RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW
BRANCH OF SERVICE: ARMY
SEPARATION DATE: 20061002
NAME: DEVERE, XXXXXXXXXXXXXX
CASE NUMBER: PD1200276
BOARD DATE: 201211O1
SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this
covered individual (CI) was an activated Army National Guard 1LT/0-2(15A, Aviation), medically
separated for neurological constellation of symptoms of unknown etiology and a low back
condition. He did not respond adequately to treatment and was unable to perform within his
Military Occupational Specialty (MOS), meet worldwide deployment standards or meet physical
fitness standards. He was issued a permanent P3L3 profile underwent a Medical Evaluation
Board (MEB). Neurological constellation of symptoms to include shooting pain with sneezing
from the neck down into the entire body, visual disturbance, and a decrease in his fine motor
skills of his right hand of unknown etiology at this time; and chronic lower back pain with
lumbar radiculopathy and herniated nucleus pulposus at L5-S1 central to the left were
forwarded to the Physical Evaluation Board (PEB) as medically unacceptable IAW AR 40-501.
Four additional conditions, identified in the rating chart below, were forwarded on the MEB
submission as medically acceptable conditions. The PEB adjudicated the neurological
constellation of symptoms of unknown etiology; and low back condition as unfitting, rated 0%
and 0% respectively, with application of the US Army Physical Disability Agency (USAPDA) pain
policy. The CI made no appeals, and was medically separated with a 0% disability rating.
CI CONTENTION: The CI states: “I have continued pain, soreness, and additional surgeries on
the open heart surgery site. Both knees have become completely disabled to the point where I
cannot resume normal activities at all.”
SCOPE OF REVIEW: The Board wishes to clarify that the scope of its review as defined in the
Department of Defense Instruction (DoDI) 6040.44, Enclosure 3, paragraph 5.e.(2) is limited to
those conditions which were determined by the PEB to be specifically unfitting for continued
military service; or, when requested by the CI, those condition(s) “identified but not
determined to be unfitting by the PEB.” The ratings for unfitting conditions will be reviewed in
all cases. The knee condition (Retropatellar Pain Syndrome) requested for consideration and
the PEB unfitting conditions meet the criteria prescribed in DoDI 6040.44 for Board purview,
and are accordingly 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 Army Board for Correction of Military Records.
RATING COMPARISON:
Condition
Severe Intermittent
Fleeting Shooting Pains
and Paresthesias
Following Each Sneeze,
Accompanied by
Momentary Visual
Disturbances and Brief
Episodes of
Incoordination of the R
Dominant Hand
Service PEB – Dated 20060913
VA (2 Mos. Post-Separation) – All Effective Date 20061003
Code
Rating
Condition
Code
Rating
Exam
5099-5003
0%
Pre-Syncope and Dizziness
(Claimed as Syncope and
Neurological Disorder)
7010-8108
NSC
20061205
No MEB Entry
Cervical Strain
Heart Murmur, Residual ASD
surgery
Scars, Residual Atrial Septal
Defect Surgery
Mid-Chest Scar, Residual Atrial
Septal Defect Surgery
5237
7099-7000
7804
7804
5243
10%
0%
10%
10%*
10%
20061205
20061205
20061205
20061205
20081119
20061205
&
5260
10%
20061205
Chronic Radiating Low
Back Pain
Gastroesophageal Reflux
Disease
Irritable Bowel Syndrome
Dyslipidemia
Retropatellar Pain
Syndrome
5243
0%
Intervertebral Disc Syndrome
Not Unfitting
Not Unfitting
Not Unfitting
Not Unfitting
No VA Entry
No VA Entry
No VA Entry
Patellofemoral Pain Syndrome, L
Knee
↓No Additional MEB/PEB Entries↓
0% X 2 / Not Service-Connected x 2
20061205
Combined: 0%
Combined: 40%
*Added by a VARD increasing combined to 40%.
