RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  	CASE:  PD1200067
BRANCH OF SERVICE:  Army	BOARD DATE:  20130430
SEPARATION DATE:  20090224

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty PFC/E-3 (92F10/Petroleum Supply Specialist) medically separated for left shoulder arthropathy and migraine headaches.  She injured her shoulder in 2007 turning a trailer elevation crank.  Later, in 2008, she was pinned between two vehicles and had a crush injury of her thorax.  Although, she had experienced occasional migraines before this accident, her headaches drastically increased afterwards.  She could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty (MOS) or satisfy physical fitness standards.  She was issued a permanent P3, U3 profile and referred for a Medical Evaluation Board (MEB).  Left shoulder arthropathy and migraines were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also forwarded four other conditions to the PEB; namely, anxiety, gastroesophageal reflux disease (GERD), intermittent low back pain (LBP), and menorrhagia with pelvic pain.  The PEB adjudicated the left shoulder condition as unfitting, rated 10%, citing the criteria of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The PEB adjudicated the migraines as unfitting, rated 0%, with application of the DoDI 1332.38 E4-12 definition of prostrating as meaning the soldier must stop what she is doing and seek medical attention.  The remaining conditions were determined to be not unfitting.  The CI appealed to the U.S. Army Physical Disability Agency (USAPDA), requesting a rating greater than 0% for the migraine headaches.  The USAPDA concurred with the PEB and the CI was separated with a combined 10% disability rating.

CI CONTENTION:  “Dysfunctional Uterine Bleeding menorrhagia with pelvic pain.  Anxiety disorder with mild depression (service connected).”

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 left shoulder and migraines conditions are addressed below.  The requested anxiety and dysfunctional uterine bleeding-menorrhagia, which were determined to be not unfitting by the PEB, are also addressed below.  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 respective Service Board for Correction of Military Records.

RATING COMPARISON:

Service Admin IPEB – Dated 20081202	VA - (5 & 19 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left (Nondominant) Shoulder Arthropathy	50995003	10%	Left Shoulder Rotator Cuff Injury	5201	30%	20090727 	
Migraines 	8100	0%	Migraine Headache Associated with Traumatic Brain Injury with Mild Memory Loss	8100	30%*	20100915 	
Anxiety	Not Unfitting	Anxiety Disorder w/ Mild Depression 	9400	30%*	20100831	
Gastroesophageal Reflux Disease (GERD)	Not Unfitting	Gastroesophageal Reflux Disease (GERD)	7346	0%*	20100915	
Pelvic Pain with Menorrhagia 	Not Unfitting	Dysfunctional Uterine Bleeding	7699-7629	30%*	20100915	
Intermittent Low Back Pain	Not Unfitting	Back Pain	5237	10%*	20100915	
No Additional MEB/PEB Entries	Other x 2	20100915	
Combined:  10%	Combined:  80%	
Derived from VA Rating Decision (VARD) dated 20100504 (most proximate to date of separation [DOS]).   
* Ratings were originally deferred, and subsequent VARD 20110211 two years post separation rated all asterisked conditions as shown based on exams done approximately 19 months post separation.

ANALYSIS SUMMARY:  The Board’s authority as defined in DoDI 6040.44, resides in evaluating the fairness of Disability Evaluation System (DES) fitness determinations and rating decisions for disability at the time of separation.  The Board utilizes service and VA evidence proximal to separation in arriving at its recommendations and DoDI 6040.44 defines a 12-month interval for special consideration of post-separation evidence.  Post-separation evidence is probative only to the extent that it reasonably reflects the disability and fitness implications at the time of separation.

Left Shoulder Condition:  There were goniometric range-of-motion (ROM) evaluations in evidence, with documentation of additional ratable criteria, which the Board weighed in arriving at its rating recommendation; as summarized in the chart below.

Left Shoulder ROM 	MEB ~ 8 Mo. Pre-Sep	VA C&P ~5 Mo. Post-Sep	
Flexion (180)	180	0-45	
Abduction (180)	180 (pain at 150)	0-30	
Comments	Measured after MVA; Tenderness to palpation over bicipital groove and anterior tubercular groove; pain with internal rotation, flexion and abduction near the end of the range of motion; positive Neer impingement test and cross arm test; negative drop arm test and lift off	Pain with motion; no laxity, tenderness, swelling, effusion, ankylosis;  normal strength, sensation, reflexes. The uninjured right shoulder had severely limited ROM; 75 deg flexion and 80 deg abduction	
§4.71a Rating	10% (5003)	30% (5201)	

