RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXX	CASE:  PD-2014-01001
BRANCH OF SERVICE:  Army	BOARD DATE:  20141014
SEPARATION DATE:  20090716

SUMMARY OF CASE:  The evidence of record indicates this covered individual (CI) was an active duty SPC/E-4 (92A, Automated Logistical Specialist) medically separated for chest pain.  The condition could not be adequately rehabilitated to meet the requirements of her Military Occupational Specialty or physical fitness standards.  She was issued a permanent P3 profile and referred for a Medical Evaluation Board (MEB).  Non-cardiac chest pain, characterized as medically unacceptable, was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded three other conditions.  The Informal PEB adjudicated chronic non-cardiac chest pain as unfitting, rated 10% with application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The remaining conditions were determined to be not unfitting.  The CI made no appeals and was medically separated.

CI CONTENTION:  “Costochondritis (chest wall pain) inflammation of the costal cartilage.”

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 rating for the unfitting non-cardiac chest pain condition is addressed below; 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 consideration by the Board for Correction of Military Records.

RATING COMPARISON:

Service IPEB – Dated 20090331 | VA* - (~1 Mos. Pre-Separation)
Condition | Code | Rating | Condition | Code | Rating | Exam
Chronic Non-Cardiac Chest Pain | 5099-5003 | 10% | Costochondritis, Chest Wall | 5399-5321 | 10% | 20090624
No Additional MEB/PEB Entries in Scope | No Additional Conditions In Scope |
Combined:  10% | Combined:  20%
*Derived from VA Rating Decision (VARD) dated 20091002 (most proximate to the date of separation (DOS))

ANALYSIS SUMMARY:  IAW DoDI 6040.44, the Board’s authority is limited to making recommendations on correcting disability determinations.  The Board’s role is thus 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 ratable severity at the time of separation.

Chronic Non-Cardiac Chest Pain.  Although the CI’s pre-service medical history and physical exam forms are not available for review by the Board, the available evidence documents that the CI experienced intermittent chest pain prior to 2006.  After service entry, her pain gradually increased in frequency and intensity.  There was no specific injury noted.  She reported having 10 to 15 episodes of sharp, sternal pain that resolved spontaneously, on a daily basis.  She noted that if she was hot, carrying something heavy or wearing individual body armor, the pain was significantly worse and lasted much longer.  She stated her left arm went “dead” and she often had shortness of breath associated with the pain and there were no specific provocative or palliative measures.  The narrative summary (NARSUM), prepared 5 months prior to separation, noted that her pain was not resolved with multiple non-steroidal anti-inflammatory medications, Nortriptyline (an anti-depressant medication indicated for the treatment of chronic pain), Lidoderm patch on chest wall (reduces pain), steroid injections and physical profiles.  The CI underwent extensive evaluation by subspecialists.  Cardiology evaluation included multiple studies that ruled out cardiac disease as the cause of her chest pain.  Pulmonology ruled out asthma or bronchospasm.  Gastroenterology ruled out gastroesophageal reflux disease and peptic ulcer disease as causes of her chest pain.  Rheumatology found no systemic disease to account for her pain.  Each of these specialists determined that her non-cardiac chest pain was secondary to costochondritis (inflammation of cartilage that connects ribs to breastbone/sternum).  The NARSUM examiner added, “The soldier's pain existed prior to Service; however, I believe it has been permanently aggravated by her military service.”  The physical exam revealed that the CI’s pain was reproduced by pressure on the sternum as there was tenderness to palpation along the sternocostal margin.  It was otherwise normal.  Her physical profile limited her from moving with a fighting load, constructing an individual fighting position, perform 3-5 second rushes, or deploy.  She was not to perform the Army physical fitness test two mile run or pushups, but may perform the alternate aerobic event of walking.

At the VA Compensation and Pension exam performed approximately a month prior to separation, the CI reported a history consistent with that summarized above.  The physical exam revealed normal heart and lung exams.  The examiner diagnosed “Costochondritis, chest wall” (non-cardiac chest pain-costochondritis) and that there was no effects of the problem on her usual daily activities.

The Board directs attention to its rating recommendation based on the above evidence.  The PEB applied the analogous code of 5099-5003 (degenerative arthritis) and rated it 10% citing VASRD principles of painful motion and functional loss.  They also acknowledged that it existed prior to service but was permanently aggravated by military service beyond the natural progression of the disease.  The VA applied analogous code 5399-5321 which is Group XXI Function: Respiration. Muscles of respiration:  Thoracic muscle group; and also rated the CI’s condition at 10%.  The VA rating decision stated:

“This disability is not specifically listed in the rating schedule; therefore, it is rated analogous to a disability in which not only the functions affected, but anatomical localization and symptoms, are closely related.  An evaluation of 10 percent is assigned for moderate muscle disability.”

The Board reviewed code 5321 and deliberated if the CI’s disability met the maximum “severe or moderately severe” rating criteria at 20%.  The Board determined the evidence did not support the 20% rating criteria since her chest wall pain did not prevent her from accomplishing her normal activities of daily living.  There are no other appropriate coding/rating schemes that could be of benefit to the CI.  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 PEB adjudication for the chronic non-cardiac chest pain 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.  The Board surmised from the record or PEB ruling in this case that no prerogatives outside the VASRD were exercised.  In the matter of the chronic non-cardiac chest pain condition 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 no re-characterization of the disability and separation determination.

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140628, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

				
XXXXXXXXXXXXXXXXX
President
Physical Disability Board of Review

SAMR-RB									

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXX, AR20150007105 (PD201401001)

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						     XXXXXXXXXXXXXXXXX
						     Deputy Assistant Secretary of the Army
						          (Review Boards)
						         
CF: 
(  ) DoD PDBR
(  ) DVA

PD-2014-01001