RECORD OF PROCEEDINGS

PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXX. BRANCH OF SERVICE: air force

CASE NUMBER: PD1100884 SEPARATION DATE: 20080603

BOARD DATE: 20120412

SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty TSgt/E-6 (3S371, Manpower Craftsman), medically separated for chest pain due to costochondritis. She initially presented with chest pain in October 2006 and was diagnosed with costochondritis. She did not respond adequately to multiple non-surgical treatments and was unable to perform within her Air Force Specialty (AFS) or meet physical fitness standards. She was placed on duty limitations and underwent a Medical Evaluation Board (MEB). Costochondritis was forwarded to the Physical Evaluation Board (PEB) as medically unacceptable IAW AFI 48-123. No other conditions appeared on the MEB’s submission. Other conditions included in the Disability Evaluation System (DES) packet will be discussed below. The PEB adjudicated the chest pain due to costochondritis condition as unfitting, rated 20% with application of the Veterans Administration Schedule for Rating Disabilities (VASRD). The CI made no appeals, and was medically separated with a 20% combined disability rating.

CI CONTENTION: “When I received my MEB, I was told that I had costochondritis which would stay with me for life. However, they only gave me a 20% disability. The VA agreed that I had costochondritis but there were no objective findings since my EKGs/X-rays were normal. However, the presence or absence of swelling is only an indicator of the severity of the condition and does not rule out the condition itself; as the nature of costochondritis is that only acute symptoms are manifested and may not always be present. Also, as I was treated on active duty for this condition, I had pain that radiated from my back to my chest. I have been awarded VA disability for a lumbar/thoracic strain which I think is related to my condition. Since being discharged I received medical treatment for my condition at the VA hospital in Kansas City. I have also not been exercising or lifting heavy items like I was when I was on active duty because I still find that it can cause the condition to appear. I believe this is why my condition did not manifest itself when I went for my initial examination. My military medical records show that I’ve had this condition off and on for years. Before I came in the military I did not have costochondritis (and my pre-entrance exam will show that) and therefore it is a service-related injury. Thus, I believe that I should have been medically retired instead of given the 20% disability and discharged without any benefits.”

RATING COMPARISON:

ANALYSIS SUMMARY: The Board acknowledges the sentiment expressed in the CI’s application regarding the significant impairment with which her service-aggravated condition continues to burden her. It is a fact, however, that the DES has neither the role nor the authority to compensate service members for anticipated future severity or potential complications of conditions resulting in medical separation. This role and authority is granted by Congress to the Department of Veterans’ Affairs (DVA). The DVA, operating under a different set of laws (Title 38, United States Code), is empowered to compensate service-connected conditions and to periodically re-evaluate said conditions for the purpose of adjusting the veteran’s disability rating should his degree of impairment vary over time. The Board utilizes VA 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.

Chest Pain Due to Costochondritis. The CI had sudden non-traumatic onset of chest pain in late 2006, and was diagnosed and treated for costochondritis. She was tried on multiple medications (including steroids and neurontin), physical therapy, osteopathic manipulative therapy, stress reduction, and injections with no relief of symptoms. Rheumatology and pain medicine specialists confirmed the diagnosis and CT and MRI imaging were normal. There was no evidence of cardiac or pulmonary etiology to the chest pain which was episodic, and worse with movements. Narrative summary (NARSUM) and MEB exams accomplished 3 and 4 months prior to separation indicated normal cardiac and pulmonary exams. Chest pain was reported as discomfort to the center of the anterior chest wall without radiation, with tenderness in the chest when touched, dull aching, and occurring as a recurring condition. Exam of the chest indicated “tenderness, tenderness of the left chest. Sternum tenderness was noted. Visual inspection revealed no abnormalities. No soft tissue crepitus. Ribs showed no abnormalities.”

The VA exam, 5 months after separation, indicated similar history, report of symptoms, and poor response to treatments. Chest percussion was normal without tenderness; there was no objective evidence of pain on deep respirations and no guarding. Pulmonary and cardiac portions of the exam were normal. Based on this exam, the VA denied service-connection (not rated).

