RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2013-00025
BRANCH OF SERVICE:  NAVY	BOARD DATE:  20140930
SEPARATION DATE:  20020430

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4 (Engraving Technician) medically separated for a headache syndrome, a back condition and a right ankle condition.  These conditions could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty or satisfy physical fitness standards.  He was placed on limited duty (LIMDU) and referred for a Medical Evaluation Board (MEB).  The headache, back and ankle conditions, characterized as “headache syndrome,” “mechanical low back pain, lumbar facet arthrosis and early degenerative lumbar disk disease” and “right ankle posttraumatic arthritis,” were forwarded to the Physical Evaluation Board (PEB) IAW SECNAVINST 1850.4E.  The MEB also identified and forwarded four other conditions.  The Informal PEB adjudicated headache syndrome, early degenerative lumbar disk disease and right ankle posttraumatic arthritis each as unfitting, rated at 10%, 10% and 0% respectively, with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The remaining conditions were determined to be both Category II (contributing to the unfitting condition) and Category III (not unfitting) therefore not subject for rating.  The CI appealed to the Formal PEB, which affirmed the IPEB findings and ratings.  The CI requested a Petition for Relief from final action which was not accepted by the Naval Council of Personnel Boards as the PFR did not meet the minimal requirements for review.  The CI made no further appeals and was medically separated.

CI CONTENTION:  “My disability from the Naval Service seriously rendered me unfit for suitable job and seriously affects my health.”

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 when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting.  Any conditions outside the Board’s defined scope of review and any contention not requested in this application may remain eligible for future consideration by the Board for Correction of Military/Naval Records.  Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards to the unfitting medical condition at the time of separation.  The Board has neither the role nor the authority to compensate for post-separation progression or complications of service-connected conditions.  That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws.  The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation. 

RATING COMPARISON:

Service FEB – Dated 20011211	VA* - (2 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Headache Syndrome	8199-8100	10%	Headaches Secondary to Head Injury	9304-8045	10%	20020806	
Early Degenerative Lumbar Disc Disease	5299-5295	10%	Lumbar DJD with Mild Canal Stenosis and Disc Bulge at L4-5 with Facet Arthropathy	5292	40%	20020806	
Right Ankle Post-Traumatic Arthritis	5299-5003	0%	Sprain Right Ankle…	5271-5010	10%	20020806	
Sensation of Anxiety	Category II	Anxiety Disorder	9400	10%	20020809	
Lumbar Facet Arthrosis	Category II	See Lumbar DJD above	--	--	20020806	
Mechanical Low Back Pain	Category II	See Lumbar DJD above	--	--	20020806	
Chronic Right Flexor Hallucis Longus Tendonitis	Category II	Right Flexor Hallucis Tendonitis	5024	NSC	20020806	
Other x 3 (Not in Scope)	Other x 4 (Not in Scope)	20020806	
Combined:  20%	Combined:  60%	
*Derived from VA Rating Decision (VARD) dated 20030212 (most proximate to date of separation (DOS))

ANALYSIS SUMMARY:

Headache Syndrome with Sensation of Anxiety.  The CI fell off a ladder and sustained a head injury in December 1999.  Subsequent to the fall, the CI developed daily headaches, insomnia, and sensations of anxiety (internal shaking, heart racing).  He was diagnosed with post-concussive syndrome.  Despite multiple medication trials, the headaches and sensations of anxiety persisted.  After an emergency room visit for a headache with prolonged confusion, the CI was evaluated by neurology on 2 April 2001.  At the time of the neurology evaluation he reported daily headaches starting at the back of his head and radiating to the top.  The non-throbbing, sharp, driving pain was rated at 6/10.  He reported light sensitivity, fatigue and dizziness with the headaches.  Stress and exertion worsened the headaches.  He took Tylenol as an abortive medication and Celexa for the anxiety symptoms.  Radiographic evaluations for intracranial pathology (computed tomography scans 1999, 2001, 2002; magnetic resonance imaging [MRI] 2000) were normal.  An electroencephalogram (EEG) performed in April 2001 to rule out seizures was negative.  The narrative summary (NARSUM) addendum dated 18 May 2001 noted daily headaches lasting on average 6 hours with light sensitivity and nausea.  The diagnosis rendered was headaches not otherwise specified (NOS) without evidence of significant intracranial pathology.  The MEB forwarded headache syndrome, sensations of anxiety and eight other conditions to the PEB.  The PEB requested a psychiatric evaluation due to reference in the MEB and medical records of anxiety disorder NOS and PTSD.  The NARSUM psychiatric addendum dated 19 July 2001 noted the CI’s episodic anxiety was due to familial stress.  An Axis I diagnosis was not rendered.  The examiner opined that his psychiatric symptoms “were not in themselves disabling.”

