RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03893
BRANCH OF SERVICE: NAVY	SEPARATION DATE:  20041103

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Engineering Aid, medically separated for “severe costochondritis,” with a 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 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 - 20040728	VARD - 20041122	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Severe Costochondritis	5299-5003	10%	Chronic Costochondritis	5399-5321	10%	20040623	
Possible HLA-B27 Seronegative Spondyloarthropathy	Category III	Seronegative Spondyloarthropathy	5299-5242	20%	20040623	
Adjustment Disorder with Mixed Anxiety and Depression	Category IV	No VA Entry	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Severe Costochondritis.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the first record in evidence is a primary care note dated 7 October 2002 where the CI reported chest pain for the prior 2 months associated with deep breathing during exercise.  She was tender over the left anterior chest wall and was referred to orthopedics.  On 20 December 2002, she was evaluated in the breast clinic (general surgery) for a painful mass in the left breast present for several months since changing the type of birth control pill she was using.  She was thought to have costochondritis (inflammation of the cartilage between the ribs and sternum [chest bone]).  She was started on a non-steroidal anti-inflammatory drug (NSAID, a medication like aspirin), but the pain persisted.  A chest CT scan on 26 April 2003 was normal.  By report, a bone scan was normal in May 2003.  She was placed on limited duty (LIMDU), but her pain did not resolve.  She was then evaluated by cardiology on 14 August 2003 and again thought to have costochondritis.  A stress echocardiogram (a test for cardiac function) on 26 August 2003 was also consistent with a non-cardiac cause of the chest wall pain.  She was then evaluated in rheumatology on 1 October 2003.  It was noted she had an MRI scan of the chest which was (implied) normal.  She had tenderness over the chest wall, left greater than right, and also of the sacroiliac joints (SIJs) between the pelvis and lower back (sacrum).  She was again thought to have costochondritis, but an evaluation to exclude an underlying spondyloarthropathy was begun.  Shortly thereafter, while back at her home of origin, she presented to a local emergency room (ER) and was treated with steroids for ankle, knee, and elbow pain.  On follow-up in rheumatology on 17 December 2003, back at her base of assignment, it was noted her work-up had essentially been negative to date and the steroids were stopped; however, she was given a 5-day steroid burst a few days later in primary care.  In rheumatology on 22 January 2004, she was thought to have a spondyloarthropathy with episodic arthritis.  Her examination that day was positive for costochondral tenderness, but the wrists, hands, knees, and ankles were not inflamed.  A rheumatology evaluation for the MEB, dated 17 March 2004, noted the ongoing costochondritis and possible spondyloarthropathy.  The narrative summary (NARSUM) dated 19 March 2004, 8 months prior to separation, noted the evaluation had been largely negative and the CI had not responded well to most treatment other than steroids.  Intermittent low back pain had been recorded, but the range of motion was normal on this examination.  The SIJs were mildly tender and the lower left costochondral border was exquisitely tender, left greater than the right.  She was diagnosed with severe costochondritis and possible human leukocyte antigen (HLA) B-27 (a genetic marker) spondyloarthropathy.  The MEB forwarded “severe costochondritis” and “possible HLA-B27 seronegative spondyloarthropathy as evidenced by severe enthesitis in the costochondral area with possible inflammatory low back pain” for PEB adjudication.  

At the VA Compensation and Pension (C&P) examination performed on 23 June 2004, 5 months before separation, the CI reported benefit from Celebrex (an NSAID) and denied incapacitation from the costochondritis condition.  She reported ongoing pain though the costochondritis and from the SIJs.  She did report 7 days of incapacitation from her low back pain.  On examination she had a normal gait.  Moderate tenderness was present over the costochondral junction (side not specified).  The range of motion (ROM) of the back was limited due to pain.  The examination of the hips, knees, ankles, and all other joints was unremarkable.  She was diagnosed with costochondritis and a history of seronegative spondyloarthropathy.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the severe costochondritis condition at 10%, coded 5299-5003 (analogous to degenerative arthritis).  The VA also rated the costochondritis condition at 10%, but coded it 5399-5321 (analogous to Muscle Group XXI [respiration]).  The Board observed there is no specific code for costochondritis and neither code offers a rating advantage over the other in this case.  No other route to a higher rating was found.  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 costochondritis condition.  

Contended PEB Conditions.  Possible HLA-B27 seronegative spondyloarthropathy and adjustment disorder with mixed anxiety and depression.  The commander’s statement noted that the CI was limited by her condition without further detail.  It was also noted that she was limited to administrative work and that her performance had been excellent.  The spondyloarthropathy condition was noted to be a possible diagnosis which was linked to the costochondritis condition and the possible inflammation of the LBP condition.  The adjustment disorder does not constitute a physical disability per DoDI 1332.38.  Both were reviewed and considered by the Board.  There was no performance based evidence from the record that either of these conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation and 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 either of the contended conditions and so no additional disability ratings are recommended.

BOARD FINDINGS:  In the matter of the costochondritis condition and IAW VASRD §4.71a and VASRD §4.73, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended possible HLA-B27 seronegative spondyloarthropathy and adjustment disorder with mixed anxiety and depression conditions, the Board unanimously recommends no change from the PEB determination as not unfitting Category III and IV conditions, respectively.  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 20140521, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR DIRECTOR, SECRETARY OF THE NAVY COUNCIL OF REVIEW
               BOARDS 

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS
 
Ref:   (a) DoDI 6040.44
       (b) CORB ltr dtd 11 Aug 16

      In accordance with reference (a), I have reviewed the cases forwarded by reference (b), and, for the reasons provided in their forwarding memorandums, approve the recommendations of the PDBR that the following individual’s records not be corrected to reflect a change in either characterization of separation or in the disability rating previously assigned by the Department of the Navy’s Physical Evaluation Board:

		- XXXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN

						  	XXXXXXXXXXXXXXXXXXXX
	     				  		Assistant General Counsel
	(Manpower & Reserve Affairs)