RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00120
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20081112

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Unit Supply Specialist, medically separated for “irritable bowel syndrome,” “right (dominant) shoulder impingement,” and “bilateral patellofemoral pain syndrome,” rated 10%, 10% and 0%, respectively, with a combined disability rating of 20%.

CI CONTENTION:  “Review 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 on 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 - 20080821	VARD - 20090305	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Irritable Bowel Syndrome	7319	10%	Irritable Bowel Syndrome	7319	0%	STR	
Right (Dominant) Shoulder Impingement	5099-5003	10%	Right Shoulder Impingement	5202	NSC	STR	
Bilateral Patellofemoral Pain Syndrome	5099-5003	0%	Bilateral Knee Pain	5257	NSC	STR	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Irritable Bowel Syndrome.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s irritable bowel syndrome (IBS) condition began around 2006 after he experienced several days of feeling sick.  At the MEB examination (recorded on DD Forms 2807 and 2808) dated 27 February 2008, 7 months prior to separation, the CI reported a history of stomach pain and cramps, and blood in his stool.  Physical examination of the abdomen was unremarkable.

During the NARSUM on 7 April 2008, 5 months prior to separation, the CI reported complaints of “going to the bathroom 4 times a day, cramping, and stomach ache.”  The examiner noted that the CI was” chronically feeling sick and going to sick call.”  He had seen multiple providers and was given a permanent profile in 2007.  The CI noted that his problems of stomach pain, vomiting and inability to keep food down began in basic training around December 2006.  He had treatment for gastroenteritis prior to the IBS diagnosis, and he had a history of GERD-like symptoms.  In June of 2007, the CI was diagnosed with an anal fissure and gastritis, and was referred to gastroenterology (GI).  The colonoscopy was unremarkable, except for a small polyp, which was removed from the rectum.  There was no endoscopic evidence of colitis, and he had no other GI findings.  It was noted there had not been any weight loss and he had a BMI of 34.  Stool studies were negative.  The diagnosis of IBS was made.  The CI underwent a second colonoscopy in March 2008, 6 months prior to separation.  The colon examination was unremarkable, with the exception of external hemorrhoids at the rectum.  The surgical pathology report returned with findings consistent with IBS.  

Physical examination at the NARSUM revealed weight of 274 pounds, height of 73 inches and blood pressure 121/74.  The abdomen was soft with normal bowel sounds that was tender to firm palpation throughout the lower half of the abdomen.  No masses were present.  There were no reports of fevers, chills, or mucus in the stool recorded in the STR prior to separation.  There was no indication of blood in his stool independent of hemorrhoids.  Treatment entries recorded stable weight and no signs of anemia.  The CI was non-attendant to the VA Compensation and Pension (C&P) examination.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the irritable bowel syndrome condition 10%, coded 7319 (irritable colon syndrome.  The VA rated the irritable bowel syndrome condition 0% coded 7319 (irritable colon syndrome), based on the STR.  

The panel deliberated whether the CI’s irritable bowel syndrome met the 10%, or the 30% 7319 rating criteria.  A 30% rating (severe) requires diarrhea documented as severe or alternating diarrhea and constipation in a severe pattern, with constant or near constant abdominal distress.  The NARSUM documented the CI’s report of bowel movement 4 times a day, which is not consistent with severe diarrhea.  The panel also noted the absence of recorded malnutrition, anemia, weight loss, or serious complications, and the bowel movement frequency recorded in the 6 months prior to separation.  All panel members agreed, the 30% level of disease burden was not demonstrated, and therefore, a 30% rating was not warranted.

After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded that there was insufficient cause to recommend a change in the PEB adjudication for the IBS condition.

Right (Dominant) Shoulder Impingement.  According to the STR and the MEB NARSUM, the CI’s right (dominant) shoulder impingement condition began in April 2007 while training on an obstacle course.  At the MEB examination (recorded on DD Forms 2807 and 2808) dated February 2008, 7 months prior to separation, the CI reported he had right shoulder pain with rotation movement.  Physical examination was unremarkable.

During the MEB NARSUM examination on 7 April 2008, 5 months prior to separation, The CI noted he had pain with abduction of 80 degrees and he had to bend his elbows in order to bring the arm over his head.  He reported daily pain in the right shoulder, but never had any swelling or neck pain, or numbness or tingling radiating to the right arm.

