RECORD OF PROCEEDINGS

PHYSICAL DISABILITY BOARD OF REVIEW

NAME: BRANCH OF SERVICE: air force

CASE NUMBER: PD0900182 BOARD DATE: 20090826

SEPARATION DATE: 20040923

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SUMMARY OF CASE: This covered individual (CI) was a Technical Sergeant Medical Services Craftsman medically separated from the Air Force in 2004 after more than eleven years of service in multiple branches of service. The medical basis for the separation was Chronic Neck Pain secondary to Degenerative Disc Disease with Vagal Response Syncopal Episodes, Right Upper Extremity Paresthesias, Migraine Headaches and Mood Disorder. CI was referred to the Physical Evaluation Board (PEB), found unfit, and separated at 10% disability.

The CI had a remote history of low back pain in August 1987 and January 1988. More recently he had an episode of low back pain in December 2002 which occurred after moving a heavy patient while at work in the Emergency Room. This episode resolved with conservative care and muscle relaxers. This same scenario occurred again in April 2003. However, he had another occurrence of low back pain after moving a heavy patient in May 2003 and this time his symptoms did not resolve with conservative therapy. He continued to have low back pain and also developed right leg pain, right arm weakness and paresthesias, neck pain, and headaches. He also had three episodes of syncope associated with turning his head to the left which were determined to be due a vasovagal response to pain. He developed depression due to a general medical condition. The CI also had a history of a biceps tendon rupture that was repaired in December 2001. The repair was considered successful and the CI had no documented physical limitations related to his right arm after his surgery and rehabilitation was complete. He was evaluated by neurology and neurosurgery and had X-rays of entire spine, MRIs of lumbar and cervical spine and brain, an MRA, EMGs and nerve conduction studies of his right upper and lower extremities, and an EEG. The only positive findings were mild spinal canal stenosis at C6-C7 due to a small posterior disc protrusion, Schmorl’s node at T8-T9, small osteophytes at T9-T10, and congenital hypoplasia of the right anterior cerebral artery.

Appropriate therapy failed to alleviate his symptoms and he was referred to the Air Force PEB. The Informal PEB (IPEB) determined he was unfit for continued military service and he was then separated with a 10% disability for 5242 Chronic Neck Pain Secondary to Degenerative Joint Disease associated with Vagal Response Syncopal Episodes, Right Upper Extremity Paresthesias, Migraine Headaches, and Mood Disorder using the Veterans Affairs Schedule for Ratings Disabilities (VASRD) and applicable Air Force and Department of Defense regulations.

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CI CONTENTION: “Rating was based on one disability factor and not on all six disability conditions but Medical Discharge was based on all six conditions. Disparity between the 10% disability rating and the Veterans Administration ratings for the same conditions. I respectfully request a review of my disability rating of 10% received from the U. S. Air Force as compared to the ratings of disability received from the Veterans Administration. I humbly request a disability rating that encompasses all of my disabling medical conditions to one that would permit me to medically retire as was supported by my Commanding Officer in his recommendation to the Air Force, attachment: Item 6. I would like to thank the Board of Review for their consideration of my request. Additionally, I am aware that this review pays particular attention to a VA rating dated within 12 months of separation. Please consider some latitude on my case due to an almost 24 month wait for the VA to release their determination on my application for disability compensation filed electronically on 20 SEP 2004. Thank you”.

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RATING COMPARISON:

Previous Determinations
Service 20040518	VA Feb-Mar 2006 (filed claim 20040920)
PEB Condition	Code
Chronic Neck Pain secondary To Degenerative Disc Disease Associated with Vagal Response Syncopal Episodes, Right Upper Extremity Paresthesias, Migraine Headaches and Mood Disorder.	5242
Mechanical Low Back Pain And Thoracic Spine Pain	5237
TOTAL Combined: 10%	TOTAL Combined (incl non-PEB Dxs): 80% from 09/24/2004 (Bilateral factor of 1.9 Percent for diagnostic codes 5020, 5020) Then… 90% from 05/1912008 (Bilateral factor of 1.9 Percent for diagnostic codes 5020, 5020)

