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AF | PDBR | CY2012 | PD2012 00901
Original file (PD2012 00901.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:    CASE: PD1200901
BRANCH OF SERVICE: Army  BOARD DATE: 20130730
SEPARATION DATE: 20031003


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SPC/E-4 (63W/Wheeled Vehicle Mechanic) medically separated for narcolepsy and for chronic diffuse joint laxity, hypermobile Type III, also known as Ehler-Danlos syndrome. These conditions could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS) or satisfy physical fitness standards. He was issued a permanent P3 U3 S3 profile and referred for a Medical Evaluation Board (MEB). The narcolepsy and chronic diffuse joint laxity hypermobile type Ehler-Danlos syndrome conditions, characterized as medically unacceptable, were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. The MEB also identified and forwarded vocal cord dysfunction (VCD) condition for PEB adjudication. The PEB adjudicated narcolepsy as unfitting, rated at 20%, and adjudicated chronic diffuse joint laxity hypermobile type Ehler-Danlos syndrome conditions as unfitting, not rated, as it existed prior to service (EPTS) and for which no service aggravation had been identified. The VCD condition was determined to be not unfitting . The CI made no appeals, and was medically separated.


CI CONTENTION: “gave me a rating for Narcolesey and depression under the same rating of 10% which it should be under different code which would of gave me a rating of 30% to VA changed my rating to 30% because they notice the problem thanks my shoulder has been coming out of its shocket in the past few years.”


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 narcolepsy and chronic diffuse joint laxity hypermobile type Ehler-Danlos syndrome conditions are addressed below. No additional conditions are within the DoDI 6040.44 defined purview of the Board. Although the CI did note a specific concern pertaining to the perceived combined rating of narcolepsy and depression, the MEB did not forward to the PEB either depression or any other mood disorder. Since depression was not a condition identified by either the MEB or PEB, then it is ineligible to be included in the scope of this review. 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 20030617
 VA – VARD Dated 20090929
Condition
 Code Rating Condition Code Rating Exam
Narcolepsy
 8108 20% Narcolepsy 8199-8108 10% STR
Chronic Diffuse Joint Laxity Hypermobile, Ehler-Danlos Syndrome
 5009-5002
- - - %
 Post-Operative Right Shoulder Laxity Repair 5203 10% STR
No Additional PEB Entries
 Other x 8
Combined: 20%
 Combined: 30%
Derived from VA Rating Decision (VA RD ) dated 200 90929 ( VARD not available near date of separation [ DOS ] ).


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 Veterans Affairs Schedule for Rating Disabilities (VASRD) standards, based on severity at the time of separation.

Narcolepsy Condition. The CI was referred on 21 March 2002 to pulmonology for shortness of breath, which was ultimately diagnosed as VCD secondary to chronic gastro-esophageal reflux disease (GERD). The pulmonologist obtained a history of possible sleep disturbance, and recommended referral for a sleep study, which diagnosed narcolepsy. Although symptoms did improve with medication, a P3 profile due to “sleeping disorder” was recorded on 2 November 2002, limiting the CI to “no driving vehicles, handling ammunition, firing weapons or performing duties requiring concentration or alertness.” The commander’s performance statement letter, dated 14 March 2003, records that the limitation of duties for narcolepsy prohibits assignments in which “sudden incapacitation would be dangerous to self or others.” The narrative summary (NARSUM), 7 months prior to separation, notes a restricted profile preventing him from driving vehicles, firing weapons, or performing duties requiring concentration or alertness. At the MEB exam, 8 months prior to separation, the CI reported a history of “near blackout while driving in the past.” The CI noted that, prior to treatment with Provigil, he would have an irresistible desire to sleep, but that, after beginning treatment, he “had no excessive sleepiness” and was “able to concentrate more clearly.” Although previous examinations had noted that the CI appeared sleepy, the MEB physical exam noted a normal mental status exam. The examiner stated “the (CI) has not described Cataplexy (sudden collapse) or REM intrusion.” The psychiatry addendum to the NARSUM noted that the CI’s impairment for military duty was moderate with definite social and industrial impairment. The prognosis stated that the Provigil helped with attention and alertness, but that the possibility of sudden drowsiness would continue. The only VA Compensation and Pension (C&P) exam available for this review was performed greater than 5 years after separation. At that time, the CI reported chronic daily fatigue. He noted the daily requirement for medication, adding that “without medication, he would doze off at the wheel or fall asleep at any time.” The VA specifically queried the frequency and type of seizures or episodes or narcolepsy, to which the CI replied that there were “no seizures” and that the “daily medication keeps [the] claimant from episodes of narcolepsy.”
The Board directs attention to its rating recommendation based on the above evidence. The PEB 20% rating for narcolepsy was based on DoDI 1332.39, E2.A1.4.1.5. (“Definite industrial impairment”) as the disability description stated “rated as definite” for impairment for civilian wages. The VASRD indicates that narcolepsy, under code 8108, should be coded and rated as epilepsy, petit mal, under code 8911, and in accordance with §4.121.and §4.122. In accordance with (IAW) VASRD guidelines, it is clear that, at separation, the CI’s condition was well controlled, but required daily medication. The MEB noted that the “possibility of sudden drowsiness would continue.” The VA examination, although well beyond the benchmark for high probative value, suggested the presence of up to two episodes of sudden drowsiness per year, while on medication. The VASRD prescribes a 10% rating for “a confirmed diagnosis…with a history of seizures,” and requiring daily medication. A rating of 20% requires a minimum of two seizures in the previous 6 months. The MEB addendum noted that the CI described no episodes of excessive sleepiness after starting the medication. The PEB 20% rating was IAW DoD I guidance in effect at the time . However, the DODI did conflict with the VASRD in effect at the time of the contested separation . Rating IAW VASRD-only criteria, given the adequate control of excessive and sudden sleepiness by medication, without cataplexy or sudden incapacitation, the Board concluded that the most appropriate rating IAW VASRD-only criteria would be 10% . After due deliberation, and given the adequate control of excessive and sudden sleepiness by the Provigil, without cataplexy or sudden incapacitation, the Board concluded that the most appropriate rating for this condition is 10%, coded 8108.

