RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03541
BRANCH OF SERVICE:  Army 	
DATE PLACED ON TDRL:  20040225	
DATE REMOVED FROM TDRL:  20070625

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reserve E4, Motor Transportation Operator, medically separated from the Temporary Disability Retired List (TDRL) for “hypertrophic cardiomyopathy” and “chronic low back pain,” rated 10% and 0%, respectively, with a combined disability rating of 10%.

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 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 – 20040122/20070504	VARD - 20040317	
Condition	Code	Rating	Condition	Code	Rating
Proximate	
		TDRL
Placement	TDRL Removal			TDRL
Placement	TDRL
Removal	
Hypertrophic Cardiomyopathy	7020	60%	10%	Hypertensive Cardiomyopathy	7007	NSC	NSC	
Chronic Low Back Pain	5299-5237	10%	0%	Degenerative Joint Disease, Thoracolumbar Spine	5242	20%	20%	
COMBINED RATING:  60% → 10%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Hypertrophic Cardiomyopathy.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI was noted to have an abnormal electrocardiogram (EKG) at his physical, prior to activation in 2003.  No further work-up was accomplished at that time and he was deployed to Southwest Asia.  On 26 June 2003, he had a cardiac evaluation which included an echocardiogram and a cardiac catheterization.  He was diagnosed with hypertrophic cardiomyopathy (HCM), a pathological enlargement of the heart muscle.  The ejection fraction was over 65%.  This condition was noted to exist prior to service (EPTS) without service aggravation.  However, the CI had greater than 8 years of active service, EPTS is irrelevant, in accordance with 10 USC 1207a.  Despite treatment, the hypertrophic cardiomyopathy condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for MEB.  The MEB forwarded “hypertrophic cardiomyopathy” for PEB adjudication. 

The MEB NARSUM examination on 26 August 2003 (6 months prior to separation) noted complaints of chest pain, with specific correlation to the amount of stress he is experiencing at the time of exertion.  During the cardiology addendum on 26 June 2003, physical examination showed no murmur, rubs or gallops.  Palpation of the precordium revealed no lifts, thrills or heaves.  The examiner noted that due to the absence of high risk features there is no further evaluation necessary, no need for medical treatment nor defibrillator placement.  The CI was diagnosed with hypertrophic cardiomyopathy (HCM), a pathological enlargement of the heart muscle.  The ejection fraction was over 65%.

At the 15 October 2003 VA Compensation and Pension (C&P) evaluation, performed 4 months before TDRL placement, the CI reported chest pain and shortness of breath which occurred three times a week for which he needed to stop and rest.  The CI had evidence of left ventricular hypertrophy on EKG and high blood pressure.  It was also recorded that an echocardiogram had documented an ejection fraction of 45%, but this is not in evidence.  

A treadmill stress test on 13 November 2003 was significant in that the CI was only able to achieve 5 METs (metabolic equivalent) exercise tolerance before the test was terminated secondary to the development of chest pain.  A repeat echocardiogram on 20 November 2003 showed persistent HCM, but a normal ejection fraction (an indication of the efficiency of the left ventricular function).  He was also found to have hypertension which was treated.  He was advised to stop smoking.  A repeat cardiac catheterization on 7 January 2004 confirmed HCM (diagnosed as idiopathic hypertrophic sub-aortic stenosis, IHSS).  A cardiology addendum to the narrative summary (NARSUM) was dated 14 January 2004.  It noted that while the CI had developed chest pain on the treadmill stress test, there had been no associated EKG changes (to suggest ischemia).  Continued medical management was recommended.  

The CI was placed on TDRL status effective 24 February 2004.  While on TDRL, a repeat echocardiogram on 2 March 2006 showed moderate concentric left ventricular hypertrophy, but made no comment on progression of the disease.  A cardiology note dated 25 April 2007 for the TDRL review recorded that the CI achieved 10.2 METs on a treadmill stress test.  The CI had no EKG changes or chest pain.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the HCM condition at 60% at TDRL placement and 10% at TDRL removal, coded 7020 (cardiomyopathy).  The VA determined the HCM condition as EPTS and denied service connection and, accordingly, did not rate it.  A rating of 100% requires congestive heart failure, a MET workload of 3 or less, or an ejection fraction of 30% or less.  None these were present at TDRL placement and a rating higher than 60% is not supported by the evidence.  The cardiology note at TDRL removal documents left ventricular hypertrophy on an EKG.  This is consistent with prior echocardiograms and the diagnosis.  The METs were over 10 and the ejection fraction normal.  No episodes of congestive heart failure were recorded.  The presence of cardiac hypertrophy at separation supports a 30% rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends no change to the 60% rating for the HCM condition at the time of TDRL placement, and a 30% rating at TDRL removal.  

Chronic Low Back Pain.  According to STR and the MEB NARSUM, the CI’s low back pain condition began in April 2003 after riding in military vehicles over rough roads.  He was unable to meet duty requirements despite treatment and medically evacuated from Iraq.  Radiographic (X-ray) studies showed findings of both degenerative disk disease (DDD) and degenerative joint disease (DJD).  Magnetic resonance imaging (MRI) confirmed multi-level DJD and DDD without frank herniation or nerve root impingement being recorded.  Despite treatment, the back condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for MEB.  The MEB forwarded chronic low back pain for PEB adjudication.  

