RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW NAME: XXXXXXXXXXXXXX BRANCH OF SERVICE: ARMY CASE NUMBER: PD1200191 SEPARATION DATE: 20051026 BOARD DATE: 20130221 SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SSG/E6 (91W/Health Care Specialist) medically separated for osteopetrosis (cervical spine, lumbar spine, shoulder, hip, knee and ankle joints). A year prior to separation, the CI was found to have osteopetrosis during an evaluation for right hip pain from running. Due to the progressive nature of the disease, it was determined that he would not regain sufficient function to return to full unlimited duty in the foreseeable future and meet the physical requirements of his Military Occupational Specialty (MOS) or satisfy physical fitness standards. He was issued a permanent P3L3 profile and referred to a Medical Evaluation Board (MEB) which forwarded osteopetrosis to the Informal Physical Evaluation Board (IPEB) as an unfitting condition. The MEB forwarded no other conditions to the IPEB. The IPEB adjudicated osteopetrosis involving the cervical spine, osteopetrosis involving the lumbar spine, and osteopetrosis involving shoulder, hip, knee and ankle joints as unfitting, rated 10%, 10%, and 0% respectively, with application of the Veterans Affairs Schedule for Rating Disabilities (VASRD). The CI appealed to the Formal PEB (FPEB); however, the records do not indicate an FPEB was accomplished. The US Army Physical Disability Agency (USAPDA) did issue an administrative correction (dated 7 Sept 2005) to the IPEB DA Form 199. This only corrected the disability description and made no change to the IPEB ratings. The CI was then medically separated with a 20% combined disability rating. CI CONTENTION: “Prior to being medically separated from the Army with a 20% rating a rebuttal was filed to the PEB but no changes were made. A formal request for continuance on active duty was made but was denied. A rating of 20% for osteopetrosis was assigned before the debilitating effects on my health were fully discovered. Less than one year later the Dept of Veteran Affairs (VA) issued a rating of 90% for various conditions caused by osteopetrosis/hypophosphatemic rickets. The Physical training and rigors of deployments to Kuwait and Iraq further exacerbated my serious medical condition. Conditions of headaches, kyphoscolisis with spinal compression fractures, left hip strain, right hip strain, left shoulder strain, right shoulder strain, hyperparathyroidism, hypertension, left and right knee strain and left and right ankle strain were not considered at the time of separation but were rated by the VA. X-ray and CT scans also revealed micro-fractures in multiple areas of my body that were not considered at the time of separation.” SCOPE OF REVIEW: The Board wishes to clarify that the scope of its review as defined in DoDI 6040.44, Enclosure 3, paragraph 5.e. (2) is limited to those conditions which were determined by the PEB to be specifically unfitting for continued military service; or, when requested by the CI, those condition(s) “identified but not determined to be unfitting by the PEB.” The ratings for unfitting conditions will be reviewed in all cases. The osteopetrosis (neck, back, shoulder, hip, knee and ankle) condition, as requested for consideration, meets the criteria prescribed in DoDI 6040.44 for Board purview and is addressed below. The remaining conditions rated by the VA at separation and listed on the DA Form 294 are not within the Board’s purview. Any conditions or contention not requested in this application, or otherwise outside the Board’s defined scope of review, remain eligible for future consideration by the Army Board for Correction of Military Records. RATING COMPARISON: Service PDA Admin Corr – Dated 20050907 VA (10 Mos. Post-Separation) – All Effective Date 20051027 Condition Code Rating Condition Code Rating Exam Osteopetrosis C spine 5299-5240 10% NO VA ENTRY Osteopetrosis L spine 5299-5240 10% Osteopetrosis w/increased bone density of pelvis, femurs, tibias, fibulas and Lumbosacral spine 5003-5013 20% Uncertain Osteopetrosis shoulder, hip, knee and ankle joints 5099-5016 0% NO VA ENTRY .No Additional MEB/PEB Entries. R shoulder strain 5299-5203 10% 20060829 L shoulder strain 5299-5203 10% 20060829 R Hip strain 5299-5203 10% 20060829 L Hip strain 5299-5252 10% 20060829 Residuals L knee strain w/osteoarthritis 5299-5260 10% 20060415 Residuals R knee strain w/osteoarthritis 5262 10% 20060415 Residuals L ankle strain 5271 10% 20060415 Residuals R ankle strain 5271 10% 20060415 Lumbar Strain…… 5299-5235 20% 20060829 Headaches 8199-8100 30% 20060829 Hypertension 7101 10% 20060829 Hyperparathyroidism 7904 10% 20060829 0% X 1 / Not Service-Connected x 2 Combined: 20% Combined: 90% *CI rated 0% for B ankle and B knees when he left the USMC in June 2001. ANALYSIS SUMMARY: The Disability Evaluation System (DES) is responsible for maintaining a fit and vital fighting force. While the DES considers all of the member's medical conditions, compensation can only be offered for those medical conditions that cut short a member’s career, and then only to the degree of severity present at the time of final disposition. The DES has neither the role nor the authority to compensate members for anticipated future severity or potential complications of conditions resulting in medical separation nor for conditions determined to be service-connected by the