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AF | PDBR | CY2013 | PD2013 01020

Original file (PD2013 01020.rtf) Auto-classification: Approved

RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX CASE: PD1301020
BRANCH OF SERVICE: Army BOARD DATE: 20140211

SEPARATION DATE: 20011109

SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty CW2 (152D/Observation Scout Pilot) medically separated for costochondritis and migraine headaches. The CI experienced intermittent chest pain beginning in 1995. Chronic costochondritis was diagnosed after multiple evaluations. Various types of therapy were of limited benefit in relieving the symptoms. The migraine headaches with aura began in 1997 and both the frequency and severity increased despite numerous medical interventions. In mid-1999, neurology recommended the CI be medically disqualified from flying due to the headaches. The costochondritis and headache conditions could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty. His profile allowed for alternate aerobic events to satisfy physical fitness standards. He was issued a permanent profile for the costochondritis and migraine headaches and referred for a Medical Evaluation Board (MEB). The chest pain and headache conditions, characterized as “chronic costochondritis” and “migraines with aura,” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. No other conditions were submitted by the MEB. The PEB adjudicated “chronic costochondritis and migraine headaches” as unfitting, rated 10% and 0%, referencing the US Army Physical Disability Agency (USAPDA) pain policy for chronic costochondritis and DoDI 1332.39 for migraine headaches. The CI made no appeals and was medically separated.

CI CONTENTION: “I was disqualified for military service for two different conditions: Chronic Costrochondritis (10% rating) and Migraines w/Aura (0% rating) for a combined rating of 10%. It is my belief the initial Migraine assignment of 0% was based in a error in and contrary to the condition documented in the MEB Narrative Summary (See attached, labeled Evidence XXXXXX, 1-B, Page 3) The rating assessment of 0% is not in accordance with the VASRD based on the evidence provided in MEB Narrative Summary which states an average 5 - 10 per month. This frequency of prostrating attacks should be rated@ 50% IAW VASRD. The DVA subsequently rated me for Migraine Headaches at 30% (See VA decision letter dated November 15, 2010). I believe the DVA rating should be at 50%; however, the current DVA rating supports the 0% rating assigned by the PEB was not accurate and not in accordance with the VASRD. I request the board review all conditions considered by the PEB, assigned disability ratings, and overall combined ratings.” [sic]

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 unfitting costochondritis and migraine headache conditions are addressed below; and, no additional conditions are within the DoDI 6040.44 defined purview of the Board. 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 Board for Correction of Military Records.

RATING COMPARISON :

Service IPEB – Dated 20011001	VA - (5 Mos. Pre -Separation)
Condition	Code	Rating	Condition	Code	Rating	Exam
Chronic Costochondritis	5099-5003	10%	Costochondritis	5299-5297	10%	20010605
Migraine Headaches	8100	0%	Migraines	8100	0%	20010605
No Additional MEB/PEB Entries	Other x 3	20010605
Combined Rating: 10%	Combined Rating: 10%

Derived from VA Rating Decision (VA RD ) dated 200 11121 ( most proximate to date of separation [ DOS ] ).

ANALYSIS SUMMARY: The Board must emphasize that the Disability Evaluation System 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. The Board considers DVA evidence within 12 months of separation only to the extent that it reasonably reflects the disability at the time of separation.

Chronic Costochondritis Condition. At the VA examination performed on 5 June 2001 (5 months prior to separation), the CI reported that onset of his pain was in September 1994 and was due to an injury. He complained of constant pain in the right chest that could flare up with prolonged activity. Pain was relieved with rest but not with medication. Examination showed a normal gait and posture. Slight tenderness was present at the right parasternal chest wall area. At the narrative summary (NARSUM) exam on 8 August 2001 (3 months prior to separation), the CI complained of constant chest discomfort that was aggravated by strenuous activity and lifting. Physical examination noted a normal chest appearance. Mild tenderness of the right costosternal junction (joint where a rib meets the breastbone) was present.

The Board directs attention to its rating recommendation based on the above evidence. The PEB assigned a 10% rating under an analogous 5003 code (arthritis, degenerative) while the VA also rated the condition at 10%, but under an analogous 5297 code (ribs, removal of). Since there is no VASRD code for costochondritis or chest wall pain, these approaches are reasonable. Board members agreed that a higher rating was not justified using either code, but considered a higher rating under an analogous 5321 code (Group XXI muscles of respiration, thoracic group). It was concluded, however, that “moderate” was the most accurate descriptor of the condition using this pathway, and therefore the next higher 20% rating was not supported. 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 chronic costochondritis condition.

