RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW
NAME:  XXXXXXXXXXXXXXXX	CASE: PD-2017-00404
BRANCH OF SERVICE: ARMY	SEPARATION DATE: 20090609

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was a Reserve E7, Infantryman, medically separated for “atypical chest pain” and “lumbar intervertebral disc syndrome [IVDS],” rated 10% each, with a combined disability rating of 20%.

CI CONTENTION: “Conditions have worsened.” The CI requested review of additional conditions not identified by the Medical Evaluation Board (MEB) and Physical Evaluation Board (PEB). 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 PEB to be unfitting for continued military service, and when specifically requested by the CI, those conditions identified by the MEB, but determined by the PEB 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. The panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections when appropriate. 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 disability at the time of separation.

RATING COMPARISON:

SERVICE PEB - 20090421	VARD – 20100419	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Atypical Chest Pain	7399-
7307	10%	GERD with Gastritis, Hiatal Hernia and History of Atypical Chest Pain and Dyspnea	7346	10%	

20100204	
			Barrett’s Esophagus	7299-7203	0%		
Lumbar IVDS	5243	10%	Lumbar Spine Degenerative Disc Disease and Degenerative Joint Disease	5237	20%		
Hearing Loss	Not Unfitting	Sensorineural Hearing Loss, Left Ear	6100	0%		
		Right Ear Hearing Loss	6100	NSC		
COMBINED RATING: 20%	COMBINED RATING OF ALL VA CONDITIONS: 30%	

ANALYSIS SUMMARY:

Atypical Chest Pain. According to the service treatment record (STR) and MEB narrative summary (NARSUM), in early 2008 the CI noted increasing chest pain, with substernal discomfort and radiating pain into his left shoulder and arm. After a thorough evaluation by cardiology, tests were negative for cardiac or pulmonary related pathology. The CI achieved METS of 13.7. He also underwent gastrointestinal (GI) evaluations and it was the medical opinion that his chest pains were probably related to his gastric pathology (reflux and Barrett’s esophagitis), with symptoms exacerbated by pressure and stress causing pressure on his diaphragm, abdomen and stomach.

The 2 April 2009 MEB NARSUM examination, 2 months prior to separation, noted complaints of chest pain with exertion that limited his ability to run and do heavy, strenuous physical activity for his military occupational specialty in a deployed environment. Medications treating his GI conditions were keeping his symptoms under control when not exacerbated by improper diet or physical exertion. The examiner noted that the GI condition had existed for years but had gotten worse with the onset of chest pain in 2008. The CI had reflux for 7 years and Barrett’s esophagitis was diagnosed in 2004. Physical examination of the abdomen, lungs and cardiovascular system was unremarkable. Chest X-rays in June 2008 and January 2009 were normal, and a nuclear medicine cardiac rest and stress scan in June 2008 was negative. Cardiac catheterization in July 2008 was also negative.

At the 4 February 2010 VA Compensation and Pension (C&P) examination, 8 months after separation, the CI reported that in 1999, as a civilian, he had GI studies that showed four healing ulcers and Barrett’s esophagitis. The condition improved with medication. When he mobilized  in 2006, the condition flared from stress and physical training, causing atypical chest pain. He reported that exertion caused reflux flares and shortness of breath. Chest pain was not reported. Physical examination revealed absence of respiratory distress, normal cardiac rate, sounds and rhythm, and no peripheral edema. The abdomen was mildly tender with a palpable mass thought to be a hernia. There was bloating and reported epigastric tenderness and retrosternal pain. Upper GI series on 23 February 2010 showed normal esophagus, a small hiatal hernia without esophageal reflux, normal stomach form, and peristalsis. There was slight thickening of gastric mucosal that might suggest gastritis.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the chest pain condition 10%, analogously coded 7307 (gastritis, hypertrophic (identified by gastroscope)), citing chronic symptomatic gastritis with small nodular lesions. The VA rated the GERD with gastritis, hiatal hernia, history of atypical chest pain, and dyspnea 10%, coded 7346 (hernia hiatal), based on the C&P examination, citing two or more of the following symptoms: epigastric distress, dysphagia, pyrosis, regurgitation, or substernal or arm or shoulder pain. The higher rating of 30% requires evidence of multiple small eroded or ulcerated areas of the stomach and symptoms. Panel members agreed, the condition did not meet this criteria and therefore, the higher rating was not justified under the 7307 code. Panel members also noted the absence of recurrent epigastric distress with GI symptoms accompanied by substernal or arm or shoulder pain. Therefore, a higher rating was not warranted under the 7346 code. There were no additional codes that would provide benefit to the CI. After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded there was insufficient cause to recommend a change in the PEB adjudication for the atypical chest pain condition.

Lumbar IVDS. According to the STR and MEB NARSUM, the CI had experienced intermittent back pain with flare-ups for the previous 10 years. Lumbar spine MRI in March 2009 showed L4-5 disc protrusion, without spinal stenosis or foraminal narrowing. Surgery was not indicated. The MEB NARSUM examination noted complaints of back pain with heavy lifting and straining, ruck march, or similar strenuous activity. Physical examination showed forward flexion was 90 degrees (normal) and combined ROM was 210 degrees (normal 240) with mild tenderness and some spasm noted.

At the C&P examination the CI reported constant “stiffness type” pain without radiation into the lower extremities. Physical examination showed lumbar spine tenderness and guarding. Thoracolumbar ROM revealed flexion to 50 degrees with pain, and combined ROM of 125 degrees. Painful motion was recorded throughout ROM testing. Neurosensory and motor strength examinations were normal.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the back condition 10%, coded 5243 (IVDS), citing limitation of motion. The VA rated the back condition 20%, coded 5237 (lumbosacral strain), based on the C&P examination, citing forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees. The panel agreed that a 10% rating, but no higher, was justified for combined ROM (greater than 120 degrees but not greater than 235 degrees), as reported on the NARSUM examination proximate to separation. There was no muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour, thus the next higher 20% rating was not justified on this basis. There was no documentation of IVDS with incapacitating episodes which would provide for a higher rating under that formula. After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded there was insufficient cause to recommend a change in the PEB adjudication for the back condition.

Contended PEB Condition: Hearing Loss. The panel’s main charge is to assess the fairness of the PEB determination that the contended condition was not unfitting. The contended condition was profiled H2; however, the condition was not implicated in the commander’s statement and did not fail retention standards. There was no performance-based evidence from the record that the condition significantly interfered with satisfactory duty performance at separation. After due deliberation, the panel concluded there was insufficient cause to recommend a change in the PEB fitness determination for the contended condition, so no additional disability rating is recommended.

BOARD FINDINGS: In the matter of the atypical chest pain and IAW VASRD §4.114, the panel recommends no change in the PEB adjudication. In the matter of the lumbar intervertebral disc syndrome and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication. In the matter of the contended hearing loss condition, the panel recommends no change from the PEB determination as not unfitting. There are no other conditions within the panel’s scope of review for consideration. Therefore, the panel recommends no modification or re- characterization of the CI’s disability and separation determination.

The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20170216, w/atchs Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record

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Dear XXXXXXXXXXXXXX:	

	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.