Chronic Diffuse Joint Laxity Hypermobile, Ehler-Danlos Syndrome Condition. The CI’s military entry history and physical (SF 88 and 93) performed in October 2000 indicated normal musculoskeletal exams and no history of any joint pathology. Without a history of shoulder or other joint problems, the CI first noted, during basic training, bilateral shoulder subluxations which spontaneously reduced. Service treatment records (STR) noted a second episode in July 2001, which also spontaneously reduced. Physical therapy (PT) was unable to prevent subsequent shoulder laxity; so that, right shoulder arthroscopy (surgery) was performed in December, 2001 for “mild multidirectional instability” with “previous traumatic injury to his right shoulder” and also “generalized ligamentous laxity of all his other joints.” The arthroscopy noted normal shoulder anatomy and an absence of pathology, except for “diffuse…capsular laxity,” which was satisfactorily repaired with thermal capsulorraphy. Although improvement was noted throughout the course of PT, the CI continued to note pain and decreased range-of-motion (ROM). He was unable fully to rehabilitate the right shoulder, and eventually required a permanent profile which limited overhead movement, such as overhand lifting or throwing. A permanent profile issued on 3 June 2003 specified “no push-ups, pull-ups, dips, or lifting objects greater than 20 lbs.” The CI also noted bilateral patellar pain, but no other joint symptoms. Referred to a geneticist, he was diagnosed with a genetic disorder known as “Ehler-Danlos Syndrome,” which is characterized by a generalized ligamentous laxity, easy bruisability and specific appearance of the skin. As his only musculoskeletal limitations were secondary to symptoms in the shoulder, his profile noted that he was cleared for all other physical activities required of his MOS, except for those activities specific to the shoulder.

Unable to rehabilitate fully from this shoulder condition, he was referred for a MEB. The NARSUM, 7 months prior to separation, notes that after his right shoulder surgery, the CI noted shoulder “pain, limitation of motion and apprehension about the right shoulder.” At the MEB exam, the CI reported that he had experienced no joint problems prior to basic training, and then suffered multiple episodes of right shoulder subluxation and a single subluxation of his left shoulder. He reported a history that he “bruises easily” subsequent to minor blunt trauma, which can be associated with the Ehler-Danlos Syndrome. The MEB physical exam noted hypermobility of all joints, but an absence of bruising. His skin showed “mild elasticity” but not the “smooth, velvety skin” which is characteristic of Ehler–Danlos Syndrome. Magnetic resonance imaging and radiographs of the shoulder were normal. The MEB concluded that his “remarkable” laxity of all joints “prevents him from performing the duties required of his MOS.” No treatment was available, for the diffuse joint laxity and instability of this genetic condition, which would allow a return to full duty. At the C&P exam performed 5 years after separation, the CI reported pain, weakness, swelling and lack of endurance in the right shoulder, and reported twelve episodes of subluxation, but no dislocation, presumably since separation 5 years before.