Migraine Headaches Condition. The CI’s headaches began in 1997 and were infrequent until 1999. He experienced 15 severe headaches during the 4-6 months prior to July 1999. At an outpatient clinic visit for costochondritis on 12 October 2000, the CI indicated he was taking no medications. On a post-deployment survey dated 26 February 2001 (deployed to Bosnia September 2000 – March 2001), the CI documented that his only unresolved medical issue was the need for a dental cleaning; he checked “No” for “any questions or concerns about your health.” On 11 April 2001 (7 months prior to separation), the commander’s statement noted that costochondritis limited his duty performance due to profile restrictions and frequent medical visits, but was silent regarding missed work due to migraine headaches. The VA examiner on 5 June 2001 (5 months prior to separation) reported that an aura, characterized as “wavy lines” in the visual field, often occurred prior to the onset of a headache. Although the CI stated that he never had a headache on two consecutive days, he also stated he was experiencing headaches three to five times per week, lasting about 12 hours. He also indicated that often he could be headache-free for several weeks. He was taking a daily medication for headache prophylaxis. The examiner opined that his occupational and daily activities would be moderately to severely affected during a migraine headache.

The NARSUM examiner on 8 August 2001 (3 months prior to separation) stated that the CI experienced five to ten headaches per month associated with visual aura and upper extremity numbness, followed by severe headache with nausea and vomiting. He was taking one abortive medication as needed and two different daily prophylactic medications. These medications provided “some but not complete success.” A follow-up neurology note on 28 August 2001 (2 months prior to separation) indicated the CI had experienced frequent headaches during his deployment to Bosnia and was now experiencing five headaches per month. If he treated a headache early enough, it could disappear within 30 minutes. Headache relief could also occur with vomiting. For some others he needed to lay down with a cold rag and get sleep, but could have a subsequent “hang over” effect. He never had headaches to the point that he could not fall asleep. He reportedly required three emergency room visits during the preceding year and had to miss work for most of his headaches. The neurologist concluded that the CI was experiencing five incapacitating headaches per month and met the definition of “prostrating headaches” three times per year. In a Notice of Disagreement letter to the VA on 27 March 2002 (4 months after separation), the CI stated he averaged 5-10 headaches per month. However, in a separate statement to the VA on 1 April 2002, he indicated a headache frequency of 5-10 per week.

The Board directs attention to its rating recommendation based on the above evidence. The PEB and VA assigned a 0% rating, indicating the evidence of record did not show that characteristic prostrating attacks were frequent enough to support the next higher 10% rating. When rating headaches under the diagnostic code 8100 (migraine headaches), VA guidance uses the clear English definition of prostrating. The standard dictionary definition of “prostration” is “utter physical exhaustion or helplessness” and does not indicate that seeking medical attention is required. However, the neurologist’s conclusion in August 2001 that the CI met the definition of prostrating headaches three times per year appeared to be based on the frequency of emergency room visits. The Board noted that the frequency of headaches as reported by several examiners was inconsistent. The VA examiner reported 3-5 headaches per week; but the Board noted the impossibility of four or five headaches per week in the context of never having consecutive daily headaches. The NARSUM examiner reported fewer headaches (5-10 per month), while the neurologist (3 weeks after the NARSUM) noted five per month. In debating the frequency of prostrating attacks during the several month period leading up to separation, Board members considered that a year prior to separation the CI was taking no headache medication; eight months prior to separation (on the post-deployment survey), headaches were not mentioned as a current problem by the CI; the commander’s statement did not mention missed work due to headaches; at the time of the VA exam he reported headache-free intervals for several weeks; and at 2 months prior to separation treatment with medication or rest often alleviated the headaches. Whether or not a post-headache “hang over effect” should be considered “prostrating” was also deliberated. The Board ultimately agreed that the described clinical picture most closely approximated the 10% criteria (“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 recommends a disability rating of 10% for the migraine headache condition.

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. As discussed above, PEB reliance on the USAPDA pain policy and DoDI 1332.39 for rating costochondritis and migraine was operant in this case and the conditions were adjudicated independently of that policy and instruction by the Board. In the matter of the chronic costochondritis condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication. In the matter of the migraine headaches condition, the Board unanimously recommends a disability rating of 10%, coded 8100 IAW VASRD §4.124a. 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
Chronic Costochondritis	5099-5003	10%
Migraine Headaches	8100	10%
COMBINED	20%

The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20130712, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans’ Affairs Treatment Record

XXXXXXXXXXXXXXXXXX, DAF
President
Physical Disability Board of Review

SFMR-RB

MEMORANDUM FOR Commander, US Army Physical Disability Agency
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation
for XXXXXXXXXXXXXXXXXX , AR20140009382 (PD201301020)

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                                                  XXXXXXXXXXXXXXXXXX
                                                      Deputy Assistant Secretary
                                                      (Army Review Boards)

CF:
( ) DoD PDBR

( ) DVA

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