RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00155
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20030807

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Armor Crewman, medically separated for “chronic abdominal pain,” with a disability rating of 10%.

CI CONTENTION:  Abdominal and lower back conditions should have been considered by the PEB.  He was under pressure to agree with the medical discharge due to legal issues.  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 – 20030424	VARD - 20030926	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Abdominal Pain	5099-5003	10%	Gastroesophageal Reflux Disease and Neuropathic Abdominal Pain	7346	10%	20030717 & 20030806	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:

Chronic Abdominal Pain.  According to the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s chronic abdominal pain condition began in December 1999.  Despite gallbladder removal, an appendectomy and treatment for gastritis, he continued to experience right upper quadrant abdominal pain.  Multiple radiologic, procedural and clinical evaluations failed to determine a clear cause of the ongoing pain.  Different medication trials resulted in improvement, but insufficient to allow unrestricted duty.  The MEB forwarded chronic abdominal pain, etiology unclear for PEB adjudication.
The permanent profile on 14 June 2002 stipulated no running or jumping, no marching, no heavy lifting, no operation of heavy machinery, and no duty greater than 12 hours.  At the MEB examination on 11 July 2002, 13 months prior to separation, the CI reported constant indigestion and stomach trouble since December 1999.  Physical examination showed no abdominal guarding, but tenderness of the right lower quadrant was present.  The MEB NARSUM examination on 25 February 2003 (5 months prior to separation), noted that the CI could function normally if he consistently used his narcotic pain medication and his electrical stimulator.  Physical examination showed diffuse abdominal tenderness, most significant in the right lower quadrant.  On a 5 March 2003 physical fitness test, the CI accomplished 46 pushups, 43 sit-ups and a 2-mile walk, which were passing scores.

At the 17 July 2003 VA Compensation and Pension (C&P) evaluation, performed 1 month before separation, the CI reported walking 2 miles, 5 days per week.  Examination showed diffuse abdominal tenderness.  The following day an exercise stress test (ETT) was performed to evaluate chest pain.  The CI exercised for 9.5 minutes and achieved a work level of 10.9 metabolic equivalents.  This exertional, strenuous test was not stopped due to abdominal pain, but because he was able to achieve a maximal heart rate of 169 beats per minute.

At a second VA C&P examination on 6 August 2003 (1 day before separation) the CI reported 9/10 severity pain in the right lower abdomen.  Treatment consisted of narcotic pain medication, activity modification and use of the electrical stimulator.  The examiner noted a history of gastroesophageal reflux disease, gastritis and possible neuropathic abdominal pain.  The CI reported that since starting a medication for reflux and gastritis (Prevacid) in February 2003, those symptoms were now absent.  Physical examination showed a normal gait, posture and balance.  The abdomen was “soft, flat and nontender” but also noted was discomfort during palpation of the right upper quadrant.  At another VA C&P examination on 4 September 2003 (28 days after separation), the CI reported he no longer took narcotic pain medication.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic abdominal pain condition 10%, coded analogously to 5003 (degenerative arthritis), citing application of the US Army Physical Disability Agency (USAPDA) pain policy.  The VA also rated the condition 10%, coded 7346 code (hiatal hernia) based on the VA C&P examination 1 day before separation, citing:  epigastric distress (upper abdominal pain) and pyrosis (heart burn).

Board members acknowledged that physical findings between examiners were inconsistent, and there is no ideal code to describe the condition and associated disability.  The Board first considered code 5003, utilized by the PEB, but this criterion does not capture the abdominal symptoms found in both STR and VA evidence.  The Board agreed with the VA that the 7346 pathway did not justify the next higher 30% rating, given a description of “asymptomatic” by the C&P examiner regarding reflux and gastritis symptoms.  Likewise, the 7307 code (gastritis, hypertrophic) offered no advantage since “multiple small eroded or ulcerated areas, and symptoms” were not present.  Although the development of the CI’s abdominal pain condition appeared to be temporally related to removal of his gallbladder, no clinical connection was established between his ongoing pain and residual disease associated with the gallbladder (such as gallstones retained within the common bile duct).  Nevertheless, the 7318 code (gall bladder, removal of) was considered.  Given objective physical examination findings however, the “severe” stipulation of the 30% rating was not met via this pathway.  Because the possibility of a neuropathic etiology was entertained by some providers, a peripheral nerve code was also examined.  However, the closest anatomical code is 8730 (neuralgia, ilio-inguinal nerve), which provides no rating higher than 10%.  Finally, under the 5319 code (muscle injury, Group XIX – abdominal muscles), the 30% rating requiring “moderately severe” symptoms as described in §4.56 was considered.  Missing however was evidence of cardinal signs of muscle disability such as weakness, loss of power, or impairments of coordination and uncertainty of movement.  Objective findings did not report loss of deep fascia, or impairment of muscle tonus and loss of power; and the ability to pass the physical fitness test (including 43 sit-ups) and perform a maximal ETT were inconsistent with significant abdominal muscle disability.  The Board agreed therefore that the clinical picture was not described by “moderately severe” symptoms, so the next higher 30% rating was not justified via this pathway.  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 chronic abdominal pain condition.

BOARD FINDINGS:  In the matter of the chronic abdominal pain condition, the Board unanimously recommends no change in the PEB adjudication.  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 20150211, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB						

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 
XXXXXXXXXXXXXXXXXX, AR20160018502 (PD201500155)

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