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AF | PDBR | CY2012 | PD2012 00701
Original file (PD2012 00701.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:    CASE: PD1200701
BRANCH OF SERVICE: Army  BOARD DATE: 20130502
DATE OF PLACEMENT ON TDRL: 19990708
Date of Permanent SEPARATION: 20020425


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SSG/E-6 (88N/Transportation Management Coordinator) medically separated for migraine headaches. The CI had a long history of headache problems first reported in 1991. Throughout the years she was treated with medication and continued being evaluated, eventually being diagnosed with migraine headaches and treated for that condition. The headache condition could not be adequately rehabilitated to meet the requirements of her Military Occupational Specialty (MOS) or satisfy physical fitness standards. The CI had also developed knee and back pain in the intervening years, so she was issued a permanent P3-L3 profile and referred for a Medical Evaluation Board (MEB). The headache condition, characterized as “migraine headaches without aura” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. The MEB also identified five other conditions for PEB adjudication. The PEB adjudicated “chronic, recurrent migraines,” rated 30%, and placed the CI on the Temporary Disabled Retirement List (TDRL) in 1999 to allow her condition to stabilize. The remaining conditions were determined to be not unfitting . A PEB in 2000 continued the CI on TDRL. In 2002 a TDRL exam was accomplished that forwarded migraine headaches to the PEB along with three other conditions listed as stable (see chart below; this exam consolidated, but reflected all conditions of the original MEB). The PEB adjudicated “migraine headaches” rated 10% and found the condition had stabilized sufficiently to remove the CI from TDRL. The CI made no appeals and was medically separated with a 10% disability rating.


CI CONTENTION: “I was removed from TDRL prematurely without a complete and accurate medical assessment. I was on medications that stabilized my condition, however; I don't believe that my condition stabilized to the point that a permanent degree of severity could be determined. My VA disability ratings for migraine headaches are: Effective date of 8 July 99 at 30%, and was increased with an effective date of 4 March 2004 to 50%.” “I also request that you determine my conditions that were included on the original MEB and PEB proceedings should have been also separately unfitting and factored in with my overall rating. Those conditions were as follows: Upper back pain, lower back pain, left knee pain, right knee pain, and reactive airway disease-asthma.”


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 rating for the unfitting migraine headache condition and the not unfitting contended conditions of upper back pain, lower back pain, right knee pain, left knee pain, and reactive airways disease (RAD) are addressed below. Any conditions or contention not requested in this application, or otherwise outside the Board’s defined scope of review, remain eligible for consideration by the Board for Correction of Military Records.
RATING COMPARISON :

Final Service PEB - 20020404
 VA (8 Mo. Prior to Adjudication Date*) - Effective 19990708
On TDRL - 19990708
 Code Rating Condition Code Rating Exam
Condition
 TDRL Sep.
Migraine Headaches… 8100 30% 10% Migraine Headaches 8100 30% 20010807
Low Back Pain…
Upper Back Pain		 Not Unfitting Thoracolumbar Strain 5295
10%		 19991111
Right Knee Pain
 Patellofemoral Syndrome, Right Knee 5099-5019 10%
Left Knee Pain Patellofemoral Syndrome, Left Knee 5099-5019 10%
Reactive Airway Disease Asthma 6602 30%
No Additional MEB/PEB Entries.
 Other x 9 19991111
Combined: 40 → 10%
Combined: 80%
VA rating evidence pr oximate to permanent separation.


ANALYSIS SUMMARY: The Board acknowledges the sentiment expressed in the CI’s application regarding the significant impairment with which his service-incurred condition continues to burden her. The Board wishes to clarify that it is subject to the same laws for service disability entitlements as those under which the Disability Evaluation System (DES) operates. 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. That role and authority is granted by Congress to the Department of Veterans Affairs (DVA), operating under a different set of laws (Title 38, United States Code). The Board evaluates DVA evidence proximal to separation in arriving at its recommendations, but its authority resides in evaluating the fairness of DES fitness decisions and rating determinations for disability at the time of separation. The Board further acknowledges the CI’s contention for service ratings for other conditions documented at the time of separation, and notes that its recommendations in that regard must comply with the same governance.

