RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW NAME: XXXXXXXXXXXXX BRANCH OF SERVICE: ARMY CASE NUMBER: PD1200421 SEPARATION DATE: 20050101 BOARD DATE: 20130221 SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, SGT/E-5 (31B/Military Police), medically separated for arteriovenous malformation (AVM) of the brain. The CI was evaluated for deployment in April 2004, and found to be hard of hearing in the left ear. An audiogram showed significant sensorineural hearing loss (SNHL) and he was referred to the ear, nose and throat specialist. As part of the evaluation of hearing, a magnetic resonance imaging (MRI) of the brain was ordered, that revealed a congenital AVM involving the hypothalamus and the right optic nerve. The AVM of the brain condition could not be risk mitigated for his Military Occupational Specialty (MOS). The AVM condition was disqualifying for enlistment, and hence found contrary to further service, and the CI was referred for a Medical Evaluation Board (MEB). Moderate SNHL and chronic iliotibial band syndrome (ITBS), identified in the rating chart below, were also identified and forwarded by the MEB as meeting retention standards. The Physical Evaluation Board (PEB) adjudicated the AVM of the brain as unfitting and rated 0%, with application of the Veterans Affairs Schedule for Rating Disabilities (VASRD). The PEB adjudicated the moderate SNHL and chronic ITB syndrome as not unfitting. The AVM condition was determined to have existed prior to service (EPTS) and was not permanently aggravated by service but was compensable IAW 10 USC 1207a (eight year rule). The CI made no appeals, and was medically separated with a 0% disability rating. CI CONTENTION: “10% was awarded for my wrist only, nothing for my hearing, knees, etc.” 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 conditions hearing loss and knee as requested for consideration meet the criteria prescribed in DoDI 6040.44 for Board purview; and, are addressed below, in addition to a review of the unfitting AVM condition. The other requested condition, (wrist) is 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 PEB – Dated 20041109 VA (1 Mos. Post-Separation) – All Effective Date 20050102 Condition Code Rating Condition Code Rating Exam Large arteriovenous (AV) malformation of the brain 7199-7113 0% NO VA ENTRY Hearing Loss Not Unfitting Left Ear Hearing Loss 6100 0% No C&P exam Right Ear Hearing Loss 6199-6100 NSC Iliotibial band syndrome Not Unfitting L knee Iliotibial band syndrome 5099-5019 0% 20050223 .No Additional MEB/PEB Entries. Left wrist strain 5299-5215 10% 20050223 Combined: 0% Combined: 10% ANALYSIS SUMMARY: Arteriovenous Malformation Condition. The narrative summary (NARSUM) noted an MRI with a coincidental finding of an AVM involving the hypothalamus and the right optic nerve. The CI related that he had undergone an imaging study for other reasons prior to his enlistment. The CI stated that civilian neurosurgeons felt that surgery or any other treatment would be too risky compared to allowing the condition to play out its natural history. The CI reported that when he entered military service, he did not describe his medical condition, because he felt it was not significant based on this information. Due to the 2-4% risk of hemorrhage per year, and spontaneous morbidity or mortality, the PEB found the CI unfit for continued service, with a condition that EPTS, without permanent aggravation by service, but compensable by the 8 year service rule. At the MEB exam, 8 months prior to separation, the CI “denies headaches, seizures, focal weakness or any other neurologic changes, except for a history of decreased vision in the right eye.” The MEB physical examiner noted “the arterial venous malformation of the brain… has caused no problems for the patient and he has no neurologic deficits whatsoever.” The commander’s statement referenced the dangers of deployment and being in a military environment, but cited no impairment of duty due to the AVM. At the VA Compensation and Pension (C&P) exam 7 weeks after separation, there was no comment or entry on the AVM condition. The Board directs attention to its rating recommendation based on the above evidence. The PEB coded 7199-7113, as analogous to arteriovenous fistula, traumatic, stating “The condition while presently asymptomatic is incompatible with the rigors of military service.” There was no history of trauma or bleeding. The Board considered alternative analogous coding under 7112 (Aneurysm, any small artery) or 8009 (Brain, vessels, hemorrhage) and could find no path to coding to qualify for any higher rating than 0% under VASRD §4.31 (0 % evaluations). The Board considered other coding under the central nervous system and vascular system, but could find no better coding than 9199-7113, analogous to arteriovenous fistula, traumatic, and noted that there were no deficits or sequellae, including the member’s right eye vision changes correctable to 20/20, that could be directly related to the presence or service aggravation of the AVM itself, according to the service treatment record (STR). 