RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXXXXX		CASE: PD-2017-03930 BRANCH OF SERVICE: MARINE CORPS	SEPARATION DATE: 20090429

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Fire Support Man, medically separated for “rhabdomyolysis” with a disability rating of 10%.

CI CONTENTION:  No specific contention was made. 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 Medical Evaluation Board (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’s assessment of the PEB rating determination is based on review of medical records and all available evidence relevant to application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards for 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, which operates 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 disability at the time of separation.

RATING COMPARISON:

SERVICE PEB - 20081224	VARD - 20100223	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Rhabdomyolysis	5099-5021	10%	Rhabdomyolysis	7541	NSC	20090722	
COMBINED RATING: 10%	COMBINED RATING OF ALL VA CONDITIONS: 50%	

ANALYSIS SUMMARY:

Rhabdomyolysis. According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s rhabdomyolysis (breakdown of muscle tissue) condition began in September 2007 with bilateral forearm swelling and dark-colored urine after vigorous physical exercising. The CI was admitted to the hospital with the diagnosis of rhabdomyolysis where his maximum creatine kinase was 156,288 U/L (normal 55-170) on 13 September 2007 and liver enzymes were also elevated. Treatment consisted of aggressive fluid hydration and monitoring. By discharge on 17 September 2007, the creatine kinase decreased to 20,480 U/L and liver enzymes were improved, but still elevated. On 21 September 2007, creatine kinase was 1,499 U/L. A hepatitis panel was negative except for hepatitis B antibody, which was consistent with immunization.

After he returned to full duty, he ran and noted the sudden onset of pain in the left costovertebral angle (“kidney pain”) and dark urine. He continued to hydrate and reported the “kidney pain” pain and the dark urine improved and cleared. The next morning the urine was dark again and the costovertebral angle pain was worse. On 5 November 2007 creatinine was 1.1 mg/dL (normal 0.6-1.5), liver enzymes were normal except for ALT that was slightly elevated at 70 U/L (normal 17-59), and creatine kinase was 2214 U/L. Repeat creatinine was 1.1 mg/dL and creatine kinase was 155 U/L. Aldolase (to rule out a muscle disorder) was normal. Follow-up studies showed myoglobin was negative, creatinine was 1.1 mg/dL, and creatine kinase was 263 U/L.

On 27 November 2007, he noted significant pain in the flanks and pectoral muscles after 10-15 pushups. He reported continued bilateral costovertebral angle tenderness with dark urine after any sort of physical exercise. A number of urinalyses were done post exercise and were negative for any blood or abnormal color. A three-phase renal CT scan was normal without evidence of a mass, calcification, hydronephrosis, or abnormal enhancement. Surrounding structures were unremarkable and there was no evidence of adenopathy. Ultrasound evaluation of the right kidney was normal; the left kidney was incompletely evaluated. Repeat myoglobin and urinalysis post exercise were negative for any evidence of renal involvement. On 26 February 2008, he reported no recent costovertebral angle tenderness, no myalgias, and no tea-colored urine, and he was not involved in heavy physical training or running. After 5 months on limited duty, flank pain resolved; however, on 16 April 2008, he had severe right greater than left flank pain following a run. There were no myalgias and no change in urine color. Creatine kinase was 263 U/L and creatinine was 1.0 mg/dL. Urinalysis was clear. The CI was advised to aggressively hydrate and take Vicodin (a narcotic/pain reliever combination) for pain.

The 30 June 2008 MEB NARSUM examination, 10 months prior to separation, noted complaints of inability to do any significant exercise. Physical examination showed a well-appearing male in no acute distress with a heart rate of 56 beats/minute, blood pressure 107/64, respiratory rate 16 breaths/minute, temperature 97.9 degrees Fahrenheit, 74 inches tall, and weight 170 pounds. His eyes and throat were normal. His neck was supple without adenopathy, bruits, or thyromegaly. The heart had a regular rhythm without a murmur, rub, or gallop. S1 and S2 sounds were normal. The lungs were clear to auscultation bilaterally. The abdomen was soft, non- tender, without masses or organomegaly. There was mild bilateral costovertebral angle tenderness with percussion. There was no clubbing, cyanosis, or edema of the extremities. No rashes were present, and neurological findings were non-focal without any tremor.

