.  She had extensive evaluation by Gynecology, without a diagnosis, and laparoscopy was normal.  The CI abdominal pain in December 2003 related to eating.  She had a history of an appendectomy and tubal ligation abdominal surgery as well as the laparoscopy for pelvic pain.  Diagnostic testing showed normal X-rays (abdominal and pelvic).  Colonoscopy and EGD [esophagogastroduodenoscopy - endoscopic examination of the esophagus, stomach and duodenum] documented findings of ileitis and a full stomach.  Surgical specialists indicated a provisional diagnosis of irritable bowel syndrome (IBS).  

OB/GYN clinical note dated 25 February 2005, 7 months prior to separation, indicated that the CI had long-standing pelvic pain and dyspareunia (painful intercourse) with exam findings of multiple internal trigger points.  The specialist recommended physical therapy with trigger point injections.  Despite treatment, the pelvic pain condition could not be adequately treated to meet the physical requirements of the CI’s military specialty and the CI was referred for an MEB.  The MEB forwarded “pelvic pain and IBS” (as a single condition) for PEB adjudication.  

The MEB NARSUM examination on 11 April 2005, 6 months prior to separation, noted complaints of chronic pelvic pain, with pain worsening around her menses to being incapacitating.  She was not able to run or perform crunches at any time.  Dietary modification and stress management had provided come relief of the IBS symptoms.  Physical examination showed a normal abdominal examination.  

The commander’s comments dated 24 May 2005, indicated there were times the CI was unable to function, was “placed on quarters on a regular basis,” and routine duty “required alteration” (at times).  Supervisor and co-worker statements dated 29 July 2005 indicated continued abdominal/pelvic pain that interfered with duty.  

At the 4 January 2006 VA Compensation and Pension (C&P) evaluation, performed 3 months after separation, the CI reported chronic severe pelvic pain associated with irregular menses that did not respond to regulation with hormones.  Treatment with Midrin was reported as fair.  Regarding IBS, she reported constipation since childhood that worsened in Service.  Stool softeners and fiber were not effective and he had enemas about once a month, without episodes of diarrhea.  Pain was in the left upper quadrant.  Physical examination showed abdominal guarding.  Bowel sounds were normal and there were no masses.  

The Board directed attention to its rating recommendation based on the above evidence.  The Formal PEB (FPEB) separated the MEB condition of “pelvic pain and IBS” into two conditions.  The FPEB rated the chronic pelvic pain condition 10%, coded analogously to 7629 (Endometriosis), citing no pelvic pain diagnosis and general ability to work full duty shifts.  The FPEB adjudged the IBS as not unfitting, coded 7699-7629 (Irritable colon syndrome (spastic colitis, mucous colitis, irritable bowel, etc.).  The VA rated the chronic pelvic pain condition “not service connected (NSC), no diagnosis” coded 7699-7612 (Cervix, disease or injury of), based on the VA C&P examination 3 months after separation, citing pain with no diagnosed disease or diagnosed chronic condition.  The VA also rated the chronic pelvic pain condition 10%, coded 7307-7319 (Gastritis, hypertrophic [identified by gastroscope] - Irritable colon syndrome), based on the VA C&P examination 3 months after separation, citing frequent episodes of bowel disturbance with abdominal distress.  

The Board considered that there were numerous conditions which could potentially overlap with pelvic pain and abdominal pain/IBS (endometriosis rating can include bowel symptoms), and discussed both conditions together.  The Board adjudged that there was insufficient evidence that the CI’s IBS with chronic constipation and episodic upper abdominal pain rose to the level of being separately unfitting.  Given the CI’s history of abdominal surgeries (appendectomy, tubal ligation and laparoscopy) and pelvic inflammatory disease, the Board also considered alternative coding of the pelvic pain analogous to code 7301 (Peritoneum, adhesions of).  However, as there was no evidence of obstruction, any rating under code 7301 would not be higher than the 10% awarded by the PEB.  