Department of Veterans Affairs (DVA) but not determined to be unfitting by the PEB. However the DVA, operating under a different set of laws (Title 38, United States Code), is empowered to compensate all service-connected conditions and to periodically re-evaluate said conditions for the purpose of adjusting the Veteran’s disability rating should the degree of impairment vary over time. The Board’s role is confined to the review of medical records and all evidence at hand to assess the fairness of PEB rating determinations, compared to VASRD standards, based on severity at the time of separation. The Board utilizes DVA evidence proximal to separation in arriving at its recommendations; and, DoDI 6040.44 defines a 12-month interval for special consideration to post-separation evidence. The Board’s authority as defined in DoDI 6044.40, however, resides in evaluating the fairness of DES fitness determinations and rating decisions for disability at the time of separation. Post-separation evidence, therefore, is probative only to the extent that it reasonably reflects the disability and fitness implications at the time of separation. The Board has neither the jurisdiction nor authority to scrutinize or render opinions in reference to the CI’s statements in the application regarding suspected DES improprieties in the processing of his case. In October 2004, the CI presented with a several week history of right hip pain. This persisted despite rest and medications. On 12 October 2004, an X-ray showed increased density of the bones. X-rays of the skull, spine, arms and legs were significant for increased density of the upper skull, which might have been a normal variant, and lumbosacral spine. A bone scan was remarkable for generalized increased uptake. Further radiographic studies and laboratory testing led to the diagnosis of adult Type II osteopetrosis with mild secondary hyperparathyroidism. This is an inherited condition with variable expression in adulthood. It was determined to be an existed prior to service (EPTS) condition, but with compensable disabilities IAW 10 USC 1207a. The CI was issued a P3L3 profile and referred to the MEB. The commander noted that he was incapable of lifting heavy boxes and parts for vehicles, repetitive bending, as well as performing vehicle maintenance and that he was incapable of performing his MOS duties in a combat environment. At the MEB examination on 3 May 2005, the CI reported that “he was currently unable to run secondary to unbearable pain in his hips and pain when he wears his load bearing vest, aid pack or rucksack.” The examiner noted that “…his disease is progressive and will result in impaired orthopedic functioning as it already has, this soldier will not regain sufficient function to return to full unlimited duty anytime in the foreseen future, if at all.” He was referred to the MEB IAW AR 40-501 Chapter 3-41 e(1) “Miscellaneous conditions and defects. Conditions and defects not mentioned elsewhere in this chapter are causes for referral to an MEB, if— (1) The conditions (individually or in combination) result in interference with satisfactory performance of duty as substantiated by the individual’s commander or supervisor.” The Board noted that the CI requested continuation of active duty implying that he thought that his conditions did not render him unfit for continued service. The Board also observed that the CI scored a 284 on his Army Physical Fitness Test (APFT) test in April 2004, 18 months prior to separation, and that his rater commented that he “maximized every PT session to improve the squad’s overall fitness, soldier has the highest APFT score in the company.” Osteopetrosis Condition of the cervical spine. There were no visits in the record for cervical spine complaints. X-rays were normal. There was one goniometric range-of-motion (ROM) evaluation in evidence which the Board weighed in arriving at its rating recommendation. At the 13 July 2005 physical therapy appointment for ROM measurements, 3 months prior to separation, the CI was noted to exceed VA normal criteria for flexion and extension, but to have reduced lateral flexion (bending) and rotation with a combined ROM of 280 degrees with a VA normal of 340 degrees, all due to pain. The neck condition was not separately addressed in either the MEB narrative summary (NARSUM) or the VA Compensation and Pension (C&P) examinations. The Board opined that the evidence does not support a finding of “unfit” for the neck condition. However, it is not within the scope of the Board to change a condition, which has been found “unfitting” by the PEB, to “not unfitting.” The PEB rated the disability at 10%, coded 5299-5240, analogous to ankylosing spondylitis, citing the reduced combined ROM. The VA did not rate the cervical spine. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (Resolution of reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the neck condition. Osteopetrosis Condition of the lumbosacral spine. There were two goniometric ROM evaluations in evidence, with documentation of additional ratable criteria, which the Board weighed in arriving at its rating recommendation. Thoracolumbar ROM Degrees MEB ~3 Mo. Pre-Sep VA C&P ~10 Mo. Post-Sep Flexion (90 Normal) 75 50 Combined (240) 195 150 Comment Limited by pain + Tenderness; painful motion §4.71a Rating 10% 20% The CI was initially seen for low back pain (LBP) in 2000 after weight lifting. There were no further entries in the records regarding LBP until a 19 November 2004 entry which noted recent LBP. X-rays the previous month during an evaluation for right groin pain had been suspicious for increased bone density of the lumbar spine. A vertebral fracture assessment scan on 23 February 2005 showed moderate compression of L1. A letter from an endocrinologist dated 29 March 2005 documented “some spinal compression fractures.” There were no other records specific for LBP in the records. The NARSUM, dictated 3 May 2005, 5 months prior to separation, recorded that the CI could not run due to pain in his hips and that he had pain (not specified) when he wore his load bearing vest, aid pack or rucksack. The ROM was slightly reduced in all planes. The commander’s letter noted that he could not lift heavy boxes nor bend repetitively. A C&P examination on 15 April 2006, 6 months after separation, for the ankles and knees noted that the CI had most of his pain in the knees and ankles, but that the hips and back were also involved. At another C&P examination on 29 August 2006, 10 months after separation, the CI reported that he had daily LBP for which he took a narcotic. It was aggravated by prolonged standing and sitting. No assistive devices were in use. Gait was documented as steady on a separate examination for the joints that same day. He was noted to have paraspinal tenderness and kyphosis. The ROM, above, was guarded. Although his symptoms increased on repetitive motion, there was no further reduction in ROM. There was no muscle atrophy. Testing for radicular irritation was negative. X-rays were normal. The PEB rated the disability at 10%, coded 5299-5240, analogous to ankylosing spondylitis, citing the reduced combined ROM. The VA rated the lumbar spine at 20% and coded it 5299-5235, analogous to a vertebral fracture, utilizing the C&P ROM. The Board considered the two examinations. It noted that there had been no visits for LBP for almost a year prior to separation other than visits which were part of the evaluation for the osteopetrosis. The Board determined that the MEB examination and ROM better fit the condition of the CI at the time of separation. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (Resolution of reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the back condition. Osteopetrosis Condition of the shoulder, hips, knees and ankles. The PEB combined osteopetrosis of the shoulder, hip, knee and ankle as a single unfitting condition, coded analogously to 5016 and rated 0%. The PEB may have relied on AR 635.40 (B.24 f.) and, or the USAPDA pain policy for not applying separately compensable VASRD codes. Not uncommonly this approach by the PEB reflects its judgment that the constellation of conditions was unfitting and that there was no need for separate fitness adjudications rather than a judgment that each condition was independently unfitting. The Board must first determine if each unbundled condition was unfitting in and of itself. If a condition is determined to be separately unfitting, the Board then applies separate codes and ratings in its recommendation IAW VASRD §4.71a. Thus, the Board must exercise the prerogative of separate fitness recommendations in this circumstance, with the caveat that its recommendations may not produce a lower combined rating than that of the PEB. Shoulder condition. The Board first considered if the shoulders were separately unfitting. The CI was seen for left shoulder pain on 23 July 2004, over a year prior to separation, and thought to have bicipital tendonitis for which he was treated conservatively with rest and medications. There are no other entries found for the shoulders in the treatment record. The commander’s letter noted difficulty lifting heavy boxes, but did not assign this to a particular joint. The profile was U1. There were no X-rays taken while on active duty, but a whole body nuclear medicine scan showed generalized increased uptake including the shoulders. X-rays taken by the VA 10 months after separation were normal. The NARSUM is silent for shoulder complaints. After due deliberation, in consideration of the preponderance of the evidence, the Board concluded that this condition was not separately unfitting for either shoulder. Hip condition. The Board considered if the hips were separately unfitting. The CI presented on 4 October 2004 with the complaint of right thigh and groin pain for 2 weeks since the CI “pulled something during sprints.” The pain was thought to be secondary to a strain of the hip flexors rather than attributed to the joint. The pain persisted leading to X-rays on 12 October 2004 which showed increased density of the pubic bones and lumbar spine. The hips were normal, though. The bone scan showed diffuse, increased uptake, consistent with the systemic osteopetrosis, but did not show an increase localized to the hips. At the NARSUM on 3 May 2004, the CI reported that he was unable to run secondary to “unbearable pain in his hips…,” but did not further address the hips. Neither the profile nor the commander’s letter apportioned the duty limitations between the lower back, hips, knees and ankles. The ROM recorded by physical therapy 3 months prior to separation was limited by pain, but nearly normal. Gait was not recorded on the NARSUM, but was noted to be steady on the C&P examinations which also noted that no assistive devices were in use. After due deliberation