At the 22 July 2009 VA Compensation and Pension (C&P) examination, 3 months after separation, the CI reported a history of rhabdomyolysis due to overexertion. Physical examination showed  a pleasant individual in no acute distress with a pulse of 57 beats/minute, blood pressure 120/48 sitting, 128/86 standing, respiratory rate 18 breaths/minute, temperature 98.5 degrees Fahrenheit, height 74 inches, and weight 172 pounds. Posture and gait were normal, and he used no ambulatory aids or braces. His skin was clear. There was no generalized lymphadenopathy, no edema, and no pallor. His head, face, eyes, and ears were normal and there was no tenderness over the maxillary sinuses. The nose, mouth and throat were clear without lymphadenopathy or thyroid enlargement. The chest was clear and the heart had a regular rhythm without murmurs and normal S1 and S2 sounds. Peripheral pulses were bilaterally symmetrical and there was no peripheral edema, cyanosis, clubbing, varicose veins, stasis pigmentation, eczema, or ulcerations. The abdomen was soft and non-tender with normal bowel sounds and without organomegaly or ventral hernias. There was mild tenderness of the lower lumbosacral spine and along the paravertebral muscle. No muscle spasm was noted. Thoracolumbar spine motions were normal with very little pain at the extreme ranges of motion. Lower extremity strength was normal and neurologic evaluation was unremarkable. Renal laboratory studies were normal.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the rhabdomyolysis condition 10%, analogously coded as 5099-5021 (myositis). The VA determined the rhabdomyolysis condition was not service-connected.

Panel members noted that myositis (5021) is rated using code 5003 (degenerative arthritis). There was no limitation of motion or painful motion of the extremities nor was there imaging documentation of any joint abnormalities related to the rhabdomyolysis. Therefore, there is no higher rating than the 10% assigned by the PEB for that rating. The panel then considered an analogous code 5099-5025 (fibromyalgia (fibrositis, primary fibromyalgia). However, the CI did not have widespread muscular pain proximate to separation, but he did have costovertebral angle pain after exercising. A 20% rating requires pain that is “episodic, with exacerbations often precipitated by environmental or emotional stress or by overexertion, but that are present more than one-third of the time.” However, unless the CI were to exercise, the pain was not reported to be present. Therefore, a 20% rating is not appropriate. No renal abnormalities were noted proximate to separation; therefore, use of any rating based on the genitourinary system IAW VASRD §4.115b is not applicable. 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 rhabdomyolysis condition.

BOARD FINDINGS: In the matter of the rhabdomyolysis 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. Therefore, the panel recommends no modification or re-characterization of the CI’s disability and separation determination.

DEPARTMENT OF THE NAVY
SECRETARY OF THE NAVY COUNCIL OF REVIEW BOARDS 720 KENNON STREET SE STE 309
WASHINGTON NAVY YARD, DC 20374-5023

IN   REPLY  REFER  TO :

1850
CORB: 003 20May20

From: Director, Secretary of the Navy Council of Review Boards 

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW  (PDBR)

Ref:	(a) DoDI 6040.44
(b) PDBRltr

1.	Pursuant to reference (a), the PDBR reviewed your case and forwarded its recommendation (reference (b)) to the Department of the Navy on 5 Mar 2020 for appropriate  action.

2.	On 20 March 2020, the Assistant Secretary of the Navy (Manpower & Reserve Affairs) accepted the recommendation of the PDBR ofno change to your characterization of separation or disability rating assigned  by the Department of the Navy's Physical Evaluation Board.

3.	The Secretary's decision on your PDBR application is final and is not subject to appeal or additional review by the Board for Correction of Naval Records.