RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-04147
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20020311

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an activated National Guard E-3 (Basic Trainee) medically separated for rhabdomyolysis.  The condition could not be adequately rehabilitated to allow her to meet the physical requirements necessary to complete initial entry training.  She was issued a permanent P3 profile and referred for a Medical Evaluation Board (MEB).  The “rhabdomyolysis with myoglobinuria” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded two other conditions (patellar tendonitis and chronic costochondritis) for PEB adjudication.  The Informal PEB (IPEB) adjudicated “rhabdomyolysis” as unfitting, rated 0%, citing application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The PEB did not address the remaining conditions.  The CI appealed to the Formal PEB (FPEB), but later withdrew her appeal and was medically separated. 

CI CONTENTION:  The applicant has asked for consideration of all her 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/Naval 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 20011211	VA* - (~12 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Rhabdomyolysis…	5099-5021	0%	Rhabdomyolysis…	5021-5025	20%	20030227	
Patellar Tendonitis	No PEB Placement	Patellar Tendonitis, Right Knee	5024-5260	0%	20030227	
Costochondritis	No PEB Placement	Chronic Costochondritis	5299-5297	0%	20030227	
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 1 	
RATING:  0%	RATING:  20%	
*Derived from VA Rating Decision (VARD) dated 20030425 (most proximate to date of separation [DOS]).  

ANALYSIS SUMMARY:  

Rhabdomyolysis.  The CI came on active duty on 5 September 2001 from a cold weather state and entered basic training in South Carolina.  She began basic training and noted total body aches and feeling faint.  On 22 September, she was admitted to the hospital for hydration and observation after she was noted to have an elevated marker of muscle breakdown.  She was also noted to have muscle protein (myoglobin) in her urine (myoglobinuria).  She denied recent illness or a prior history, but reported that she had been “smoked” in training.  Her accession physical, dated 8 March 2001, noted that she was 57 pounds overweight and had a body fat of 28%, 2% less than the maximum.  On the day of accession she was noted to be 62 pounds overweight and to have body fat of 29.96 %.  Over the next 4 days, this improved rapidly and she was diagnosed with rhabdomyolysis (an excessive breakdown of muscle tissue).  She was also noted to have diffuse muscle tenderness and in particular, right knee pain which was diagnosed as patellar (kneecap) tendonitis.  She was issued crutches for this.  Due to the likelihood of recurrence with a resumption of training, separation from the service was recommended at hospital discharge on 26 September 2001.  She did well, but complained of persistent chest wall pain which was diagnosed as costochondritis (inflammation of the cartilage junction between the ribs and the sternum) in internal medicine on 3 November 2001.  Treatment with NSAIDs (non-steroidal anti-inflammatory drugs such as ibuprofen, aspirin, etc.) was recommended.  She also reported persistent right leg pain and reflex sympathetic dystrophy (RSD) was considered by orthopedics as a diagnosis; this was later excluded.  

At the MEB examination on 31 October 2001, 4 months prior to separation, the CI reported cramps in her legs after hours of running.  The examiner noted no specific findings.  The narrative summary (NARSUM) was signed 20 November 2001, but relied on the physical examination from admission on 22 September 2001.  At that time, she was noted to have diffuse tenderness, but normal motor strength for the upper and lower extremities as well as a normal gait.  Following separation on 11 March 2002, the CI apparently did well until she was admitted for 3 days on 14 January 2003 with recurrent rhabdomyolysis.  She reported that she frequently worked out and that she had recently had a viral illness, infectious, 10 days earlier.  Rhabdomyolysis has been linked to infectious mononucleosis, caused by the Epstein-Barr virus, but this is a rare complication.  Two weeks after hospital discharge, on 3 February 2003, she was evaluated in neurology.  She reported that her prior episode was in the Army when she sustained heat stroke after being in 110 degree heat without water for 6 hours.  The Board found no record of heat stroke in the service and noted that her body temperature was normal when she was admitted in September 2001.  She was otherwise noted to be in good health and she reported that she exercised three times a week running 2 miles at a time and that she lifted weights.  Her neurological examination, including strength and gait, were normal.  It was thought that a primary muscle abnormality was unlikely, but further evaluation was recommended.  

At the VA Compensation and Pension (C&P) examination performed on 27 February 2003, just under 12 months after separation, the CI reported a loss of muscle strength in her arms and legs with daily spasms.  She reported missing work 1-2 days a month due to muscle cramps.  On examination, she was noted to be emotional when discussing her disabilities.  Her strength was recorded as 4/5 for the upper and lower extremities.  However, the examiner also noted that she could do an unassisted deep knee bend to 150 degrees.  The Board observed the inconsistency between the level of activity and examination recorded by the neurologist only a few weeks after her second episode of rhabdomyolysis and this examination.  Another neurology evaluation was done on 27 October 2004, over 2 years after separation.  It noted that the CI reported ongoing muscle aches and spasms and that these had never really resolved.  She had a third episode of rhabdomyolysis in May 2004 for which no trigger was found.  Electrodiagnostic testing in April 2003 was not consistent with an underlying myopathy (muscle problem).  A muscle biopsy showed some isolated atrophy and genetic testing was recommended; this was normal.  The examiner noted that the CI wore tight fitting pants which he thought could explain some of her symptoms.  It was also noted that she might have sleep apnea (she was obese and snored) which could account for some of her symptoms.  Her strength was normal, but give-way weakness was possibly present (a sign of less than full effort).  The tone and bulk of the musculature was normal and tenderness absent.  It was recommended that she complete her work-up for a possible inherited metabolic myopathy; however, the examiner could not “say that the rhabdomyolysis seen in basic training represented anything other than a response to an injury at that time.”  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the rhabdomyolysis condition at 0%, coded 5099-5021 (analogous to myositis).  The VA rated the condition at 20%, coded 5021-5025 (myositis-fibromyalgia).  The VA rater cited the 4/5 strength recorded by the C&P examiner and also the reported daily muscle cramps and spasms.  The Board observed that this history and examination are not consistent with the neurology examination 3 weeks earlier or with a neurology evaluation, by a different neurologist, over one year later.  Both of these examinations recorded normal motor function and the first recorded that the CI lifted weights and ran 2 miles three times a week.  The Board also noted that the CI was overweight at her accession physical and, 9 months later, had gained weight by the time she reported for training.  She moved from a cold to a warm climate.  Although the CI reported a heat injury to the neurologist and VA, this was not recorded in the military records.  In fact, it was noted that her body temperature was normal when she was admitted.  The action officer opined that this picture is most consistent with that of a deconditioned individual entering a vigorous physical program and sustaining an acute injury (overuse) which resolved rapidly with removal from the physical stresses of basic training.  The second episode, 10 months after separation, followed a reported infection with Epstein-Barr virus, an uncommon but reported complication.  A neurology evaluation several years after separation noted a third episode without a known trigger; these records were not in evidence and the neurologist noted this only in passing.  The evidence shows that at the time of separation, the CI had recovered from the initial episode of rhabdomyolysis and was without residual effects.  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 PEB did not address the patellar tendonitis and chronic costochondritis.  The Board’s threshold for fitness determinations requires a preponderance of evidence, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  Neither condition was profiled nor specifically implicated in the commander’s statement.  The patellar tendonitis met retention standards; the MEB did not comment on the costochondritis condition.  Neither was listed in the NARSUM.  Both were reviewed and considered by the Board.  There was no performance based evidence from the record that either condition 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 either contended 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 §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended patellar tendonitis and chronic costochondritis 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, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for AR20160005476 (PD201404147)

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