ANALYSIS SUMMARY:

Fitness:

The Air Force IPEB stated: ‘None of member's medical conditions individually prevent him from reasonably performing the duties of his office, grade, rank, or rating, however, taken in totality, they make the member unfit for continuous military service. Therefore, the IPEB rates the condition that would be most advantageous to the member, chronic neck pain, and recommends Discharge with Severance Pay with a disability rating of 10% IAW DoD and VASRD guidelines.’ The Commander’s Letter stated that the CI could not perform his duties as a medic in the Emergency Room because of his neck and back pain, headaches, and numbness in his upper extremity. It also stated the CI’s daily pain limited his capabilities and that the CI could not deploy. The Service Treatment Record (STR) documented that while the CI continued to work in the Emergency Room, he was doing administrative work only, not patient care.

Mechanical Low Back Pain and Thoracic Spine Pain and Right Lower Leg Pain/Radiculopathy:

The IPEB stated this condition was not unfitting, however the CO’s letter specifically states this conditions interfered with CI’s ability to perform his job and this does appear to be a reasonable conclusion. Tenderness to palpation and painful motion warrant rating at 10% (paragraph 4.59). Radiculopathy does not appear to be present. While CI had subjective complaints of pain in his right leg, there is no objective evidence of sensory or motor nerve disturbance. Even if present, the rating would not change because the general rating formula for the spine states the rating is with or without symptoms such as pain. EMG and nerve conduction velocity (NCV) studies were performed in 2003 by the Air Force and 2006 by the VA and neither showed any abnormality. VA exam in 2006 did not show any radiculopathy in lower extremity.

Chronic Neck Pain secondary to Degenerative Disc Disease with Syncopal Episodes:

The IPEB stated this condition was not unfitting, however they rated the condition as Chronic Neck Pain Secondary to Degenerative Joint Disease associated with Vagal Response Syncopal Episodes. Also, the CO’s letter specifically states neck pain interfered with CI’s ability to perform his job and this does appear to be a reasonable conclusion. The CO’s letter does not mention syncope. Painful motion (paragraph 4.59) and decreased ROM warrant a 10% rating for neck pain. The syncope was felt to be a vasovagal response to the pain caused by movement of the neck and is not a separately unfitting condition.

Right Upper Extremity Paresthesia/Radiculopathy vs. Neuritis:

The IPEB stated this condition was not unfitting, however they included this condition as right upper extremity paresthesias associated with the rated condition of chronic neck pain. Also, the CO’s letter specifically states right arm numbness (no mention of weakness) interfered with CI’s ability to perform his job.

The ROM is not limited enough to warrant a compensable rating under 5206 or 5207 Limitation of Flexion or Extension of Forearm. EMG and NCV tests done in both 2003 and 2006 do not show nerve impairment related to either the biceps reconstruction or a cervical radiculopathy. While subjective symptoms were present, it appears that neither a cervical radiculopathy nor a neuropathy was present in the right upper extremity and therefore no rating is applied.

Migraine Headache:

The IPEB stated this condition was not unfitting, however they included this condition as migraine headaches associated with the rated condition of chronic neck pain. Also, the CO’s letter specifically states that headaches interfered with CI’s ability to perform his job.

Migraine headaches are vascular in nature and are not related to neck pain. Tension headaches, which the CI most likely had in addition to his migraines, can be related to neck pain. Regardless of the type of headache involved the rating depends on prostrating attacks. There is only one prostrating attack documented in the STR and prostrating attacks are not mentioned in the NARSUM. The VA exam and rating rationale contain the CI’s report that he has prostrating attacks 2-3 times a month but there is no other evidence to support this. Prostrating attacks less frequent than one in every two months over the least several months warrant a rating of 0%.

