RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD1201983
BRANCH OF SERVICE:  AIR FORCE	BOARD DATE:  20130522
SEPARATION DATE:  20081031

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty/SSgt/E-5 (7SOX1/Special Investigation Craftsman]) medically separated for recurrent bronchospasm and left thigh conditions.  The CI first noticed the symptoms after returning from a deployment to Afghanistan.  On 23 October 2007, the CI complained of shortness of breath (SOB) and chest tightness during exercise, and nighttime wheezing.  Additionally, she experienced pain in her left thigh trauma to her hemangioma.  The recurrent bronchospasm and left thigh conditions could not be adequately rehabilitated to meet the physical requirements of her Air Force Specialty or satisfy physical fitness standards.  She was issued a duty limiting condition report and referred for a Medical Evaluation Board (MEB).  The recurrent bronchospasm and left thigh conditions, characterized as asthma, moderate persistent and hemangioma on left thigh, were forwarded to the Physical Evaluation Board (PEB) with the recommendation of return to duty IAW AFI 48-123.  No other conditions were submitted by the MEB.  The PEB adjudicated recurrent bronchospasm and left thigh pain due to cavernous hemangioma as unfitting, rated 10% and 10%, with application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) IAW National Defense Authorization Act of 2008.  The CI made no appeals, and was medically separated.

CI CONTENTION:  “Due to increased severity of the Hemangioma/Venous Malformation for which I was medically discharged from the Air Force, I had undergone seven (7) additional sclerotherapy surgeries.  I was misdiagnosed by the military and as of December 2011, and had to have my left lateral quadriceps muscle bundle surgically removed in my left leg.  This has resulted in additional issues, limited mobility, and leg numbness at the surgery site.  As you will see in the photographs, my leg is permanently concaved/disfigured from the loss of the muscle bundle.  I was issued a permanent handicap parking pass, as a result of my condition.  Due to overcompensation with my right leg, my gait is thrown off and I have regularly scheduled chiropractic visits to help.  At one appt, it was noted by my chiropractor that I had three (3) ribs out of place because of my gait.”  Additionally, the CI attached a five page statement to her application which was reviewed by the Board and considered in its recommendations.

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e. (2).  It is limited to those conditions determined by the PEB to be unfitting for continued military service and those conditions identified but not determined to be unfitting by the PEB when specifically requested by the CI.  The ratings for the unfitting recurrent bronchospasm and left thigh conditions are addressed below; and, no additional conditions are within the DoDI 6040.44 defined purview of the Board.  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 Board for Correction of Military Records.

RATING COMPARISON:

Service IPEB – Dated 20080912	VA - (~1 Mo. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Recurrent Bronchospasm	6699-6602	10%	Asthma/Recurrent Bronchospasm	6602	10%	20080404	
Left Thigh Pain Due to Cavernous Hemangioma	8799-8726	10%	Cavernous Hemangioma, Left Thigh	8799-8726	10%	20080404	
No Additional MEB/PEB Entries	Other x 1	20080404	
Combined:  20%	Combined:  30%	
Derived from VA Rating Decision (VARD) dated 20080404 (most proximate to date of separation [DOS]).  

ANALYSIS SUMMARY:  This case was adjudicated as part of the pilot disability evaluation system under the policy and procedure directive type memorandum of 21 November 2007 (DoD VA Disability Evaluation System [DES] Pilot Program).  The Board’s role in these cases, as confirmed by consultation with DoD, is two-fold.  First, it must assess the fairness of the PEB’s fitness adjudications, and may offer recommendations for rating (s) of any condition which it determines would have (independently or in combination) rendered the CI incapable of adequately performing required duties.  The Board’s threshold for countering DES fitness determinations is higher than the VASRD §4.3 (Reasonable doubt) standard used for its rating recommendations; but, remains adherent to the DoDI 6040.44 “fair and equitable” standard.  Second, the Board must review the fairness and accuracy of the VA assigned rating, and may recommend a higher rating if warranted.  As with all such recommendations (IAW DoDI 6040.44) the Board may not recommend a rating lower than that received prior to application.

Recurrent Bronchospasm.  The CI developed SOB, wheezing, and chest tightness with decrease exercise tolerance, after return from deployment to Afghanistan in 2006.  Symptoms worsened and she was diagnosed with asthma in October 2007.  Daily anti-asthma medications improved her symptoms so that she rarely needed the use of the Albuterol inhaler.  Pulmonary function tests (PFT) performed while CI was on inhaled steroids and other anti-asthma medications showed FEV1 104% of predicted value with a normal FEV1/FVC.  Therefore PFTs were unreliable in ruling out asthma.  Methacholine challenge test for asthma was negative but noted most likely to be a false negative.  The pulmonary medicine consultant was reluctant to discontinue medications for the purpose of further testing because the CI was markedly better with them, although symptoms were not entirely controlled during very cold weather.  As of 21 March 2008, there was no objective evidence of asthma because PFTs, methacholine challenge, and exercise induced asthma tests had been negative.  A second methacholine challenge off medications for a longer period of time prior to testing was planned.  At the VA Compensation and Pension (C&P) exam, 6 months prior to separation, the CI noted the Advair 500/50 (Fluticasone and Salmeterol), Albuterol, Singulair and Zyrtec medications kept the asthma under control but with strenuous exertion she experienced some SOB and wheezing.  Exam showed lungs were clear to without wheezes, rales, or rhonchi.  PFT showed FEV1 109% of predicted value, and FEV1/FVC=85% of predicted value.  The CI had repeat methacholine bronchoprovocation testing and PFTs after discontinuing all controller asthma medications and completion of 6 weeks of antibiotics.  FEV1 never dropped below the threshold (-20%) that is diagnostic of asthma, but it dropped to -17%, and her FEF 25-75% dropped to -32% (suggestive of small airway obstruction, but not diagnostic of asthma).  Symptoms returned, requiring Albuterol multiple times daily and SOB with mild exercise.  Controller asthma medications were restarted.  At the MEB narrative summary (NARSUM) the CI noted daily limitations (bronchospasm from gun powder, and inability to participate in tactical training).  Medications included Advair 500/50, Singulair, Flonase, and Claritin daily, and Albuterol as needed.  