Migraine Headaches. The TDRL entry narrative summary (NARSUM) dictated 9 November 1998 notes the CI had a history of headaches diagnosed as migraines that lasted one to 5 days with a recent frequency of 1 to 2 times per week. The CI remained functional with the headaches except for very severe migraines that would be incapacitating. Service treatment records (STRs) indicated that in the year prior to TDRL entry the CI was provided medical care and or sent to quarters to take her own migraine medication approximately monthly. According to the NARSUM a CT scan of the head in February 1998 was normal. At the MEB exam, the CI reported headaches varying in intensity, at times severity rated 10/10. The headaches were associated with light and sound sensitivity, nausea at times, and were improved by lying down or sleeping. The MEB physical exam noted a normal neurological exam. A neurological addendum to the MEB on 5 March 1999 stated the CI reported headaches 2 to 4 times per week with two to three of the migraines severe enough to warrant leaving her duties to lie down. No preventive medications were helpful to the CI and she was treating her migraines with abortive medical therapy. The MEB referred the CI to the PEB and the PEB adjudicated the migraine condition as unfitting and placed the CI on TDRL rated at 30% to allow the condition to stabilize. At the first VA Compensation and Pension (C&P) exam on 11 November 1999, approximately 4 months after TDRL entry, the CI reported migraine headaches two to three times per week associated with sound sensitivity, lasting a day or at times longer. The CI was using pain medications for severe headaches. The examiner noted that during headaches the CI was on bed rest. The VA exam noted a normal neurological exam. At the first TDRL re-evaluation on 3 October 2000 the CI reported her migraine headaches had improved significantly and occurred approximately one to two times per month and lasted a week. During the headaches the CI was unable to continue her activities. The PEB in November 2000 continued the CI on TDRL at 30%. At the TDRL re-evaluation NARSUM on 27 March 2002, approximately a month prior to separation, the CI reported that the frequency and intensity of her migraines attacks had decreased, occurring on average every 4 to 6 weeks and lasting for 2 to 5 days. The CI was on abortive treatment only for her migraines. The CI reported that most of the time she was able to work even if she had a mild headache, whereas previously she could not. The MEB exam showed a normal general physical examination. At the VA C&P exam on 7 August 2001, 8 months prior to separation, the CI reported migraine attacks almost monthly; her last attack for which she went to the emergency room was a month prior to the exam. The headaches were associated with light sensitivity and occasionally nausea and vomiting. The CI was on daily medication for migraine prevention at that time. The VA exam noted a normal neurological exam.

The Board directs attention to its rating recommendation based on the above evidence. At TDRL entry the PEB rated the migraine condition as 8100 (migraine) at 30%. The VA rated as 8100 at 10% initially, but a 6 July 2000 VARD increased it to 30% upon receipt of additional treatment records. The VASRD §4.124a rating schedule for 8100 (migraine) rests heavily on the frequency of ‘prostrating’ attacks. By precedence the Board requires evidence that an attack requires abandonment of work or activity at hand to seek treatment (which includes self-medication and/or sleep), or to escape noxious stimuli in the immediate environment, in order for it to be characterized as prostrating. The Board considered the CI’s history of migraine headache attacks at TDRL entry. STR notes during the year prior to TDRL entry support that the CI had prostrating migraine headache attacks on average monthly. However at the MEB exam, the MEB neurological evaluation, and the C&P exam the CI reported headaches one to three times per week, some of which required the CI to lie down in a dark room and or seek medical treatment. The commander’s letter noted that from September 1998 to March 1999 the CI had been placed on quarters fourteen times (consistent with a prostrating headache frequency of two to three times per month) and due to her medical conditions had missed 1-2 days per week of work. The Board agreed that the migraine condition was best coded as 8100 (migraine) and the criteria for a 30% rating (prostrating attacks occurring on an average once per month over the last several months) were met. The Board next checked to see if the criteria for the 50% rating (frequent, completely prostrating and prolonged attacks productive of severe economic inadapability) were achieved. Based on the evidence in the record the CI experienced prostrating migraine attacks 2 to 3 times per month lasting for days associated with significant lost work time. The Board agreed that this most nearly met the 50% disability rating IAW §4.124a. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 50% for the migraine headache condition at TDRL entry. At permanent separation the PEB rated the migraine condition at 10% coded as 8100. The VA continued the previous 30% rating of the migraine condition. The Board deliberated on the rating of the CI’s migraine condition at permanent separation. At the MEB exam the CI reported a migraine once every one to 2 months, but that “most of the time” she was able to continue to work. The CI described her migraines condition as improved because of both decreased frequency and intensity of the headaches. At the C&P exam the CI reported headaches almost monthly without mention of the frequency of prostrating attacks. The Board opined that at the time of permanent separation as evidenced in the record the CI’s migraine condition most nearly met the disability rating of 10% of 8100 specified as “characteristic prostrating attacks averaging one in 2 months over last several months.” 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 migraine headache condition at permanent separation.

Contended PEB Conditions. The Board’s main charge is to assess the fairness of the PEB’s determination that the left upper back pain, lower back pain, left knee pain, right knee pain and reactive airways disease conditions were not unfitting. 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.

