RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-04243
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050719

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Infantryman, medically separated for “chronic anterior rib cage pain” with a disability rating of 0%.  “Dysthymic disorder” was determined to have existed prior to service (EPTS) and was not rated.

CI CONTENTION:  Conditions continue to worsen and negatively impact daily activities.  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 - 20050719	VARD - 20060417	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Anterior Rib Cage Pain	5099-5003	0%	Costochondritis	5299-5297	0%	20060324	
Dysthymic Disorder	9433	EPTS	Chronic Dysthymia 	9433	10%	20060331	
Partner Relationship Problems	Not Unfitting					
Recurrent Lower Back Pain	Not Unfitting	Chronic Low Back Pain	5237	NSC	20060331	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:

Chronic Anterior Rib Cage Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI reported a several month history of rib pain in March 2004, without specific injury or trauma.  Serial X-rays were normal and a CT scan was unremarkable.  The CI was seen in pain management on 2 August 2004 where he reported a 2-year history of progressive upper abdominal pain just below the rib cage.  He was noted to have small, reducible bulges (Spigelian hernias) of an abdominal muscle (lateral rectus was noted, but this is almost certainly the lateral aspect of the abdominal rectus as the lateral rectus is an eye muscle); palpation of these reproduced his pain.  The ribcage was non-tender.  A CT scan was accomplished (not in evidence) and was negative for a hernia.  A surgical evaluation did not find a surgical problem.  The 12 April 2005 MEB NARSUM examination, 3 months prior to separation, noted complaints of bilateral anterior lower rib pain aggravated by sit-ups and running.  The physical examination referenced the DD Form 2808 dated 31 January 2005, which was unremarkable and respiratory distress was not recorded.  

Six months after separation, the CI was seen in the VA primary care clinic on 24 January 2006.  On examination, the entire abdomen was tender to deep palpation, but the ribs were not tender.  Respirations were noted to be easy and regular.  At the 24 March 2006 VA Compensation and Pension (C&P) examination, 9 months after separation, the CI reported ongoing rib pain which had been refractory to treatment, but had not caused loss of duty time.  He was working as a security guard.  On physical examination, the CI had a normal gait and posture.  The ribs were tender to palpation, but there was no increased pain with deep inspiration.  Respiratory distress was not recorded.  He was thought to have costochondritis.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the rib cage condition 0%, analogously coded 5099-5003 (arthritis, degenerative), citing moderate and intermittent pain IAW the US Army Physical Disability pain policy.  The VA also rated the rib cage condition 0%, analogously coded 5299-5297 (ribs, removal) based on the C&P examination, citing a non-compensable evaluation because a rib had not been removed.  The panel noted that multiple radiographic examinations had not shown any pathology of the rib cage.  The examinations did not consistently show tenderness and respiratory distress was not present.  Neither the 5003 code nor the 5297 code support a compensable rating.  The panel considered use of code 5321 (Group XXI muscles [respiration]), but this option warrants no higher than a 0% rating.  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 rib cage condition.

Dysthymic Disorder.  The panel first considered if the pre-existing dysthymic disorder was permanently service aggravated.  The CI reported that he graduated from high school, but left home in his late teens and lived on the streets.  He was involved with drugs and alcohol as well as fighting.  He reported being discouraged and depressed.  He joined the Army at 21 and his depression initially improved, but returned while assigned to Korea.  There he was treated for depression.  It was noted that there was significant marital stress at the time of the mental health evaluation (for the MEB).  He was thought to have early onset chronic dysthymia with chronic depression since childhood with poorly defined symptom free periods.  He was also noted to have a personality disorder not otherwise specified (NOS).  The CI was thought to fail retention standards due to these EPTS factors.  The panel noted that the CI carried an S1 profile until he was in the MEB process.  The commander noted the CI performed his administrative tasks with much success.  The panel determined that the preponderance of evidence supported the PEB adjudication that the dysthymic disorder was not permanently service aggravated.  

Contended PEB Conditions:  Partner Relationship Problems and Recurrent Low Back Pain.  The panel’s main charge is to assess the fairness of the PEB determination that the contended conditions were not unfitting.  Neither of the conditions were profiled or implicated in the commander’s statement, and both were judged to meet retention standards.  There was no performance-based evidence from the record that either of the conditions 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 either of the contended conditions, so no additional disability ratings are recommended.  
BOARD FINDINGS:  In the matter of the rib cage condition and IAW VASRD §4.71a and 4.73, the panel recommends no change in the PEB adjudication.  In the matter of the dysthymic disorder and IAW VASRD §4.130, the panel recommends no change in the PEB adjudication.  In the matter of the contended partner relationship problems and recurrent low back pain, the panel recommends no change from the PEB determinations 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:

AR20180016628, XXXXXXXXXXXXXXXXXX 

Dear XXXXXXXXXXXXXXXXXX

	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.