The PEB remarks indicated “The Board notes your chest pain is persistent and not improving with therapy and you have physical limitations.” The PEB rated the CI’s costrochondritis as 5022-5297 analogous to Periostitis (5022) and removal of two ribs (5297) for their 20% rating level. Independent rating of the exams and ideal coding would be 5022-5321 at 20%, as there was no radiographic evidence of rib abnormality or history of rib removal. The commander’s comment of “(the CI) suffers from uncontrollable spasms in her chest and as a result experiences severe pain to the point she has to stop working for lengthy periods throughout the day until the pain subside.” May reasonably equate to “evidence of occasional incapacitating exacerbations” as indicated in the 20% rating criteria. Alternate coding under §4.73 – schedule of rating – muscle injuries, analogous to group XXI (function: respiration. muscles of respiration: thoracic muscle group) has a maximum rating of 20%, and although changing coding would not provide any benefit to the CI, it is predominate to the PEB coding. IAW DoDI 6040.44, the Board may not recommend a rating lower than that received prior to application. Therefore, all evidence considered, there is not reasonable doubt in the CI’s favor supporting a change from the PEB’s 20% rating decision for the chest pain/costrochondritis condition, although coding should be modified to 5022-5321.

Other Contended Conditions. The CI’s application asserts that compensable ratings should be considered for lumbar/thoracic strain as she was treated on active duty for this condition, and “had pain that radiated from my back to my chest.” This condition was reviewed by the action officer and considered by the Board. Back exams at the MEB and NARSUM were normal with no duty limitations attributable to the thoracolumbar spine. The VA exam after separation indicated pain with motion and tenderness of the spine. There was full range of motion with no radiculopathy or mention of referred chest pain. There was no evidence for concluding that any thoracolumbar spine condition interfered with duty performance to a degree that could be argued as unfitting. The unfitting symptom of anterior chest pain was attributed and rated as costrochondritis above and VASRD §4.14 (avoidance of pyramiding) was considered. The Board determined therefore that the stated thoracolumbar spine condition was not unfitting and not subject to service disability rating.

Remaining Conditions. Other conditions identified in the DES file were carpal tunnel syndrome, patellofemoral syndrome, knee surgery, cholycystectomy, and menorrhagia with bilateral tubal ligation and hysterectomy. Several additional non-acute conditions or medical complaints were also documented. These conditions were reviewed by the action officer and considered by the Board. None of these conditions were significantly clinically or occupationally active during the MEB period, none carried attached profiles, and only the knee condition with prior surgery (2005) was implicated in the commander’s statement. The Board considered if anxiety (stress reduction was mentioned in the DES, but there was no axis I diagnosis and no mental health limitation mentioned on the AF Form 459, duty limiting condition report) or any mental disorder could be the etiology of the CI’s chest pain; however, there was no indication of panic attacks, or linkage of the chest pain to any mental health diagnoses, even in the post-separation VA mental disorder exam. The MEB/NARSUM exams of the knee were not detailed, but indicated normal lower extremity function and normal gait. The VA detailed knee exams after separation documented full painless ROMs. It was determined that none of the conditions could be argued as unfitting and subject to separation rating.

Additionally painful scars, dysthmic disorder claimed as depression, left shoulder strain, right ankle strain with mild degenerative joint disease, bilateral pes planus with mild degenerative changes, tinnitus, and several other non-acute conditions were noted in the VA proximal to separation, but were not documented in the DES file. The Board does not have the authority under DoDI 6040.44 to render fitness or rating recommendations for any conditions not considered by the DES. The Board therefore has no reasonable basis for recommending any additional unfitting conditions for separation rating.

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 chest pain/costochondritis condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication. The Board prefers the 5022-5321 coding route, but sees no point in recommending a change in code since rating is unaffected. In the matter of the thoracolumbar spine condition, the Board unanimously agrees that it cannot recommend a finding of unfit for additional rating at separation. In the matter of the left knee condition or any other medical conditions eligible for Board consideration; the Board unanimously agrees that it cannot recommend any findings of unfit for additional rating at separation.

RECOMMENDATION: The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of her prior medical separation.

The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20111003, w/atchs

Exhibit B. Service Treatment Record

Exhibit C. Department of Veterans Affairs Treatment Record

XXXXXXXXXXX

President

Physical Disability Board of Review

SAF/MRB

1500 West Perimeter Road, Suite 3700

Joint Base Andrews MD 20762

Dear XXXXXXXXXXXX

Reference your application submitted under the provisions of DoDI 6040.44 (Title 10 U.S.C. § 1554a), PDBR Case Number PD-2011-00884.

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.

I have carefully reviewed the evidence of record and the recommendation of the Board. I concur with that finding, accept their recommendation and direct that your records be corrected as set forth in the attached copy of a Memorandum for the Chief of Staff, United States Air Force. The office responsible for making the correction will inform you when your records have been changed.

Sincerely,

XXXXX

Director

Air Force Review Boards Agency