Physical examination showed no evidence of inflammation, and absence of tenderness in the AC joint.  Range of motion (ROM) recorded forward flexion to 130 degrees (180) and abduction to 110 degrees (180); painful motion was noted throughout ROM testing.  Repetitive motion did not cause further decrease in ROM, but it did cause weakness and loss of endurance with limitations in function.  There was no incoordination or instability.  X-rays of the right shoulder in April 2008 were normal.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right (dominant) shoulder impingement condition 10%, coded analogously as 5099-5003 (degenerative arthritis), citing painful motion.  The VA did not service connect the right (dominant) shoulder impingement condition coded 5202 (other impairment of humerus).

The panel considered the rating under 5003, degenerative arthritis and agreed there was painful motion and functional loss due to pain, weakness, and fatigability supporting the 10%, IAW VASRD 4.40, 4.45, and 4.59.  There is insufficient evidence to justify the higher rating of 20% using this code since there were no incapacitating episodes.  The panel considered the 5201 for reduced range of motion and agreed the reduced ROM was not compensable under any code.  

The panel also considered other applicable codes; however, no alternative shoulder code was supported in justification of a rating higher than 10%.  There was no evidence of ratable peripheral nerve impairment which would provide for additional or higher rating.  

After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded that there was insufficient cause to recommend a change in the PEB adjudication for the right (dominant) shoulder impingement condition.  

Bilateral Patellofemoral Pain Syndrome.  According to the STR and the MEB NARSUM, the CI’s bilateral patellofemoral pain syndrome condition began during or shortly after basic training in 2006 with no specific injury or trauma.  

At the MEB examination (recorded on DD Forms 2807 and 2808) dated February 2008, 7 months prior to separation, the CI reported right knee pain and stiffness.  The examiner addressed the right knee only and noted that the knee was not previously evaluated prior to the MEB exam.  Physical examination showed no abnormality of the lower extremity, but noted moderate pes planus.

During the MEB NARSUM examination on 7 April 2008, 5 months prior to separation, the CI reported that when he walked, or ran upstairs, and whenever he ran, he heard a cracking sound in the kneecaps.  His knees were painful with prolonged standing. There was no history of knee swelling or use of knee braces.  

Physical examination showed no evidence of swelling or inflammation in either knee.  He had no crepitus with ROM in either knee, except for with repetitive sitting and standing motion.  Right knee ROM recorded flexion to 130 degrees.  Painful motion was absent.  Left knee ROM recorded 130 degrees of flexion with pain.  There was no evidence of instability.  The examiner did not note if 1 knee was worse than the other, or if the CI had experienced loss of function due to knee condition.  There was no report of knee give way or instability in the STR, and no evidence of treatment of his knees.  Radiographs of each knee were unremarkable.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated each knee condition at 0%, coded analogously as 5099-5003 (degenerative arthritis), citing there was consideration of 4.10, 4.40. 4.45, and 4.59, and that the condition was expected to resolve.  The VA did not service connect the bilateral patellofemoral pain syndrome condition coded 5257 (other impairment of knee).

Panel members considered the objective findings and associated disability for each knee were identical.  There was no limitation of motion which supported a rating under the diagnostic codes for limitation of flexion or extension (5260, 5261) and no evidence of painful motion with functional loss supporting a 10% rating for either knee (based on §4.59, §4.40 and §4.45) since the CI had no radiographic evidence of a knee pathology, no muscle atrophy of disuse, and no evidence that his knee condition resulted in functional loss.  The Commander’s Statement (CS) dated 8 months prior to separation, made no mention of his knees.

The NARSUM examination did not demonstrate the presence of ligamentous instability or laxity (5257), and there was no history of dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258), or history of surgery to remove a meniscus (5259) to support a rating under the respective codes.  There was no fracture, non-union, or malunion of the femur or tibia to support consideration under the respective codes for knee impairment related to long bone conditions (5255, 5262).  There was no VASRD §4.71a route to a compensable rating for either knee.

After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded that there was insufficient cause to recommend a change in the PEB adjudication for the bilateral patellofemoral pain syndrome condition.  

BOARD FINDINGS:  In the matter of the irritable bowel syndrome condition and IAW VASRD §4.114, the panel recommends no change in the PEB adjudication.  In the matter of the right (dominant) shoulder impingement condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the bilateral patellofemoral pain syndrome condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  

There are no other conditions within the panel’s scope of review for consideration.  

The panel, 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 20160310, with attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170013363, XXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found your separation disability rating and your separation from the Army for disability with severance pay to be accurate.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed), and I accept its recommendation.  I regret to inform you that your application to the DoD PDBR is denied.  

	This decision is final.  Recourse within the Department of Defense or the Department of the Army is exhausted; however, you have the option to seek relief by filing suit in a court of appropriate jurisdiction.

Sincerely,					      
						      					
Enclosure