RECORD OF PROCEEDINGS

PHYSICAL DISABILITY BOARD OF REVIEW

NAME: BRANCH OF SERVICE: ARMY

CASE NUMBER: PD0900032 BOARD DATE: 20100729

SEPARATION DATE: 20060314

________________________________________________________________

SUMMARY OF CASE: This Covered Individual (CI) was an Active Guard Reservist SSG/E-6, (31R, Transmission System Operator) medically separated from the Army National Guard in Mar 2006 after 17 years of active service and 6 years of inactive service. Medical basis for separation was cervical degenerative disc disease, and migraine headaches. These two conditions were determined to be medically unacceptable IAW AR 40-501. CI was referred to the Physical Evaluation Board (PEB), determined unfit for continued military service, and separated at a 20% combined disability using the Veterans Affairs Schedule for Rating Disabilities (VASRD) and applicable Army and DoD regulations.

________________________________________________________________

CI’s CONTENTION (20090118): The CI states ‘During my PEB I was rated for my cervical degenerative disc disease concentrating on the C4-C6 area. An initial rating of 10% was established for discharge. I filed a Formal Appeal to request a higher rating as well as add my migraine headaches to my proceedings and have my PTSD addressed. The Formal Board concluded 10% for my Cervical DDD, and 10% for my migraines with no consideration for my PTSD. I was diagnosed with PTSD in September of 2005 at Evans Army Hospital approximately six months prior to my PEB yet it was never documented on my proceedings or allowed to be addressed during my Formal Board. Upon discharge I was later rated at 5O % by the Department of Veterans Affairs for this disability as well as other medical conditions that require continuous care and treatment. The Department of Veterans Affairs matched the 10% disability ratings for my CDDD and migraines. I currently have an appeal in process for a disability rate increase for my migraines via VA Form 9.’

________________________________________________________________

RATING COMPARISON:

________________________________________________________________

ANALYSIS SUMMARY:

Neck condition: CI began having neck problems in 1986. A magnetic resonance imaging (MRI) of C-spine (Sep 2004) showed some radiologic abnormalities at multiple levels (C5-C6 and C6-C7). He was treated with physical therapy which did not significantly help his symptoms. He also received multiple injections to the neck. In April 2005, CI was seen by neurosurgery at Brooke Army Medical Center (San Antonio, TX), and neck surgery was not recommended. In Oct 2005, CI reported he was having neck pain 75% of the time. Pain was described as ‘squeezing’ and was located at the lower posterior neck bilaterally. Cervical range-of-motion (ROM) testing revealed forward flexion of 76 degrees, and combined cervical ROM of 326 degrees. Over the past few years, the neck condition has been diagnosed as cervical spondylosis, cervicalgia, facet arthropathy, cervical disk herniation, and degenerative disc disease (DDD). CI has also had symptoms related to his left arm and left hand. On electromyogram (EMG), there were findings consistent with mild chronic left C7 radiculopathy. However, neurologic examination (Jul 2005) showed no objective (motor or sensory) evidence of radiculopathy. CI was referred to the Army PEB, was found unfit for his neck condition, and was rated at 10%. Following separation, CI filed a claim with VA, and the VA also rated his neck condition at 10%.

The Board reviewed all evidentiary information available. IAW VASRD §4.71a-20, when combined cervical ROM is greater than 170 degrees but not greater than 335 degrees, the rating agency should assign an evaluation of 10 percent. After careful consideration and lengthy deliberation, the Board unanimously recommends a 10% rating for the Neck condition. It is appropriately coded 5243, and IAW VASRD §4.71a-20 meets criteria for the 10% rating. Although a separate rating evaluation could be granted for the mild left C7 radiculopathy (noted on EMG), the Board has determined that the radiculopathy was not separately unfitting. Furthermore, there was no objective clinical evidence of radiculopathy (motor or sensory) found on neurologic examination. Therefore, a separate rating evaluation for radiculopathy is not warranted since clinical examination did not show any neurological signs of impairment as a result of the mild left C7 radiculopathy.