The earliest documentation in the service treatment records (STR) of a left shoulder problem is a radiology report of the left shoulder dated 7 September 2007 that was normal; the X-ray had been requested for a history of severe pain in the left anterior shoulder after an apparent anterior subluxation on the previous day.  Examination by physical therapy in October noted left shoulder abduction limited to 160 degrees and flexion limited to 170 degrees, both by pain.  Current pain level was 7 out of 10 with worst pain reported as 8 out of 10 and best at 3 out of 10.  There was tenderness to palpation over the bicipital groove.  The therapist also reported the CI had been seen by orthopedics and had been in a shoulder immobilizer for 2 weeks after a subluxation.  A repeat examination in November 2007 recorded full ROM with pain reported as ranging from 0 out of 10 to 3 out of 10.  On 18 April 2008, her commander signed a Physical Disability Evaluation System (PDES) referral statement, stating that she was unable to perform the duties or her MOS.  On the Report of Medical Examination (DD Form 2808) for the MEB, dated 6 May 2008, the examiner noted “left shoulder-tenderness to palpation (anterior aspect)” and “no limitation of movement.”  However, pain was elicited with elevation, external rotation, and abduction at the end of the ROM.  Also, both upper extremities had normal 5/5 strength and 2+ deep tendon reflexes (DTRs).  While awaiting MEB for her left shoulder, on 10 May 2008, she suffered multiple injuries when a parked car rolled and pinned her against another car.  No shoulder injuries were noted, but she was admitted to the ICU, having suffered a fractured first rib and bilateral pneumothoraces, requiring a bilateral chest thoracotomy.

The MEB narrative summary (NARSUM) 8 months prior to separation documents constant pain in the anterior left shoulder, radiating into the left scapula, ever since the original injury in September 2007, worse at the limits of flexion, abduction, and external rotation and not responding to conservative therapy, including subacromial injection, physical therapy including transcutaneous electrical nerve stimulation (TENS), pain management, and chiropractic care.  The physical examination findings are noted in the chart above.  The NARSUM notes a magnetic resonance imaging (MRI) of the left shoulder suggested a little bit of subacromial inflammation but was otherwise normal and did not document any labral tears or rotator cuff injury.  The MEB diagnosis was left shoulder arthropathy.  The examiner noted that serial Armed Forces Health Longitudinal Technology Application (AHLTA) encounters with an orthopedist documented concern that complaints and examination findings differed from visit to visit and that this could indicate some type of secondary gain.  The VA Compensation & Pension (C&P) examination 5 months after separation, noted pain in the left shoulder, difficulty reaching, lifting and carrying, and subjective weakness of left rotator cuff muscles (supraspinatus, infraspinatus, teres minor, and subscapularis [SITS]).  The CI was not employed and she was attending college.  The physical findings are noted in the chart above.  Additionally, clinic visits for occipital nerve blocks to treat headaches, from August through November 2008 (prior to her separation), noted spasms of the upper trapezius muscles of both shoulders, but did not address left shoulder ROM.  A later C&P mental disorders examination in August 2010 included psychological testing that was consistent with “a pattern of over endorsement of problems that likely resulted in exaggerated and distorted symptom reporting.  Such a result raises concerns of the objective accuracy of her self-report.”  This examination was completed 19 months after separation.

The MEB NARSUM and PEB state that the CI is right handed.  The 2010 VARD noted that the STR showed that she is right handed, but at the VA C&P, the CI stated that she is left handed.  Physical therapy notes from 2007 document that she is left hand dominant.