1) LEFT UPPER BACK PAIN: On the SF 93 dated 15 October 1998, the CI reported constant low back pain (LBP), right and left knee pain and migraine headaches without mention of upper back pain. The TDRL entry NARSUM noted a history of upper and lower back pain and noted that she was unable to do sit ups due to LBP. The MEB exam noted left trapezius muscle tenderness and spasm. Reflexes, strength and sensation of the upper and lower extremities were normal bilaterally. STR notes indicated a few visits for upper back muscular strain following a motor vehicle accident in August of 1995, 4 years prior to TDRL entry. There were no other visits for upper back pain until the left upper back is mentioned in the orthopedic evaluation for the MEB. Thoracic spine X-rays were normal.

2) LEFT KNEE PAIN: Notes in the STR indicated visits for left knee pain in 1989. STR notes post 1994 indicate treatment for right knee pain. The orthopedic exam for the MEB indicated right knee pain only. On the SF 93 the CI reported left knee pain. The TDRL entry NARSUM noted the CI fell during basic training on both her knees and had intermittent bilateral knee pain, mild on the left. Symptoms were mostly on the right knee. The MEB exam showed full ROM of the left knee without effusion, instability, or laxity. There was TTP of the medial femoral condyle, but not of the lateral or of the joint lines. There was no crepitus with ROM.

3) REACTIVE AIRWAY DISEASE (RAD): The CI was diagnosed with RAD in 1998 and placed on inhalers including a long acting bronchodilator, an inhaled corticosteroid and a rescue inhaler. Chest X-ray 9 January 1998 was normal. The NARSUM noted a history of dyspnea on exertion, increased with activity and improved with medications. Pulmonary exam was normal. Pulmonary function tests (PFTs) showed an FEV1 of 69% predicted normal FEV1 with improvement with bronchodilator. The MEB examiner noted that the RAD had not limited the CI’s physical duties. The C&P exam indicated the same history of asthma treated with inhalers daily. Lungs were clear and PFTs showed mild obstruction. Chest X-ray was normal.

4) RIGHT KNEE PAIN: The TDRL entry NARSUM noted the CI had a long history of right knee pain following a fall on both her knees. The right knee pain was worse than the left. The CI had an arthroscopy on the right in April 1994 that showed chondromalacia. The right knee pain did not respond to treatment and that the CI was unable to do perform the duties of her MOS due to her knee pain. The MEB exam showed full ROM without effusion, instability or laxity. There was TTP of the medial femoral condyle, but not of the lateral, or of the joint lines. There was TTP of the patella and crepitus with ROM. Evidence in the record indicates the CI received a permanent profile for her right knee pain in August 1997 diagnosed as retropatellar pain syndrome/chondromalacia. The MOS/Medical Review Board (MMRB) referred the CI to the Army Physical Disability System as a result of a profile due to chronic right anterior knee pain. A commander’s statement indicated that the CI could not perform the physical demands of her MOS due to a P3L3 profile. The anterior right knee pain was not mentioned specifically in the commander’s statement but was listed on the permanent profile. At the C&P exam on 11 November 1999 the CI reported right knee pain associated with weakness, swelling, instability, fatigue and lack of endurance, intermittent in the summer and constant in the winter. The VA exam showed no effusion, instability, laxity, or signs of meniscal injury. There was crepitus. Right knee ROM was flexion 0-100 degrees (normal 0-140 degrees); extension was normal. Painful motion was noted. X-rays of the bilateral knees were normal. The PEB adjudicated the right knee condition as not unfitting at TDRL entry. The VA coded it as 5099-5019 (bursitis) and rated at 10%. The TDRL re-evaluation NARSUM indicated the CI had some knee problems due to chondromalacia and that sometimes she would go to get a prescription anti-inflammatory medication that she used as needed. Reflexes and strength were normal, no specific knee exam was documented. At the C&P exam, approximately 8 months prior to permanent separation, the CI’s right knee was not re-evaluated.