At the VA Compensation and Pension (C&P) examinations in August 2002 (2 months after separation), the CI reported that he experienced headaches, sensations of a rapid heart rate, tremors, insomnia, heat radiating from his head to his legs and shaking since the fall.  He described the headaches as throbbing with light sensitivity.  He reported daily headaches lasting about 4 hours.  He reported minimal relief with medications.  The CI stated that at times the headaches would require a dark room and that he was unable to function.  The neurologic examination was normal.  The psychiatric examination was significant for a down mood, constricted affect and an inability to perform serial sevens.  The examiners diagnosed headaches and anxiety disorder NOS.  The Global Assessment of Functioning score was 60 (low moderate).  The C&P examiner diagnosed headaches.  The psychiatry examiner opined that mild symptoms of anxiety disorder NOS and depressive symptoms interfered with the CI’s ability to obtain and retain a job.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB adjudicated the headache syndrome unfitting and the sensation of anxiety as Category II, related to the headache syndrome.  The rated the headache syndrome, coded 8199-8100 analogous to migraine headaches at 10%.  The VA rated the headaches secondary to head injury at 10%, coded 9304-8045, brain disease due to trauma and anxiety disorder at 10%, coded 9400 (anxiety disorder).  The Board considered that there was no evidence of headaches or sensations of anxiety prior to the fall.  Under the VASRD criteria for traumatic brain injury in effect at the time of separation, the maximum rating for “purely subjective complaints such as headache, dizziness, insomnia, etc., recognized as symptomatic of brain trauma” was rated at 10% and could not be combined with any other rating for a disability due to brain trauma.

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 headache syndrome and sensation of anxiety conditions.  The Board, however; does recommend an administrative VASRD code change to reflect that the headaches were secondary to head injury; VASRD code 9304-8045 (brain disease due to trauma).

Degenerative Lumbar Disc Disease with Lumbar Facet Arthrosis and Mechanical Low Back Pain.  The CI sustained a head injury after a fall off of a ladder in December 1999.  Subsequent to the fall, the CI developed low back pain (LBP).  He was treated with pain medications and physical therapy.  A physical therapy note dated 17 July 2000, documented low back pain with prolonged sitting rated 7/10.  The therapist noted that the CI was wearing a lumbar corset.  The range-of-motion (ROM) evaluation demonstrated a 50% reduction in forward flexion and side bend, tenderness to palpation of the right lumbar paraspinous muscles, and a positive right straight leg raise.  An orthopedic evaluation on 28 February 2001 referenced an MRI which demonstrated moderate canal stenosis at two levels of the lumbar spine with disc bulging.  The orthopedic examination was significant for lower back pain greater with extension than flexion, pain with rotational movement and tenderness to palpation of the lumbar mid-spine and paraspinal areas.  A diagnosis of low back pain secondary to facet syndrome was rendered.  The CI was started on a trail of Celebrex and offered a referral to pain clinic for facet blocks.  The MEB Standard Form 88 dated 17 April 2001 noted that the CI used a back support device.