The Board directs its attention to its rating recommendation based on the above evidence.  The Air Force PEB and the VA characterized the condition as “recurrent bronchospasm,” coded it as 6602 and rated the CI’s condition at 10%.  Using data from the treatment record, the Board determined that at the time of final separation from military service, the CI was being treated with daily inhalational Advair and daily Singulair (an indirect oral bronchodilator) supporting a 30% rating.  There was no evidence for respiratory failure, frequent exacerbations requiring physician intervention, or use of systemic corticosteroids.  Therefore, a higher rating of 60% was not justified.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (Reasonable doubt), the Board unanimously recommends a separation disability rating of 30% for the asthma condition.

Left Thigh Pain Due to Cavernous Hemangioma.  Hemangioma of the left thigh was discovered in basic training, in 1997.  She developed swelling, bleeding, and pain.  She had sclerotherapy three times and medications for pain.  Magnetic resonance imaging of the left thigh, in April 2001, showed an infiltrative venous malformation (hemangioma) that had decreased from an earlier size.  Neither surgery nor other invasive procedures were considered good treatment options, at that time.  The CI reported that it felt like the left thigh bone was jagged, like with “teeth,” that rubs against the hemangioma and makes it swell.  With trauma and swelling the thigh became painful and she was unable to walk.  Compression stockings and medications help reduce the swelling.  At the C&P exam, performed 6 months prior to separation, the CI reported hemangioma flared up with strenuous exercises and caused pain and swelling but she was able to “work with it.”  During flare ups of the hemangioma, she wore a compression stocking over the left thigh and took medication for pain.  Exam showed a well coordinated normal gait and no assistive devices but diffuse swelling of left thigh measuring 10 x 9 centimeters.  It was most pronounced on contraction of the left quadriceps muscle and on standing.  There was mild tenderness to palpation over the swelling with no evidence of bruising or bleeding into the skin.  Sensory and exam and coordination were intact.  Deep tendon reflexes were 2+ and symmetrical.  At the time of the MEB NARSUM, the CI noted the hemangioma swelled with activity and trauma and she experienced daily soreness.  

The Board directs its attention to its rating recommendation based on the above evidence.  The VA characterized the condition as “cavernous hemangioma, left thigh,” coded it as 8799-8726 (neuralgia involving the quadriceps extensor muscles) and rated the CI’s condition at 10% for mild incomplete paralysis of the thigh muscle.  The PEB adopted the VA rating.  The Board discussed whether the condition was mild vs. moderate.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (Reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the adjudication for the cavernous hemangioma condition.

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.  In the matter of the bronchospasm condition, the Board unanimously recommends a disability rating of 30%, coded 6602 IAW VASRD §4.100.  In the matter of the cavernous hemangioma condition and IAW VASRD §4.124a, 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 recommends that the CI’s prior determination be modified as follows; and, that the discharge with severance pay be recharacterized to reflect permanent disability retirement, effective as of the date of her prior medical separation:

UNFITTING CONDITION	VASRD CODE	RATING	
Bronchospasm/asthma	6602	30%	
Cavernous Hemangioma	8799-8726	10%	
COMBINED	40%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20121130, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

	XXXXXXXXXXXXXXXXXXXX, DAF
	President
	Physical Disability Board of Review

SAF/MRB
1500 West Perimeter Road, Suite 3700
Joint Base Andrews MD 20762

Dear XXXXXXXXXXXXXXXXXXXX:

	Reference your application submitted under the provisions of DoDI 6040.44 (Title 10 U.S.C. § 1554a), PDBR Case Number PD-2012-01983.

	After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was not appropriate under the guidelines of the Veterans Administration Schedule for Rating Disabilities.  Accordingly, the Board recommended your separation be re-characterized to reflect disability retirement, rather than separation with severance pay.

	I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding, accept their recommendation and determined that your records should be corrected accordingly.  The office responsible for making the correction will inform you when your records have been changed.

	As a result of the aforementioned correction, you are entitled by law to elect coverage under the Survivor Benefit Plan (SBP).  Upon receipt of this letter, you must contact the Air Force Personnel Center at (210) 565-2273 to make arrangements to obtain an SBP briefing prior to rendering an election.  If a valid election is not received within 30 days from the date of this letter, you will not be enrolled in the SBP program unless at the time of your separation, you were married or had an eligible dependent child, in such a case, failure to render an election will result in automatic enrollment.  

							Sincerely,

XXXXXXXXXXXXXXXXXXXX
Director
Air Force Review Boards Agency

Attachment:
Record of Proceedings

cc:
SAF/MRBR
DFAS-IN