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 him. The Board wishes to clarify that it is subject to the same laws for 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 acknowledges that an electroencephalography (EEG) was referenced in
the service treatment record (STR) but the results were not available in the evidence before it,
and could not be located after the appropriate inquiries. However, the CI responded that he
had had the study which had been scheduled prior to the MEB, in addition at the VA exam he
reported he did not have a seizure disorder thus he likely was referencing the normal results.
Further attempts at obtaining the relevant documentation would likely be futile and introduce
additional delay in processing the case. The missing evidence will be referenced below in
relevant context, and it is not suspected that the missing evidence would significantly alter the
Board’s recommendations.
Neurological Constellation of Symptoms of Unknown Etiology Condition. The CI began having
episodes of sneezing which resulted in “extreme pain shooting from my neck down throughout
my entire body, and will see starts and dots, and lose my peripheral vision” which would last 3-
4 minutes. He had 3-4 in the summer of 2005 prior to seeing his flight surgeon in the fall of
2005. The CI underwent an extensive evaluation by Cardiology, Neurology, Optometry and
Internal medicine. The Cardiology evaluation revealed a defect of the heart, (Atrial Septal
defect [ASD]), which may have contributed to his symptoms and therefore this was repaired.
The postoperative course was uneventful and even a month later the cardiologist documented
his prior symptoms of lightheadedness or losing his vision with sneezing had gone away.
However, the episodes reoccurred, became more frequent and gradually worsened. A
transesphogeal echocardiogram was performed which revealed the "the heart was fine, and
the repair was holding." The Internal Medicine evaluation included; Cervical Spine (C-Spine)
and brain Magnetic Resonance Imaging (MRI) studies which were within normal limits. In late
April 2006 the CI reported new symptoms of "losing the fine motor skills in my right hand".
Multiple neurologic evaluations were conducted which included; physical exams, laboratory
evaluations, a repeat MRI of his C-spine, and new images of his Thoracic (T-spine) and Lumbar
(L-spine) spine, nerve conduction studies of the upper and lower extremities, and a lumbar
puncture that were all were within normal limits. The neurologist could not find any specific
etiology for his symptoms and opined the ASD was a coincidental finding. The Optometry
evaluation documented no abnormalities except for farsightedness.
The neurologist
summarized for the MEB; the CI was evaluated extensively for Valsalva related paresthesias in
extremities (L’hermitte’s sign) with negative results for organic causes to include; multiple
sclerosis, cervical stenosis and neuropathy and diagnosised tingling (paresthesias) with
subjective complaints related to neck flexion without definitive etiology and no neurologic
diagnosis. An electroencephalography (EEG) was scheduled after the neurology opinion and
prior to the MEB yet the result was not in evidence. The profile allowed for wearing of
protective mask and chemical equipment only and otherwise was limited in all functional
activities. The commander’s statement additionally documented the CI was reassigned to
medical hold and that his paresthesias impacted his fine motor skills in his hands which made it
difficult for him to be a pilot and with writing.
At the MEB exam, the CI reported the episodes were occurring 2 to 3 times a week lasting 1 to
4 minutes with all symptoms occurring 30% of the time and just visual symptoms 70% of the
time. These had been occurring only with sneezing; however, more recently he would
occasionally get the visual symptomatology with having a bowel movement. The episodes did
not occur with coughing or with a regular Valsalva maneuver to clear his ears. He also reported
gradually worsening in his fine motor skills in his right hand. He did not report abnormalities
with his gait or other neurologic symptoms. He was concerned with his sneezing episodes
which “could be catastrophic as a pilot” and that he had difficultly handling the instruments
with his right hand. The MEB physical exam documented a very fine intension tremor on the
right, and possibly very slight on the left otherwise normal neurologic and cardiac findings. The
examiner cited the unremarkable laboratory; X-rays and other studies completed for the
evaluation and added no new diagnoses. At the VA Compensation and Pension (C&P) exam,
the CI additionally reported having; recurring headaches which were not migraines which
happened after sneezing, 3 times per week lasting 10 minutes and dizziness 3 times per week.
He reported he did not suffer from a seizure disorder and he was able to work with
medications. The C&P exam additionally demonstrated a heart murmur without evidence of
congestive heart failure, cardiomegaly, or cor pulmonale, noted normal neurologic findings and
was silent to a tremor exam.
