RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01713
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20040622

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reserve 01, Security Forces Officer, medically separated for chronic rhabdomyolysis with a disability rating of 10%.  

CI CONTENTION:  “It has changed my life.  Limited employment opportunities.”  The complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The panel’s scope of review is defined in DoDI 6040.44.  It is limited to review of disability ratings assigned 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 or non-compensable.  Any conditions outside the panel’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 panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The panel’s assessment of the PEB rating determination 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(s) at the time of separation.  The panel 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 panel 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 - 20040408	VARD - 20050601	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Rhabdomyolysis	7900-7999	10%	Heat Stroke with Residuals…	7199-7911	40%	20041227	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  70% 	

ANALYSIS SUMMARY:  

Chronic Rhabdomyolysis.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI had an initial episode of heat injury and rhabdomyolysis in May 2003 while training.  He had another episode of muscle weakness 2 weeks later and was subsequently removed from training.  He continued to have episodes of elevated CK [creatine kinase, a protein found in muscle breakdown] and muscle aches with only minimal exertion, and was extremely limited in his ability to perform his duties.  He was evaluated by nephrology, rheumatology, genetics, and neurology with extensive testing.  The evaluations were normal other than a periodically elevated CK.  On 17 February 2004, it was noted in neurology that the CI had sustained a heat stroke previously and had residua from it which included fatigue with over-heating.  It was also noted that this could persist for months to years due to hypothalamic injury.  The examiner determined that the CI did not have a history of rhabdomyolysis as there was no evidence of spillage of myoglobin (a muscle protein) into the urine.  The CI was also noted to have a history of migraine headaches (unrelated to the heat injuries).  The evaluation, which included a muscle biopsy, was unremarkable.  

During the 19 March 2004 MEB examination, 3 months prior to separation, the CI was noted to have recurrent rhabdomyolysis without an identified etiology.  (The panel observed that this was not consistent with the neurology evaluation.)  The physical examination was unremarkable.  A review of the record showed that CI was seen for symptomatic weakness on 18 May 2003, 18 June 2003, 18 and 31 July 2003, 21 May 2004, and 17 June 2004.  The CI was also seen for episodes of what was determined to be a complicated migraine.  

At the 27 December 2004 VA Compensation and Pension (C&P) evaluation, 6 months after separation, the CI reported that he worked at a desk job.  He also reported additional episodes of fatigue and dehydration.  He also noted ongoing muscle spasms 1-2 times a month, particularly in the summer.  The CI also reported that the initial episode was on a day with a temperature over 105 degrees with 75% humidity.  On physical examination, the CI was noted to be 72 inches tall and 254 pounds.  The medical officer observed that the CK was a reflection of muscle mass and could be elevated in the absence of pathology.  It was also observed that heat intolerance was more common in overweight individuals.  The examination was otherwise unremarkable for the unfitting condition.  Laboratory testing showed trace ketones (consistent with fasting) in the urine.  The chemistry profile was normal other than a mildly elevated CK.  He was thought to have a history of heat illness/stroke and mild to moderate impairment from heat intolerance.  Following separation, it was noted on 23 July 2008 that with treatment with magnesium and acupuncture, he had regained some heat tolerance and was able to work in his shop for 1 hour at temperatures of 105 F.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic rhabdomyolysis condition 10%, coded analogously to 7900 (hyperthyroidism), in accordance with DoD and VASRD guidelines.  The VA initially rated the heat stroke associated with rhabdomyolysis condition at 0%, coded 8199-8108 (narcolepsy).  A Decision Review Officer subsequently rated the condition at 40%, coded 7911 (Addison’s disease [adrenal cortical hypofunction]), based on the C&P examination 6 months after separation, noting the criteria of three Addisonian crises during the past year, or five or more Addisonian episodes during the past year.  

The evidence shows that the CI continued to have muscle spasms at a frequency of 1-2 times a month.  However, there is only evidence that he was symptomatic enough to seek medical care (for the heat injury/rhabdomyolysis condition) 4 times in the year leading up to separation.  In all of these, he was treated with fluids and released.  The only admission was at the initial presentation.  The panel observed that there is not a code in the VASRD for either heat stroke/injury or rhabdomyolysis.  The codes used by both the PEB and VA are for endocrine conditions; neither was thought to match the clinical impairment present.  Of the two though, the 7911 code used by the VA was thought to better match the impairment.  No better coding option was found.  A 20% rating was supported by the presence of 2-4 episodes over the prior 12 months.  The panel determined that the self-reported muscle spasms did not rise to the level of severity implied by “episodes” as described in the VASRD.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 20% for the chronic rhabdomyolysis condition, coded 7900-7911.  

BOARD FINDINGS:  In the matter of the Rhabdomyolysis condition, the panel unanimously recommends a disability rating of 10%, coded 7900-7911 IAW VASRD §4.120.  There are no other conditions within the panel’s scope of review for consideration.  

The panel recommends that the CI’s prior determination be modified as follows, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic Rhabdomyolysis	7900-7911	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20161103, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

SAF/MRB
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD  20762

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2016-01713.

After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was not appropriate under the guidelines of the Veterans Affairs Schedule for Rating Disabilities.  Accordingly, the Board recommended modification of your assigned disability rating without re-characterization of your separation with severance pay. 

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding, accept their recommendation and direct that your records be corrected as set forth in the attached copy of a Memorandum for the Chief of Staff, United States Air Force.  This will not result in any change to your separation documents or the amount of severance pay you are entitled to.  Disability severance pay is computed the same regardless of a rating of 0, 10 or 20 percent.

Sincerely,

XXXXXXXXXXXXXXXXXX
Director
Air Force Review Boards Agency

Attachment:
1.  Directive 
2.  Record of Proceedings 

cc:
SAF/MRBR