The Board directs attention to its rating recommendation based on the above evidence.  The PEB rated the condition analogous to 5003 and rated 10% based on painful motion.  The VA rated the condition as 5201 (arm, limitation of motion), and assigned a 30% rating based on flexion and abduction of the left shoulder limited to a point midway between side and shoulder level on the dominant side.  There is a clear discrepancy between the limitations of motion documented on the NARSUM and C&P examinations.  The Board carefully deliberated its probative value assignment to these conflicting evaluations, and carefully reviewed the service file for corroborating evidence in the 12-month period prior to separation.  While there is ample evidence documented painful motion prior to separation, there is no evidence of limitation of left shoulder ROM to shoulder height or less prior to or at separation.  The ROM values reported by the VA examiner, 5 months after separation, are significantly worse than those reported by the MEB dated 8 months prior to separation.  While outpatient treatment notes for visits that occurred after the C&P examination was completed do not include ROM measurements, they do not indicate any significant worsening of the left shoulder condition.  There is no record of recurrent injury or other development in explanation of the more marked impairment reflected by the VA measurements.  The Board places greater probative value on the NARSUM examination.  Although, it appears the PEB incorrectly stated the CI was right hand dominant, this does not materially affect the rating.  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 left shoulder condition.
Migraine headache condition:  An initial neurology addendum to the MEB NARSUM was completed in mid-August 2008 after the serious crush injury with bilateral pneumothoraces, a liver laceration, and a fractured left first rib on 10 May 2008 described above.  The CI had a brief loss of consciousness (2-5 minutes) and brief amnesia with confusion, seeing stars, and tinnitus at the time of injury.  The CI reported daily moderate-to-severe headaches that were left temporal, stabbing in nature, and associated with nausea, photophobia, and episodic numbness or swelling on the left side of her face.  The headaches were triggered by stress or anger, would last for hours, and were relieved with narcotics.  She also reported a history of one to two headaches per month in her early twenties, prior to the accident.  Neurologic examinations were normal and MRIs of her brain and cervical spine were normal in June 2008.  The diagnosis was traumatic brain injury (TBI) without intracranial hemorrhage and refractory migraines with documented compliance with therapy.  An update to the addendum at the end of August, noted some relief with Indocin, pain management injections, and chiropractic manipulations.  Although Depakote had achieved therapeutic levels in June 2008, it did not provide any relief and it was discontinued.  A later update, completed in October 2008, noted refractory migraines with documented compliance with therapy, worse since the injury in May 2008.  The headaches occurred several hours each day and were associated with significant nausea, photophobia, and impaired concentration.

The Board reviewed the STRs to determine the frequency and severity of the CI’s headaches.  The STRs note two small, 1 by 2 centimeter contusions in front of and behind left ear in early June 2008 and initiation of treatment or migraine headaches with Depakote and Midrin.  At a visit to primary care in July 2008, the CI reported headaches occurring at least once a week.  The CI reported stopping the medications prescribed by the neurologist.  She had 50% relief of headache symptoms with a Toradol injection and she was prescribed Phenergan and Fioricet.  Six days later, she was seen with a headache and depressed mental status that was thought to be a reaction to the Fioricet.  She was given Vicodin instead for acute symptoms.  A pain clinic evaluation on 12 August 2008 noted a headache nearly every day with varying severity.  Treatment with occipital nerve blocks and trigger point injections was started.  Later in August, she reported an occipital headache with mild dullness and she received injections a second time.  A day later in the neurology clinic, her pain was reported as 2 out of 10 and the neurologist noted her headaches were relieved with Indocin and injections.  A week later, the CI had pain at 4 out of 10 and she reported she had no significant headaches since the last injections.  The injections were repeated.  At the next visit, 5 days later, the CI reported 2 out of 10 for pain and stated she had been pain free for 6 days.  The injections were repeated.  At a follow-up 7 weeks later, the CI reported 4 out of 10 for pain and stated she had relief for 6 days after her last injections.  It is not clear if there were visits or injections during the intervening seven weeks.  Injections were repeated.  The final follow-up visit documented in the record was a week later, and documented that the previous injections had resulted in relief for 6 days, with the first headache occurring the night before the visit.  She reported no headache and 0 out of 10 for pain at this visit; the injections were repeated.  The plan was to follow-up in a week but no further clinic visit notes are available for review.  With regular occipital nerve blocks and trigger point injections in addition to her medications, it appears the frequency of the CI’s headaches decreased from nearly every day to approximately once a week.  The record does not contain information regarding the CI’s need to leave work or stop her activities when her headaches occurred.  On the visits where the CI did report a current headache, she rated her pain at levels ranging from 2 to 4 out of 10.  At the C&P exam performed 5 months after separation, the CI reported being incapacitated for 1 to 3 days with two migraines per month. She was not taking Imitrex because she was breast feeding an infant at the time.  The CI reported she was essentially incapacitated for 24 to 72 hours during an acute migraine and that her headaches prevented shopping, exercise, sports, recreation, traveling, and driving and severely affected feeding, toileting and grooming.