Mood Disorder Due To A General Medical Condition:

The IPEB stated this condition was not unfitting, however they included this condition as mood disorder associated with the rated condition of chronic neck pain. The CO’s letter does not mention whether mood disorder interfered with CI’s ability to perform his job. The CI’s symptoms appeared to be controlled on medication and the psychiatrist felt he had no impairment for military duty or social and industrial adaptability. This warrants a 10% rating.

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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 PDBR to the extent they were inconsistent with the VASRD in effect at the time of the adjudication. After careful consideration of all available information, the Board concluded by simple majority that the CI’s condition is appropriately rated at a combined 30% for 5242 Chronic Neck Pain and 5237 Mechanical Low Back Pain and Thoracic Spine Pain using the VASRD general rating formula for spine and 8199-8100 Headaches, and 9435 Mood Disorder due to a General Medical Condition using the VASRD general rating formula for mental disorders.

The Board determined that the CI’s back pain, neck, pain, headaches, and mood disorder were unfitting conditions. The 10% rating for 5242 Chronic Neck Pain secondary to Degenerative Disc Disease with Syncopal Episodes is based on the NARSUM’s description of decreased lateral rotation of the cervical spine and an examination from 20041103 that documented painful motion. The 10% rating for 5237 Mechanical Low Back Pain and Thoracic Spine Pain is based on the NARSUM’s description of pain on extension of the thoracolumbar spine and tenderness to palpation and an examination from 20041103 that documented a total ROM of the thoracolumbar spine of 230 degrees and tenderness to palpation. The 0% rating for 8199-8100 Headaches is based on prostrating attacks occurring less frequently than one in every two months over the least several months. The 10% rating for 9435 Mood Disorder due to a General Medical Condition is based on the diagnosis of a mental condition with symptoms that are controlled with continuous medication.

The Board also examined Right Upper Extremity Paresthesia and Radiculopathy and Right Lower Extremity Radiculopathy and did not find these conditions to be present. The Board also examined bilateral patellofemoral syndrome and chondromalacia patella, scar status post right bicep reconstruction, and hypertension and did not find these conditions to be unfitting. The other diagnoses rated by the VA were not mentioned in any PEB paperwork and could not be considered by the Board.

The single voter for dissent (who recommended a combined rating of 20% with 5242 at 10%, 5237 at 10%, and 8199-8100 at 0%) elected not to submit a minority opinion.

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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 the CI’s prior medical separation.

Unfitting Condition	VASRD Code	Rating
Chronic Neck Pain secondary to Degenerative Disc Disease with Syncopal Episodes	5242	10%
Mechanical Low Back Pain and Thoracic Spine Pain	5237	10%
Headaches, including Migraines	8199-8100	0%
Mood Disorder Due To A General Medical Condition	9435	10%
Combined	30%

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The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20090219, w/atchs.

Exhibit B. Service Treatment Record.

Exhibit C. Department of Veterans' Affairs Treatment Record.

PDBR PD-2009-00182

MEMORANDUM FOR THE CHIEF OF STAFF

Having received and considered the recommendation of the Physical Disability Board of Review and under the authority of Section 1554, Title 10, United States Code (122 Stat. 466) and Section 1552, Title 10, United States Code (70A Stat. 116) it is directed that:

The pertinent military records of the Department of the Air Force relating to XXXXXXXXXXXX be corrected to show that:

a.  The diagnoses in his finding of unfitness be amended to include mechanical low back pain and thoracic spine pain, VASRD code 5237, rated at 10%; headaches, including migraines, VASRD code 8199-8100, rated at 0%; and, mood disorder due to a general medical condition, VASRD code 9435, rated at 10%, with a combined rating of 30%.

b. On 22 September 2004, he elected not to participate in the Survivor Benefit Plan and his spouse concurred with his election.

c.  He was not discharged on 23 September 2004 with entitlement to disability severance pay; rather, on that date he was released from active duty and on 24 September 2004 his name was placed on the Permanent Disability Retired List.

JOE G. LINEBERGER

Director

Air Force Review Boards Agency