The goniometric ROM evaluations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.
Shoulder ROM
(Degrees)
 MEB ~ 09 Mo. Pre-Sep
(20030124)		 VA C&P ~6 Years Post-Sep
 (20090803)
Left Right Left Right
Flexion (180 Normal)
 160 180 180 150
Abduction (180)
 Not available 110 180 120
External Rotation (90)
 60 60 60 30
Internal Rotation (90)
 full full 90 90
Comments
 Bilateral shoulders reveal positive apprehension, mildly positive impingement, increased translation of humeral head in the glenoid fossa , equal bilaterally. CI notes r igh t shoulder pain, limited ROM and apprehension. In right shoulder, CI noted pain, weakness, swelling, lack of endurance. Exam revealed tenderness, guarding, abnormal movement, weakness and painful motion.
§4.71a Rating
 0% 10% 0% 10%

The Board directs attention to its rating recommendation based on the above evidence. The generalized ligamentous laxity of Ehler-Danlos Syndrome was determined to be unfitting for continued service. As this genetic condition would have existed from birth, it would be considered to be EPTS . The PEB determined that this condition was not aggravated by service, as the condition itself exists regardless of any injuries which result from it. However, the CI’s actual physical limitations, as recor ded on the profile, limited thos e movements and activities specific to the shoulder , limitations which did not exist prior to enlistment . Additionally, the CI’s specific shoulder symptoms were the only musculoskeletal sympto ms which resulted in his being found unfit for continued service. The patellar pain, as well as the generalized ligamentous laxity discovered on physical examination, were not severe enough to limit any of his activities. Therefore, in light not only of the CI’s shoulder symptoms but also the objective findings re corded on the MEB examination, this Board careful ly considered if a service aggravation to this condition had developed . The shoulder instability was severe enough to require surgical stabilization , which the STRs do state did relieve the instability . However, pain with motion and loss of motion persisted.

Shoulder injuries can be rated on the basis either of instability of the glenohumeral joint (VASRD c ode 5202) , impairments to ROM (VASRD c ode 5201), or under c ode 5003 , and in accordance with VASRD §4.59 (painful motion ) when the sy mptoms are not ratable under those codes which are specific to the shoulder itself. In this case, even though the instability had been surgically corrected, and that laxity, with apprehension, had been noted, the shoulder was stable. No dislocations occurre d after surgery, even up to 5 years after separation. No other pathology except for ligamentous laxity had been noted under arthroscopy. Although ROM was mildly limited, it was not limited enough to warrant rating under Code 5201. However, VASRD c ode 5003 does allow for rating at 10% when there are symptoms, including limitation of motion and pain with motion. Although the Ehler-Danlos Syndrome, which predisposed th e CI to his shoulder injury, was indeed EPTS, the shoulder injury and surgery occurred while the CI was on active duty and was indicative of permanent service aggravation . There was no pre-service evidence of shoulder or joint disability and therefore no pre-existing deduction is warranted.

After due deliberation, considering all of the evidence and mindful of VASRD §4.59 (painful motion) and §4.3 (reasonable doubt), the Board concluded that the right shoulder pain represents a permanent service aggravation of the pre-existing Ehler-Danlos Syndrome, and recommends a disability rating of 10%, under c ode 5099- 5003 , for the Ehler-Danlos Syndrome, with permanent service aggravation of the right shoulder .


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. As discussed above, PEB reliance on DoDI 1332.39 for rating narcolepsy was operant in this case and the Board considered that instruction in its deliberations. In the matter of the narcolepsy condition, the Board unanimously recommends a disability rating of 10% coded 8108 IAW VASRD §4.71a. In the matter of the Ehler-Danlos condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication that this condition is unfitting, and EPTS; however, the right shoulder residual was adjudged permanent service aggravation and the Board unanimously agrees that it was unfitting and unanimously recommends a disability rating of 10% coded 5099-5003, IAW VASRD §4.71a.


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

UNFITTING CONDITION
 VASRD CODE RATING
Narcolepsy Condition
 8108 10%
Ehler-Danlos Syndrome, With Permanent Aggravation of Right Shoulder Condition
 5099-5003 10%
COMBINED
 20%


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20120617, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans’ Affairs Treatment Record




Physical Disability Board of Review


 SFMR-RB                                                                         


MEMORANDUM FOR Commander, US Army Physical Disability Agency
(TAPD-ZB),


 SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for AR20130018097 (PD201200901)

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                                                 
                                                      (Army Review Boards)

CF:
( ) DoD PDBR
( ) DVA

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