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 AVM condition. Contended PEB Conditions. The contended conditions adjudicated as not unfitting by the PEB were ITBS and hearing loss. The Board’s first charge with respect to these conditions was an assessment of the appropriateness of the PEB’s fitness adjudications. The Board’s threshold for countering fitness determinations is higher than the VASRD §4.3 (Resolution of reasonable doubt) standard used for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard. Chronic Iliotibial Band Syndrome. The CI stated his left knee was injured while rappelling out of a helicopter in 1998. The record shows he had several courses of physical therapy, ultrasound phonophoresis with steroids, anti-inflammatory medications steroid injections and eventually a left neoprene knee brace in Jan 2002 all directed at the IBTS. Although both knees are frequently mentioned in the STR, the left knee was usually more painful and symptomatic than the right. Treatments were aimed at correcting subtle left leg length differences with ¼ inch left lift shoe in 2001, and participation in run-walk programs. The CI underwent multiple knee MRI exams, and had numerous P/L2 and P/L3 profiles. The Board considered if there was a preponderance of evidence that the left knee condition would have rendered the CI unfit for duty. The Board considered the commander’s statement about the CI’s L2 profile knee causing the CI a “lack of agility” and found no other STR evidence to support this. The Board found evidence that the CI had continued to successfully pass two 12 mile road marches, the first in May 2002 and the second in August 2003, despite his left knee condition. The Board noted that the CI passed his modified Army Physical Fitness Test in March 2004, 9 months prior to separation. The Board noted the L2 profile knee condition did not limit the CI’s ability to deploy. The Board noted that the CI was preparing to deploy in May 2004, under ongoing permanent knee L2 profile restrictions from April 2002, and that in all likelihood if it were not for the PEB deeming his AVM condition incompatible with the rigors of military service, he would have proceeded to deployment. Given this information, the Board opined that there was no preponderance of the evidence that the CI’s left knee condition would have been in and of itself unfitting. After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the chronic IBTS condition and no additional disability rating is recommended. Hearing Loss. The Board turned its attention to the fit vice unfit determination for the CI’s left ear hearing loss. The Board noted that the commander’s letter referenced the CI’s poor hearing as causing difficulty with performing his duties of his MOS, despite him wearing a hearing aid. The audiologist evaluation indicated 100% speech discrimination in both ears and hearing loss between 250-2K cycles per second hearing frequency. The Board noted the CI was permanently profiled H2 hearing loss as “Moderate to mild mixed hearing loss from 250-3000 Hz in the left ear,” without duty restrictions by the audiologist, but recommendations of “No exposure to noise in excess of 85dBA or weapon firing without the use of properly fitted hearing protection. Hearing aid issued to improve communication in quiet environments. Annual audiogram required.” The Board directed attention to its fitness recommendation based on the above evidence. The final profile was H1, despite prior H2 profile and audiogram evidence which fit an H2 profile. The Board noted that both H1 and H2 hearing profiles are not unfitting in the military police MOS. After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the hearing loss condition and no additional disability rating is recommended. 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. In the matter of the AVM condition and IAW VASRD §4.104, the Board unanimously recommends no change in the PEB adjudication. In the matter of the contended chronic IBTS and hearing loss conditions, the Board unanimously recommends no change from the PEB determinations as not unfitting. 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 Large Arteriovenous Malformation of the Brain 7199-7113 0% RATING 0% The following documentary evidence was considered: Exhibit A. DD Form 294, dated 20120427, 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 / xxxxxxxxxxx), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557 SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for xxxxxxxxxxxxxxxxx, AR20130005534 (PD201200421) 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 xxxxxxxxxxxxxxxxxxxxxx Deputy Assistant Secretary (Army Review Boards)