There was evidence that the CI had pelvic pain or heavy or irregular bleeding that was not controlled by treatment (possible 30% criteria); however, there was no evidence of endometriosis on laparoscopy.  The Board deliberated if analogous rating using code 7629 was IAW VASRD §4.20 (Analogous ratings), given the note under code 7629 that “Diagnosis of endometriosis must be substantiated by laparoscopy.”  There was no laparoscopically substantiated diagnosis of endometriosis, and the Board majority adjudged that analogous rating using code 7629 for any rating higher than that awarded by the FPEB was not supported.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board majority concluded that there was insufficient cause to recommend a change in the PEB adjudication for the chronic pelvic pain condition.  

Migraine Headaches.  According to the STR and the MEB NARSUM, the CI’s headaches occurred since adolescence.  In 2003 diagnostic imaging (normal brain CT) was performed for new onset headaches awakening the CI from sleep.  An MRI of the head in August 2004, for 2 months of increased headache was normal.  Neurology evaluation in November 2004 diagnosed mixed migraine versus menstrual migraine, with Elavil getting a response.  There were no focal neurologic findings.  Despite treatment, the migraine headache condition could not be adequately treated to meet the physical requirements of the CI’s military specialty and the CI was referred for an MEB.  The MEB forwarded “persistent, incapacitating migraines” for PEB adjudication.  The MEB NARSUM examination on 11 April 2005, 6 months prior to separation, noted complaints of severe and debilitating migraine headaches without relief despite multiple prophylactic medications.  Use of Elavil and Midrin had decreased the frequency of her headaches, but they continued to be debilitating at times.  Physical examination was noncontributory.  

At the 4 January 2006 VA C&P evaluation, performed 3 months after separation, the CI reported migraine headaches occurring every 2-3 days and lasting 24 hours, and being worse during menses.  Treatment was Midrin and Imitrex, and response to treatment was fair.  Physical examination was noncontributory.  The physician’s summary indicated that there was no significant effect on usual occupation from the migraine headaches.  

The Board directed attention to its rating recommendation based on the above evidence.  The FPEB rated the migraine headaches condition 10%, coded 8100 (Migraine), citing two severe migraines in the last 6 months.  The VA rated the migraine headaches condition 0% coded 8100, based on the VA C&P examination 3 months after separation, citing lack of characteristic prostrating attacks averaging one in 2 months over the last several months.  There was insufficient evidence of characteristic prostrating attacks occurring on an average once a month over last several months to warrant any rating higher than that awarded by the FPEB.  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 migraine headaches condition.  

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the PTSD, IBS, and tobacco habituation conditions were not unfitting.  The IBS condition was discussed above with the unfitting pelvic/abdominal pain and adjudged to be not unfitting.  The tobacco habituation is a condition not constituting a physical disability, IAW DoDI 1332.38.  Therefore, the Board has no basis for recommending it as unfitting.  The PTSD condition was not profiled and was not specifically implicated in the commander’s statement.  
The psychiatric NARSUM addendum dated 28 April 2005, 5 months prior to separation, indicated a diagnosis of PTSD with no military or social and industrial impairment.  The psychiatrist indicated that the condition had responded fairly well to medication and therapy and that “this disorder is not considered to make (the CI) unfit for duty.”  There was no performance-based evidence from the record that PTSD significantly interfered with satisfactory duty performance at separation.  After due deliberation, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for any of the contended conditions and so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the chronic pelvic pain condition and IAW VASRD §4.116, the Board majority recommends no change in the PEB adjudication.  The single voter for dissent recommended re-characterization and did not elect to submit a minority opinion.  In the matter of the migraine headaches condition and IAW VASRD §4.124a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended PTSD and IBS 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 20140714, with attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAF/MR

Dear XXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2014-03450.

After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was appropriate.  Accordingly, the Board recommended no re-characterization or modification of your separation.

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding and their conclusion that re-characterization of your separation is not warranted.  Accordingly, I accept their recommendation that your application be denied.

Sincerely,

Attachment:
Record of Proceedings