The Board directs attention to its rating recommendation based on the above evidence. The
PEB assigned a rating of 0% coded analogous to 5003 (arthritis, degenerative) for infrequent
episodes with sneezing and for moderate, intermittent pain. The VA coded analogous to 8108
(Narcolepsy) with 7010 (Supraventricular arrhythmias), a neurologic and cardiac VASRD code
respectively, for pre-syncope and dizziness symptoms which could be related to a heart,
neurologic or cervical spine condition. Since these symptoms were not actually diagnosed the
VA denied service-connection. The Board considered multiple coding options, including; the
PEB’s recommendation to code under a musculoskeletal code for pain due to possible C-spine
pathology, the VA’s analogous coding to the neurologic code 8108, the analogous cardiac code
7010 (Supraventricular arrhythmias), an analogous code to 8210, (tenth (vagus) nerve paralysis)
for autonomic vasovagal symptoms, an analogous cardiac code 7000 (Valvular heart disease)
for vasovagal symptoms related to heart disease and finally an analogous code to 8911 (petit
mal seizure) for vasovagal symptoms and the other residual neurologic symptoms and signs,
specifically the tremor. Due to lack of evidence for C-spine pathology and residual heart
pathology the Board agreed that a VASRD musculoskeletal or cardiac code is not applicable to
the clinical unfitting pathology of neurologic constellations of symptoms. This disability is not
specifically listed in the rating schedule; therefore, therefore the Board considered rating
analogous to a disability in which not only the functions affected, but anatomical localization
and symptoms, are closely related. The Board considered the 8210 code and the 8911 code
neurologic codes. The VASRD specifies if syncope is seizure-associated to analogize to 8911 and
if vasovagal related to analogize to 8210. The Board agreed the evidence does not reflect a
diagnosis of seizures, and the symptoms were more valsalva (vasovagal) related and therefore
the Board agreed the 8210 code best captures the residual neurologic impairments without a
diagnosis. After due deliberation, considering all of the evidence and mindful of VASRD §4.3
(reasonable doubt), the Board recommends a disability rating of 10% for the neurologic
constellation of symptoms of unknown etiology condition.
Low Back Condition. During one of his neurologic exams the CI reported atraumatic low back
pain with sitting which radiated into his left leg and left foot. An MRI of the L-Spine revealed a
moderately large central and to the left, herniated nucleus pulposus (HNP) at L5-S1, which
seemed to affect the S1 nerve root and a mild bulge at L4-5. He was referred to a pain
specialist and underwent 2 epidural steroid injections with a week of improvement with the
first and little improvement with the second. He was further recommended to seek care with
chiropractic treatment which resulted in no manipulations. He reported he would seek possible
surgical treatment at a later date. There were three 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.
DOS 20061002
MED Exam ~4 Mo. Pre-
Thoracolumbar ROM
Flexion (90⁰ Normal)
Ext (0-30)
R Lat Flex (0-30)
L Lat Flex 0-30)
R Rotation (0-30)
L Rotation (0-30)
Combined (240⁰)
Comment
Sep
45/45/48⁰
10/10/10⁰
30/30/30⁰
30/28/30⁰
20/20/20⁰
20/20/20⁰
155⁰
MEB ~2 Mo. Pre-Sep
VA C&P ~2 Mo. Post-Sep
64/63/68⁰
30⁰
30/27/32⁰
28/28/27⁰
42/44/44⁰
43/45/46⁰
215⁰
painful motion, no
90⁰
30⁰
30⁰
30⁰
30⁰
30⁰
240⁰
painful motion normal
spasm, normal gait and
posture
10%
posture, curvature, gait
10%*
§4.71a Rating
20%
*Conceding painful motion 4.59
At the MEB exam, the CI reported an average pain level is "6 to 7", aggravated by; running,
lifting and carrying (max 20 pounds), prolonged sitting and standing (max 45 minutes each), sit-
ups and push-ups, biking, swimming and prolonged walking (max a half a mile). The back and
leg pain were improved with the use of narcotic pain medications. The MEB physical exam
demonstrated no tenderness over the lumbar spine or SI joint and normal neuromuscular
findings. At the C&P exam the CI additionally reported his condition did not cause
incapacitation and he could function with medication. He also reported difficulty moving
during a flare-up but there was no evidence of the frequency of flare-ups. The C&P exam
demonstrated a sensory deficit of the bilateral posterior thighs otherwise normal
neuromuscular findings and no DeLuca observations. The lumbar spine X-ray findings were
within normal limits.
