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AF | PDBR | CY2013 | PD-2013-02672
Original file (PD-2013-02672.rtf) Auto-classification: Approved
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXX  CASE: PD-2013-02672
BRANCH OF SERVICE: Army  BOARD DATE: 20150409
SEPARATION DATE: 20080309


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Human Intelligence Collector) medically separated for a thyroid, joint pain and feet conditions. These conditions could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty or satisfy physical fitness standards. He was issued a permanent P3/U2/L3/S1 profile and referred for a Medical Evaluation Board (MEB). Post-ablative hypothyroidism, arthralgia and plantar fasciitis were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. The MEB also identified and forwarded three other conditions. The Informal PEB adjudicated hypothyroidism to include arthralgia, and bilateral plantar fasciitis as unfitting, rated 10%, and 0% respectfully 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: CI contends his rating would be different with application of the VASRD. He also contends he was not evaluated for back and PTSD conditions. His complete submission is at Exhibit A.


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 when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting. Any conditions outside the Board’s defined scope of review and any contention not requested in this application may remain eligible for future consideration by the Board for Correction of Military/Naval Records. Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate. The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards to the unfitting medical condition at the time of separation. The Board has neither the role nor the authority to compensate for post-separation progression or complications of service-connected conditions. That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws. The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation.


RATING COMPARISON :

Service IPEB – Dated 20071220
 VA* - (16 Days Pre-Separation)
Condition
 Code Rating Condition Code Rating Exam
Hypothyroidism…Arthralgia 7903 10% Hypothyroidism 7903 30% 20080222
Bilateral Plantar Fasciitis 5399-5310 0% Plantar Fasciitis 5276 NSC 20080222
Grave’s Disease Not Unfitting No VA Placement
Acute Stress Reaction Not Unfitting No VA Placement**
Bilateral Shin Splints Not Unfitting Bilateral Shin Splints 5310 0% 20080222
Other MEB/PEB Conditions x 0 (Not In Scope)
RATING: 10%
 RATING: 40%
*Derived from VA Rating Decision (VARD) dated 200 80423 (most proxima te to date of separation [ DOS ] )
* * VARD dated 20100907 awarded service connection for PTSD r ated at 30% effective 20080310 (day after DOS)


ANALYSIS SUMMARY:

Hypothyroidism Post Ablative Therapy for Grave’s Disease to include Arthralgia. Service treatment records and narrative summaries (NARSUM) detailed that the CI was diagnosed with Graves’ disease (immune disorder of the thyroid) in 2006. History indicated prior-to-enlistment obesity with 100 pounds weight lost prior to enlistment. In early 2005, the CI had episodes of cough and shortness of breath (dyspnea) with palpitations (rapid heartbeat sensation), chest pain, night sweats and dizziness initially treated as asthma. Asthma was ruled out and the endocrinologist stated “in retrospect, this might have been an early manifestation of his thyroid disease.”

On further complaints and evaluation for dyspnea on exertion, malaise, and fatigability the CI was diagnosed with hypothyroidism in February 2006. He was diagnosed with Grave’s disease (autoimmune disease of the thyroid) and was treated with thyroid ablation with radioactive iodine and replacement Synthroid (medication). He deployed to Iraq and was returned from theater due to inability to control medications and symptoms which included fatigue and inability to work a full day or participate in convoy operations. “Despite the severe shortage of interpreters, his command finally redeployed him to CONUS due to his marked lack of physical stamina.” The CI had significant weight gain (40 pounds over 8 months), multiple musculoskeletal complaints (feet, knees, lower legs) and was difficult to manage on medications with his Synthroid doses being changed multiple times with periods of hyperthyroidism and hypothyroidism. Symptoms in treatment notes and the DD Form 2807, MEB Report of Medical History, dated 23 August 2007 included: “constipation which is chronic, alternating with diarrhea”; heat intolerance to cold; decreased concentration ability; depression or excessive worry; and, frequent trouble sleeping.

At the time of the DD Form 2808, MEB Report of Medical Examination, on 28 August 2007 (7 months prior to separation), the CI’s thyroid stimulating hormone was high (indicating insufficient synthroid replacement) and his weight was 260 pounds (height 70 inches). By the time of the NARSUM (typed on 11 December 2007), 3 months prior to separation, the laboratory testing indicated adequate synthroid replacement. The NARSUM noted that evaluations excluded any endocrine or medical etiology for the weight change. Symptoms at the NARSUM included he reports diffuse weakness and easy fatigability with walking, insomnia and depressive symptoms (on medication) attributed to weight gain and his potential separation. Exam documented obesity with normal appearance of the neck with no palpable thyroid or nodules. Cardiac exam was normal without bradycardia. Motor strength was normal and reflexes and sensory exams were normal. The examiner stated “the (CI) has a combination of conditions resulting in markedly limiting lower extremity arthralgias, plantar fasciitis and generalized weakness with poor exercise tolerance that result from his hypothyroidism and obesity.”