The Board directs attention to its rating recommendation based on the above evidence.  The PEB rated the headaches using 8100 and rated 0% for prostrating headaches occurring less than one per every 2 months.  The PEB cited the DoDI 1332.38 definition of prostrating as meaning the soldier must stop what she is doing and seek medical attention.  Using the same code, the VA assigned a 30% based on prostrating headaches that occurred about once every 2 weeks.  The VA determined that during a migraine attack, the CI was unable to perform usual daily activities and had to go to a dark room and sleep until the symptoms resolved.  The standard VA definition of prostrating does not require seeking medical attention but does require the affected individual must stop what they are doing and take medications or rest.  While the frequency of headaches reported at the VA examination is not incompatible with the documented frequency of headaches in the STR, the STR contains no evidence supporting or refuting the CI having to stop her activities to seek care or rest when a headache occurred.  The STR does contain pain scale ratings during headaches that range from 2 to 4 out of 10.  These pain scale ratings do not support a determination of these headaches as prostrating.  However, it is clear that the CI did not seek medical care every time she had a headache.  Therefore, it is reasonable to determine that of the weekly headaches the CI had in the several months prior to separation, one out of every eight headaches was just as likely as not to meet the VA definition of prostrating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 Reasonable doubt, the Board recommends a separation rating of 10% for the migraine condition.

Contended PEB Conditions.  The contended conditions adjudicated as not unfitting by the PEB were anxiety and pelvic pain with menorrhagia.  The Board’s first charge with respect to these conditions is an assessment of the appropriateness of the PEB’s fitness adjudications.  The Board’s threshold for countering 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.  Neither of these conditions were profiled, neither were implicated in the commander’s statement and neither were judged to fail retention standards.  There was no indication from the record that either condition significantly interfered with satisfactory duty performance.

Anxiety:  STRs in September, 2006, note that the CI was referred to mental health during basic training for depression, insomnia and loss of pleasure.  There are no clinic notes available; however, the STR problem list includes an entry during this period for adjustment disorder with depressed mood.  STRs do note that the CI had been referred to mental health but did not follow up.  The CI stated on 18 September 2006 that she was homesick and had an appointment with the chaplain.  After her motor vehicle accident (MVA) in May 2008, she was prescribed clonazepam for anxiety, and on 3 July 2008, experienced a panic attack when involved in a minor MVA (“fender bender”) in a parking lot on base.  A mental health NARSUM to the MEB on 5 August 2008 notes that anxiety symptoms secondary to her MVA had improved.  She noted that she had stopped taking the clonazepam.  The CI stated that on this occasion that she was “happy” and denied that psychiatric symptoms interfere with her “ability to perform her duties or…with her social relationships.”  This summary concluded that, although she “initially met criteria for acute stress disorder” secondary to her accident, she “did not progress to post traumatic stress disorder.”  The summary noted that she did “not meet criteria for an anxiety disorder” and that she met retention criteria.  There was no suicidal ideation, delusional or hallucinatory symptoms, speech disturbance, cognitive impairment or other abnormalities.  After due deliberation in consideration of the preponderance of evidence, the Board’s consensus is that there is insufficient evidence to challenge the PEB’s fitness conclusion, and there were no clinical features or specific functional limitations which would render the anxiety condition unfitting.  Therefore, no service disability rating for this condition can be recommended.

Pelvic Pain with Menorrhagia:  Having entered basic training on 31 May 2006, on 18 August 2006, the CI first noted pelvic pain “for three months,” noting a history of heavy menstrual bleeding and pelvic pain.  On 28 August 2006, she reported a family history of endometriosis.  She added that a “doctor at home told her she probably had endometriosis.”  She stated that she had not reported this problem to her recruiter.  She was diagnosed with an ovarian cyst, and, when symptoms worsened in September 2006, she was diagnosed in the emergency department (ED) with pelvic inflammatory disease (PID).  On 9 June 2007, she underwent a C-section, and on 30 April 2008, returned to the ED for cramping pelvic pain and vaginal bleeding.  There was no documentation that this condition resulted in any permanent work restrictions.  The MEB NARSUM noted that this condition was “mitigated with medications” and it met retention standards.  After due deliberation in consideration of the preponderance of evidence, the Board’s consensus is that there is insufficient evidence to challenge the PEB’s fitness conclusion, and there were no clinical features or specific functional limitations which would render the pelvic pain with menorrhagia condition unfitting.  Therefore, no disability rating for this condition can be 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.  In the matter of the left shoulder condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  Although the CI was left hand dominant, this did not affect the disability rating.  In the matter of the migraine condition, the Board unanimously recommends a separation rating of 10%, coded 8100 IAW VASRD §4.124a.  In the matter of the contended anxiety and pelvic pain with menorrhagia 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, effective as of the date of her prior medical separation:  

UNFITTING CONDITION	VASRD CODE	RATING	
Left (Nondominant) Shoulder Condition	5099-5003	10%	
Migraines 	8100	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20111213, 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 AR20130010842 (PD201200067)

1.  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 to modify the individual’s disability rating to 20% without recharacterization of the individual’s separation.  This decision is final.  

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.   

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						
						         (Army Review Boards)

CF: 
(  ) DoD PDBR
(  ) DVA