The Board directs attention to its rating recommendation based on the above evidence. The
PEB and VA both applied the code 5243 (Intervertebral disc syndrome) which is appropriate to
the diagnosis and rated IAW §4.71a—Schedule of Ratings–Musculoskeletal System under the
general rating formula for diseases and injuries of the spine. Although there are no relevant
differences in the ratable parameters between the MEB and VA exams, it was agreed that the
MEB evidence, 2 months prior to separation, was most probative for its proximity to the date of
separation. The Board notes the MEB evidence, 4 months prior to separation reflects a more
limited flexion from either of the other exams likely reflective of the waxing and waning
functional pain impairment of his back condition. The PEB’s 0% rating, derived from the
USAPDA pain policy, is not compliant with VASRD §4.71a criteria. The ROM measurements by
both the MEB and VA are consistent with a 10% rating IAW §4.71a. The Board considered
whether additional rating could be recommended under a peripheral nerve code for the
residual sciatic radiculopathy at separation. Firm Board precedent requires a functional
impairment tied to fitness is required to support a recommendation for addition of a peripheral
nerve rating to disability in spine cases. The pain component of a radiculopathy is subsumed
under the general spine rating as specified in §4.71a. The sensory component in this case has
no functional implications; and no motor weakness was in evidence. Since no evidence of
functional impairment exists in this case, the Board cannot support a recommendation for
additional rating based on peripheral nerve impairment. There was no documentation of
incapacitating episodes which would provide for higher rating. 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 low back condition.
Contended PEB Conditions. The contended conditions adjudicated as not unfitting by the PEB
was retropatellar pain syndrome. 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. This condition was not profiled, not implicated in the commander’s
statement, and, not judged to fail retention standards. This was reviewed by the action officer
and considered by the Board. There was no indication 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 retropatellar
pain syndrome and, therefore, no additional disability ratings 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. The Board did not
surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD
were exercised. As discussed above, PEB reliance on the USAPDA pain policy for rating the
unfitting and fitting conditions was operant in this case and the conditions were adjudicated
independently of that policy by the Board. In the matter of the neurologic constellation of
symptoms of unknown etiology condition, the Board unanimously recommends a disability
rating of 10%, with the analogous code 8299-8210 IAW VASRD §4.124a. In the matter of the
low back condition, the Board unanimously recommends a disability rating of 10%, coded 5243
IAW VASRD §4.71a. In the matter of the contended retropatellar pain condition, the Board
unanimously recommends no change from the PEB determination 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 his prior medical separation:
UNFITTING CONDITION
VASRD CODE RATING
8299-8210
5243
COMBINED
10%
10%
20%
Severe Intermittent Fleeting Shooting Pains and Paresthesias
Following Each Sneeze, Accompanied by Momentary Visual
Disturbances and Brief Episodes of Incoordination of the R
Dominant Hand
Chronic Radiating Low Back Pain
The following documentary evidence was considered:
Exhibit A. DD Form 294, dated 20120314, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans’ Affairs Treatment Record
XXXXXXXXXXXXXXXXXXX
President
Physical Disability Board of Review
SFMR-RB
MEMORANDUM FOR Commander, US Army Physical Disability Agency
(TAPD-ZB / ), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557
SUBJECT: Department of Defense Physical Disability Board of Review Recommendation
for XXXXXXXXXXXXXXXXXX, AR20120020916 (PD201200276)
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
CF:
( ) DoD PDBR
( ) DVA
XXXXXXXXXXXXXXXXXXXXXXX
Deputy Assistant Secretary
(Army Review Boards)
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