in consideration of the preponderance of the evidence, the Board concluded that this condition was not separately unfitting for either hip. Knee condition. The Board considered if the knees were separately unfitting. The CI was initially seen for right knee pain in 1999 during his first enlistment, in the USMC. He was diagnosed with patella-femoral pain syndrome (PFPS) and treated with medications and physical therapy during this enlistment. He separated from the USMC on 30 June 2001 and was granted service-connection for left and right knee strain by the VA. He enlisted in the Army on 2 October 2001 and was seen on 18 October 2001 noting bilateral knee pain after running for three weeks. He was again treated with medications and duty limitations with apparent resolution. On 1 March 2004, he reported a history of bilateral knee pain for over two years related to activity. Bilateral magnetic resonance imaging (MRI) with contrast performed on 2 March 2004. These showed intact ligaments, menisci and articular cartilage. The left knee did show evidence of a quadriceps tendinosis at the insertion into the patella. The CI was treated with physical therapy without significant benefit, but declined a profile. The last treatment note for the knees in the record was for physical therapy and dated 14 June 2004, 16 months prior to separation. The NARSUM did not specifically address the knees, only noting the hip pain with running and pain from load bearing which was not specified. Again, the knees were not specifically profiled nor did the commander specifically address the knees. The ROM measured by the physical therapist was not noted as being abnormal, although both were ten degrees less than the VA normal values. No X-rays were obtained prior to separation. The C&P examination 6 months after separation noted normal ROM with some crepitus, but no instability. Asymmetric joint space narrowing was noted on X-rays. As already noted, the gait was steady and no assistive devices were in use on the post-separation VA examination 10 months after separation. The Board noted that the knee pain had been present for over 4 years at the time of entry into the DES process, existed prior to his enlistment into the Army and that the CI had declined a profile limiting duty. After due deliberation in consideration of the preponderance of the evidence, the Board concluded that this condition was not separately unfitting for either knee. Ankle condition. The CI was seen one time for his ankles, at age 21, while still in the USMC. He was service-connected by the VA for each ankle after separation. There is no record in evidence that he sought treatment for his ankles while in the Army. Neither the commander nor the profile specifically addressed the ankles. The NARSUM is silent for the ankles other than noting a past history of plantar fasciitis. The ROM obtained by the physical therapist 3 months prior to separation showed slightly, but symmetrically reduced dorsiflexion in the ankles and symmetrically increased plantar flexion. Post-separation imaging obtained by the VA was normal. After due deliberation in consideration of the preponderance of the evidence, the Board concluded that this condition was not separately unfitting for either ankle. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (Resolution of reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the bundled shoulder, hip, knee and ankle conditions. BOARD FINDINGS: IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication. The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised, although it is not clear from the record what policy was used by the PEB for rating the bundled condition. In the matter of the neck, back, and bundled shoulder, hip, knee and ankle conditions and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication. There were no other conditions within the Board’s scope of review for consideration. RECOMMENDATION: The Board, therefore, recommends that there be no recharacterization of the CI’s disability and separation determination, as follows: UNFITTING CONDITION VASRD CODE RATING Osteopetrosis Involving the Cervical Spine 5299-5240 10% Osteopetrosis Involving the Lumbar Spine 5299-5240 10% Osteopetrosis Involving the Shoulder, Hip, Knee and Ankle Joints 5099-5016 0% COMBINED 20% The following documentary evidence was considered: Exhibit A. DD Form 294, dated 20120215, w/atchs Exhibit B. Service Treatment Record Exhibit C. Department of Veterans’ Affairs Treatment Record XXXXXXXXXXXXXXXXXXXXX, DAF Acting Director Physical Disability Board of Review SFMR-RB MEMORANDUM FOR Commander, US Army Physical Disability Agency (TAPD-ZB / XXXXXXXXXX), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557 SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXX, AR20130005526 (PD201200191) I have reviewed the enclosed Department of Defense Physical Disability Board of Review (DoD PDBR) recommendation and record of proceedings pertaining to the subject individual. Under the authority of Title 10, United States Code, section 1554a, I accept the Board’s recommendation and hereby deny the individual’s application. This decision is final. The individual concerned, counsel (if any), and any Members of Congress who have shown interest in this application have been notified of this decision by mail. BY ORDER OF THE SECRETARY OF THE ARMY: Encl XXXXXXXXXXXXXXXXXXX Deputy Assistant Secretary (Army Review Boards)