At the VA Compensation and Pension exam dated 22 February 2008, 16 days prior to separation, the CI reported similar symptom onset and treatment history. He attributed his weight gain and fluctuation from 198 pounds to his exam-date weight of 285 pounds to his hypothyroidism. He complained of intolerance to hot or cold conditions, chronic constipation with occasional loose stools, poor sleep, insomnia, and lack of energy. He was taking Synthroid daily. Exam documented a normal skin and scalp exam with non-palpable thyroid. Blood pressure was normal with a normal heart rate (70 bpm). Testing for muscle strength, reflexes and sensation were normal.

The Board directed attention to its rating recommendation based on the above evidence. The rating criteria for hypothyroidism are copied below:

7903     Hypothyroidism
                  Cold intolerance, muscular weakness, cardiovascular involvement,
                           mental disturbance (dementia, slowing of thought, depression),
                           bradycardia (less than 60 bea ts per minute), and sleepiness      100
                  Muscular weakness, mental disturbance, and weight gain   60
                  Fatigability, constipation, and mental sluggishness      30 VA
                  Fatigability, or; continuous medication required for control     10 PEB

The PEB (10%) disability description included MEB diagnoses #1 and #2 (1. Post-ablative hypothyroidism, and 2. Arthralgias, multiple sites) and stated:

“Hypothyroidism post ablative therapy for Grave's disease. Chemically this condition is controlled with Synthroid, however, he attributes his obesity and arthralgias to this condition despite his preservice obesity. His commander's letter is not specific but the MEB physician feels this condition should be considered a contributing factor to his; obesity, fatigue, diffuse arthralgias. Thus, it is rated for fatigability and continuous medication. The endocrinologist specifically states that this is not the cause of his weight gain. There is no mental disturbance nor muscular weakness. Therefore neither 30% or 60% are appropriate.”

The VARD noted fatigability and constipation without evidence of mental sluggishness and cited VASRD §4.7 (higher of two evaluations) to assign a 30% rating. The Board deliberated between the 10% and 30% criteria and discussed the evidence and factors of weight gain (60% criterion) with mixed attribution to the hypothyroidism and/or diffuse arthralgias (and other musculoskeletal conditions), constipation, depressed mood, cold intolerance, and the tenants of VASRD §4.3 (reasonable doubt) as well as §4.7. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 30% for the hypothyroidism condition.

Bilateral Plantar Fasciitis. The CI’s entry physical documented mild, asymptomatic pes planus (flat feet) with use of inserts (orthotics) for both feet. The CI had increased symptoms of bilateral plantar fasciitis in 2006 with weight gain and pre-deployment preparation. Post-deployment treatment including exercises and new custom orthotics and night splints with some decrease in symptoms. Foot pain increased to 5/10 during prolonged standing or activity. Pain improved with rest and soft-soled boots.

The NARSUM exam, 3 months prior to separation, documented normal gait and posture with normal strength and motion in the ankles. There was excessive pronation and pes planus with tenderness on the bottom of the foot at the heel on both feet.

The VA exam, 16 days prior to separation, the CI reported continued use of inserts, intermittent pain with standing and inability to walk over one-half mile. Exam of the feet documented pes planus of the left foot with the Achilles tendon angled 5 degrees toward the great toe. There was “no tenderness to palpation, even deep palpation, on the plantar surfaces.” Left ankle dorsiflexion was 10 degrees (normal 20) with all other ankle motions normal, and no ankle instability. The examiner indicated that the CI stated that on the day of the exam he had not been using his feet; however, if he had been standing he stated he would have had pain.

The Board directed attention to its rating recommendation based on the above evidence. The PEB rated the bilateral plantar fasciitis analogous to 5310, Group X muscle function as “slight” at 0%. The VA did not rate the condition as there was no clinical evidence of plantar fasciitis on exam. There was no evidence for a higher muscle rating IAW §4.73 when applying the tenants of VASRD §4.55 (principles of combined ratings for muscle injuries) and §4.56 (evaluation of muscle disabilities). The Board considered possible analogous coding using 5276 (flatfoot, acquired).

There was clear evidence of pre-existing pes planus with use of orthotics at entry. The exam noted excessive pronation and the VA exam indicated the weight bearing line (of the Achilles) deviated towards the great toe. The exam documented heel area tenderness (essentially pain on manipulation); however, by the time of the prior to separation VA exam, tenderness had resolved. The CI’s disability picture was closest to the 0% criteria of “Mild: symptoms relieved by built-up shoe or arch support.”