Head pain: After the onset of neck problems, CI began having headaches, which were felt at that time to be stress-related. The headaches were initially bi-frontal, and occurred almost daily. In Oct 2005, headaches were occipital and bi-temporal in location. He described them as ‘throbbing,’ and they ranged in severity from mild to ‘lay-down.’ CI was seen by a neurologist, who felt that the headaches were possibly a migraine variant, but the degenerative disease in the neck may have been acting as a trigger, and the head pain was possibly related to neck pain that was being referred upward into the head region. Army PEB found him unfit for his headache condition, and he was rated at 10%. When CI went to the VA, the VA also rated his head pain at 10%.

Once again, the Board has carefully reviewed the available evidence. IAW VASRD §4.124a-10, migraine headaches should be rated based on severity and frequency of painful attacks. In July 2005, the headaches were occurring infrequently. Nine months later (April 2006), headaches were occurring 1-3 times per week, with 3-4 incapacitating episodes during the preceding 12 month period. The Board unanimously recommends a 10% rating for the Headache condition in compliance with VASRD §4.124a-10.

PTSD: During deployment, CI experienced a frightening episode while he was on a bus near the Kuwait-Iraq border. He thought he might be killed. After return to CONUS, he started to experience insomnia, nightmares, intrusive thoughts, emotional detachment, diminished interest in activities, irritability, and increased startle response. On 14 Sep 2005, CI was seen by an Army psychiatrist (Dr. B.) and diagnosed with PTSD. In his report, Dr. B. stated ‘IAW AR 40-501, soldier is psychiatrically fit for duty.’ The four physicians who signed page 2 of DA Form 3947 agreed with Dr. B. that the PTSD was not unfitting. During Formal PEB proceedings, three voting members at the PEB also determined that the PTSD was not unfitting.

The Board has carefully reviewed the evidence with regard to CI’s psychiatric condition at the time of separation from service. The Board finds that there is no compelling evidence to suggest that CI’s psychiatric symptoms rendered him unfit for military service, and therefore unanimously recommends that PTSD be considered not unfitting and not ratable for disability separation.

History of Other Conditions (documented in Disability Evaluation System package): Dyslipidemia, back pain, varicocele, carpal tunnel syndrome, thumb dislocation, allergy symptoms, sinusitis, skin problems, knee pain, quadriceps strain, tightness in chest, insomnia, shortness of breath (SOB), electrocardiogram (ECG) abnormalities, dental problems, eye strain, defective visual acuity, serous otitis, acoustic trauma, tinnitus, hearing loss, elbow pain/tenderness (bilateral), arthritis, leg cramps, weight loss, head trauma, dizziness/lightheadedness, and high blood pressure were all discussed and considered by the Board. There is no clearly documented evidence that any of these other conditions caused any significant adverse effect on the performance of required military duties. These other conditions are all judged by the Board to be not unfitting at the time of separation from service, and are not relevant for disability rating. The Board therefore has no reasonable basis for recommending any additional unfitting conditions.

History of Other Conditions (not documented in Disability Evaluation System (DES) package) -

Gastro-esophageal reflux disease (GERD) was also considered by the Board. There is no clearly documented evidence that this condition was a matter of record in the DES package. Therefore, this condition is judged to be outside the scope of this Board. ________________________________________________________________

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 Chronic Neck Pain condition, the Board recommends by unanimous decision a rating of 10%, coded 5243 IAW VASRD §4.71a-20. In the matter of the Chronic Headache condition, the Board recommends by unanimous decision a rating of 10%, coded 8199-8100 IAW VASRD §4.124a-10. In the matter of the dyslipidemia, back pain, varicocele, carpal tunnel syndrome, thumb dislocation, allergy symptoms, sinusitis, skin problems, knee pain, quadriceps strain, tightness in chest, insomnia, shortness of breath (SOB), electrocardiogram (ECG) abnormalities, dental problems, eye strain, defective visual acuity, serous otitis, acoustic trauma, tinnitus, hearing loss, elbow pain/tenderness (bilateral), arthritis, leg cramps, weight loss, head trauma, dizziness/lightheadedness, and high blood pressure, 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.

GERD, rated by the VA, was not mentioned in the Disability Evaluation System package and is therefore outside the scope of the Board. The CI retains the right to request his service Board of Correction for Military Records (BCMR) to consider adding this condition as unfitting.

________________________________________________________________

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

________________________________________________________________

The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20090118, w/atchs.

Exhibit B. Service Treatment Record.

Exhibit C. Department of Veterans' Affairs Treatment Record.