The MEB NARSUM examination on 26 August 2003 (6 months prior to separation) noted complaints of low back pain.  Physical examination showed a normal forward flexion of 90 degrees with subjective complaint of discomfort, extension of 10 degrees (30 normal), normal side bending and rotation of 30 degrees and a combined range of motion (ROM) of 220 degrees (240 normal).  Straight leg-raise was negative bilaterally, deep tendon reflexes were normal and normal muscle strength.  There were no signs of radiculopathy or neurologic deficit noted on the examination.

At the VA C&P examination on 15 October 2003, performed 4 months before separation, the CI reported constant dull aching pain in the low back area.  The pain radiated to the right leg, but did not cause incapacitation.  He reported that he could garden and push a lawn mower.  On examination, there were no complaints of radiating pain on movement, no spasms, no tenderness, and provocative testing for nerve root irritation was negative.  Motion was painful and limited.  There was no ankylosis of the spine, and there were signs of intervertebral disc syndrome at the lumbar spine.  ROM measurements recorded a flexion of 40 degree (90 normal) and a combined ROM of 175 degrees.  

The CI was separated and placed on TDRL with a disability rating of 10% effective 24 February 2004.  Following separation, the CI worked as a truck driver.  While on TDRL, a VA C&P examination on 30 December 2006 showed a normal gait and an absence of tenderness, guarding, or spasm.  ROM was full and pain free.  The motor and reflex examinations were normal.  

At a 25 January 2007 VA C&P examination for hypertension, performed 5 months before removal from TDRL the CI reported that he walked a mile a day and also went dancing and bowling.  He denied incapacitation.  At a spine examination the same day, the ROM was full and pain free.  The motor and reflex examinations were normal as was the gait.  Tenderness, spasm, and guarding were absent.  A primary care note dated 20 March 2007 documented that his back pain was stable with (home) exercises and the CI declined pain medications.  No TDRL removal examination was found in evidence.  The TDRL removal PEB recorded that there was no muscle spasm, tenderness, deformity, or radiculopathy.  The ROM was normal.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic low back pain condition 10% coded 5299-5237 (analogous to lumbosacral strain), citing painful motion at TDRL placement.  The VA rated the back condition 20%, coded 5242 (degenerative arthritis of the spine), based on the VA C&P examination 4 months before separation, citing limitation of forward flexion.  The Board first considered its rating recommendation at the time of placement on TDRL.  The Board considered the probative value to these somewhat conflicting examinations, the Board noted that the MEB measurements were consistent with the diagnostic and clinical pathology in evidence.  The probative value of the VA examination was judged to be compromised as the CI stopped the ROM at the onset of pain for each measurement.  The MEB measurements were consistent with the pathology in evidence, the measured ROM at a subsequent examination, and the reported level of function.  It is therefore assigned a higher probative value for rating purposes at TDRL placement.  This examination supports the PEB adjudicated rating of 10%.  The Board next considered its recommendation for permanent disability rating at the time of removal from the TDRL.  The VA examination 5 months prior to TDRL removal was essentially normal.  Considering the totality of the evidence and mindful of VASRD §4.3 (reasonable doubt), Board recommended no change in the PEB rating at the time of TDRL placement or removal.  

BOARD FINDINGS:  In the matter of the hypertrophic cardiomyopathy condition, the Board unanimously recommends no change to the disability rating at the time of placement on TDRL and 30% rating at the time of removal from TDRL, coded 7020 IAW VASRD §4.104.  In the matter of the back pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication at TDRL placement or TDRL removal.  There were no other conditions within the Board’s scope of review for consideration.  The Board recommends that the CI’s prior determination be modified as follows; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	RATING	
		TDRL	PERMANENT	
Hypertrophic Cardiomyopathy	7020	60%	30%	
Chronic Low Back Pain	5299-5237	10%	0%	
RATING	60%	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140711, w/attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20160011573,  

Dear 

I accept the recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) to re-characterize your separation as a disability retirement with the combined disability rating of 30% effective the date of your medical separation for disability with severance pay.  Enclosed is a copy of the Board's recommendation and record of proceedings for your information.

The re-characterization of your separation as a disability retirement will result in an adjustment to your pay providing retirement pay from the date of your original medical separation minus the amount of severance pay you were previously paid at separation.

The accepted DoD PDBR recommendation has been forwarded to the Army Physical Disability Agency for required correction of records and then to the U.S. Defense Finance and Accounting Service to make the necessary adjustment to your pay and allowances.  These agencies will provide you with official notification by mail as soon as the directed corrections have been made and will provide information on your retirement benefits.  Due to the large number of cases in process, please be advised that it may be several months before you receive notification that the corrections are completed and pay adjusted.  Inquiry concerning your correction of records should be addressed to the U.S. Army Physical Disability Agency, (AHRC-00), 

A copy of this decision has also been provided to the Department of Veterans Affairs and to the counsel you listed on your application, 

Sincerely,

7/29/2016

Enclosure