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 bilateral plantar fasciitis condition.

Contended PEB Conditions. The Board’s main charge is to assess the fairness of the PEB’s determination that Grave’s disease, acute stress reaction (contended as posttraumatic stress disorder [PTSD]) and bilateral shin splints were not unfitting. The Board’s threshold for countering fitness determinations is preponderance of the evidence, but remains adherent to the DoDI 6040.44 “fair and equitable” standard. The Grave’s disease, acute stress reaction and bilateral shin splints conditions were not profiled and were not judged to fail retention standards. The commander’s statement noted the CI’s difficulty getting to work due to sleeping difficulties and his being not physically fit to go on missions or work long hours, but did not note any specific condition or diagnosis.

Grave’s Disease: Grave’s disease is an autoimmune condition affecting the thyroid gland. The thyroid gland was ablated and any residuals relating to the thyroid gland or Grave’s disease were considered under the unfitting hypothyroidism condition above.

Acute Stress Reaction (contended as PTSD). The profile did not list any mental health (MH) (“S”) limitations and there was no Axis I MH diagnosis on the MEB or PEB. The CI had seen social workers and was diagnosed with an acute stress reaction with a primary care provider prescribing an anti-depressant medication (Wellbutrin). A psychiatrist’s memo in November 2007 stated that “It does not appear that (the CI) has any current psychiatric symptoms interfering with his ability to function in the military setting,” and that he met retention standards. The NARSUM indicated “Acute Stress Reaction- acute in nature and responding appropriately to counseling/medication; medically acceptable.” The VA psychiatric assessment (clinical intake) dated 3 September 2008 (the CI’s DOS) diagnosed “Adjustment Disorder with Mixed Anxiety and Depressed Mood.”

As noted in the Scope section above, only the acute stress reaction (and no other MH condition or diagnosis) can be considered by the Board. Acute stress reaction is not an Axis I diagnosis (IAW DSM IV; although acute stress disorder is an Axis I condition) and is not a condition or circumstance constituting a physical disability IAW DODI 1332.39 in effect at the time. The VA diagnosis of adjustment disorder at separation, although an Axis I diagnosis, would also be non-compensable IAW DODI 1332.39.

Bilateral Shin Splints. Treatment notes indicated lower leg complaints beginning shortly following thyroid ablation and weight gain as noted above. The NARSUM indicated that bilateral shin splints were of “recent onset, responding to rest, medically acceptable.” Exam documented a normal gait, normal skin exam and normal reflexes and strength in the lower extremities. The prior to separation VA exam demonstrated tenderness to deep palpation over the front of the shins with normal skin exam and no swelling or weakness in the legs. Radiographs were normal.

All of the contended conditions were reviewed and considered by the Board. There was no performance based evidence from the record that any of these conditions significantly interfered with satisfactory duty performance. 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 any of the contended conditions and so no additional disability ratings are 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 hypothyroidism condition, the Board unanimously recommends a disability rating of 30%, coded 7903 IAW VASRD §4.119. In the matter of the bilateral plantar fasciitis condition and IAW VASRD §4.73, the Board unanimously recommends no change in the PEB adjudication. In the matter of the contended Grave’s disease, acute stress reaction and bilateral shin splints 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 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 his prior medical separation:

UNFITTING CONDITION VASRD CODE RATING
Hypothyroidism… 7903 30%
Bilateral Plantar Fasciitis 5399-5310 0%
COMBINED 30%



The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20131213, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans Affairs Treatment Record



XXXXXXXXXXXXXXXXXXXX
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 XXXXXXXXXXXXXXX , AR20150012417 (PD201302672)


1. Under the authority of Title 10, United States Code, section 1554(a), I approve the enclosed recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) pertaining to the individual named in the subject line above to recharacterize the individual’s separation as a permanent disability retirement with the combined disability rating of 30% effective the date of the individual’s original medical separation for disability with severance pay.

2. I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum:

         a. Providing a correction to the individual’s separation document showing that the individual was separated by reason of permanent disability retirement effective the date of the original medical separation for disability with severance pay.

         b. Providing orders showing that the individual was retired with permanent disability effective the date of the original medical separation for disability with severance pay.

         c. Adjusting pay and allowances accordingly. Pay and allowance adjustment will account for recoupment of severance pay, and payment of permanent retired pay at 30% effective the date of the original medical separation for disability with severance pay.

         d. Affording the individual the opportunity to elect Survivor Benefit Plan (SBP) and medical TRICARE retiree options.





3. I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures.

BY ORDER OF THE SECRETARY OF THE ARMY:




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






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