5) LOW BACK PAIN: The TDRL entry NARSUM noted that the CI had a history of LBP that was diffuse, non-radiating and had gradually worsened. At the MEB exam approximately 8 months prior to TDRL entry the CI reported a dull ache with sharp exacerbations that at times required medication and bed rest. The MEB exam showed the CI’s back was straight. She was able to heel and toe walk. There was TTP of the lumbar spine and musculature. Straight leg raise (SLR) was negative. Lumbar ROM was described as fingertips to her proximal calf with pain; extension was 10 degrees with pain. Muscle strength, sensation and reflexes were normal in both lower extremities. The examiner noted the CI could not do sit ups due to LBP and walking two miles would sometimes cause back pain. In the year prior to TDRL entry there were three notes in the STR for LBP. The CI was seen in September 1998 for an episode of back pain with full lumbar ROM with pain with toe touching, normal sensation, strength and negative SLR on exam. She was referred to physical therapy and the last visit was 24 April 1999 for recurrent LBP, exam was normal except for “unable to fully touch toes” secondary to discomfort. Thoracic and lumbar spine X-rays were normal. At the C&P exam the CI reported upper and lower back pain which would come and go at the same time with no specific pattern since 1991; it occurred monthly and lasted for several days. It was increased by activity and relieved by rest and pain medication. The VA exam showed normal posture and gait. Strength, sensation and reflexes were normal. There was TTP of the lumbar and thoracic muscles. SLR was negative. Flexion was 85 degrees and painful motion was present. There was no muscle spasm noted. X-rays of the thoracic and lumbar spine were normal. The PEB adjudicated the LBP condition as not unfitting at TDRL entry. The VA coded it as 5295 (lumbosacral strain) rated at 10%. The TDRL re-evaluation NARSUM noted only that the CI indicated that she had not had any back problems for the past 6 months and that it did not interfere with her daily activities. She took an anti-inflammatory medication as needed. Reflexes and strength were normal, no specific back exam was documented. At the C&P exam, the CI’s back was not re-evaluated.

The chronic left upper back pain and left knee pain conditions were not profiled; the RAD (asthma) condition was listed on the permanent profile but the MEB examiner noted that it did not impair duty performance and was forwarded to the PEB as medically acceptable. None were implicated in the commander’s statement or judged to fail retention standards. All were reviewed by the action officer 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 chronic left upper back pain, left knee pain, or RAD contended conditions and so no additional disability ratings are recommended for them. The right knee pain was permanently profiled in August 1997 and also included on the final permanent profile. There was a commander’s statement specifically addressing the impairment of duty performance due to right knee pain. LBP was permanently profiled; limitations in the commander’s statement that impaired duty performance included no prolonged standing, sitting, no bending or stooping, and there was evidence of treatment for recurring LBP in the year prior to TDRL entry. After due deliberation, the Board agreed that the preponderance of the evidence with regard to the functional impairment of the right knee pain and LBP contended conditions favor their recommendation as additionally unfitting conditions for disability rating at TDRL entry. The Board must apply VA rating guidelines in effect at the time of TDRL entry and it did so. At TDRL entry the right knee pain condition is coded 5099-5003 (patellar pain syndrome) and meets the VASRD §4.71a criteria for a 10% rating. The LBP condition is coded 5299-5295 (lumbosacral strain) at 10%. At the time of permanent separation the evidence in the record available indicated that the right knee pain and low back conditions had improved and no longer met the 10% disability ratings of codes 5099-5003 and 5299-5295 respectively; therefore the after due deliberation the Board recommends a rating of 0% for the right knee pain condition and 0% for the LBP condition at permanent separation.


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 migraine headache condition, the Board unanimously recommends a disability rating of 50% at TDRL entry and a permanent disability rating of 10%, coded 8100 IAW VASRD §4.124a. In the matter of the contended chronic upper back pain, left knee pain and RAD conditions, the Board unanimously recommends no change from the PEB determinations as not unfitting. In the matter of the contended right knee pain condition, the Board unanimously agrees that it was unfitting at TDRL entry and recommends a disability rating of 10% and a permanent disability rating of 0%, coded 5099-5003 IAW VASRD §4.71a. In the matter of the contended LBP condition, the Board unanimously agrees that it was unfitting at TDRL entry and recommends a disability rating of 10% and a permanent disability rating of 0%, coded 5299-5295 IAW VASRD §4.71a. 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
TDRL PERMANENT
Migraine Headache Condition 8100 50% 10%
Right Knee Pain Condition 5099-5003 10% 0%
Chronic Low Back Pain Condition 5299-5295 10% 0%
COMBINED
 60% 10%


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20120612, 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 AR20130010297 (PD201200701)


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 reject the Board’s recommendation and hereby deny the individual’s application. There is insufficient justification to support the Board’s recommendation in accordance with Army and Department of Defense regulations.

2. Although the PDBR has recommended an increase of individual’s temporary rating, this is not authorized by law or regulation which allows a review of certain separations with a rating of 20% of less. The applicant’s temporary rating of 30% would not satisfy that requirement.

3. The PDBR also recommended adding 2 unfitting conditions. This recommendation, however, only applied to the individual’s temporary rating.

4. The PDBR’s review of the individual’s permanent rating of 10% is authorized by statute but the PDBR did not recommend any change to his permanent rating.

5. 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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