The NARSUM dated 28 April 2001, a year prior to separation, noted a lumbar injury in December 1999 with a diagnosis of mechanical low back pain.  The physical examination demonstrated tenderness to palpation throughout the lumbar spine with decreased ROM in all planes with pain at extremes.  Diagnoses of mechanical low back pain, lumbar facet arthrosis, and early degenerative lumbar disk disease were rendered.  A physical therapy note dated 01 May 2001, documented a 50% reduction in forward flexion, lateral bending and left rotation. At the VA C&P examination dated 06 August 2002 (2 months after separation), the CI reported daily pain in the lower back.  The pain was slightly relieved by Celebrex.  He reported that he was unable to stand, lift, or exercise due to the lower back pain.  He reported that he slept 2 to 3 hours secondary to pain.  The examiner noted that the CI wore a back brace.  There was right sided scoliosis, significant spasms on of the left musculature and midline tenderness of the lumbosacral spine.  Forward flexion was limited to 40 degrees and extension to 5 degrees.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB adjudicated early degenerative lumbar disc disease as unfitting rated analogous to 5295 lumbosacral strain at 10% and identified lumbar facet arthrosis and mechanical low back pain as Category II conditions.  The VA rated the lumbar degenerative joint disease at 40% for severe lumbar spine limitation of motion, coded at 5292.  The Board considered the several examinations which evidenced chronic lower back pain with limitation of ROM.  Both the VA and in STR document 50% or greater decreased forward flexion and extension.  There was evidence of stenosis (narrowing of spinal canal), arthrosis of spine, persistent tenderness to palpation, muscles spasms, marked loss of forward bending and right sided scoliosis (listing).  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that the lower back condition could be characterized as severe lumbosacral strain and met the criteria for a 40% disability rating.

Right Ankle Post-traumatic Arthritis with Chronic Right Flexor Hallucis Longus Tendonitis.  Available treatment records evidence that the CI sustained a right ankle injury after his fall in 1999.  Approximately a year after the fall he continued to report 6/10 ankle pain.  An orthopedic evaluation dated 25 September 2000, noted persistent right ankle pain which worsened with activity, but was without swelling or instability.  The ankle examination demonstrated tenderness to palpation at the medial malleolus and deltoid ligament.  The examiner identified rule-out diagnoses of deltoid ligament tear versus osteochondral defect versus post-traumatic degenerative joint disease.  There was a recommendation for a bone scan.  At an orthopedic follow-up dated 06 November 2000.  The examiner documented that the CI was using ankle support, completed physical therapy, had an ankle injection and used non-steroidal anti-inflammatory medications.  The ankle examination demonstrated tenderness to palpation at the deltoid ligament.  Testing for lateral ankle instability (talar tilt) was slightly positive.  There was pain over the flexor hallucis longus tendon (FHL) with grinding on motion (crepitus).  The orthopedist diagnosed questionable FHL tendonitis.  The narrative summary (NARSUM) noted that the CI was diagnosed with post-traumatic arthritis and FHL tendonitis.  The examiner referenced a bone scan dated 11 October 2000 which showed minimal uptake in the inferior right calcaneus.

At the VA C&P examination, the CI reported daily right ankle pain with walking and standing.  He reported intermittent swelling, but denied instability.  The examination was significant for medial greater than lateral malleolar tenderness to palpation and pain with active inversion/eversion.  The examiner reviewed X-rays which showed degenerative joint disease of the right ankle.  A diagnosis of post-traumatic arthritis was rendered.  The VA rated the ankle condition IAW VASRD §4.59, painful motion at 10%.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB adjudicated the right ankle post traumatic arthritis as unfitting with a disability rating of 0%, coded 5299-5003 analogous to degenerative arthritis and chronic right flexor hallucis longus as Category II.  The VA rated the right ankle post traumatic arthritis at 10% for painful motion, coded 5271-5010, ankle limitation of motion-arthritis due to trauma.  The Board considered the non-compensable objective evidence of pain limitation of motion with motion and radiographic evidence of degenerative joint disease met the criteria for application of VASRD§ 4.59, painful motion.  The Board agreed with the PEB adjudication of the FHL tendonitis as Category II, contributing to the unfitting right ankle, because ankle pain associated with arthritis and tendonitis is the primary symptom contributing to the functional impairment.
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 right ankle post-traumatic arthritis 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.  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 headache syndrome condition, the Board unanimously recommends no change in the PEB adjudication.  The Board recommends an administrative VASRD code change to reflect that the headaches were secondary to head injury; VASRD code 9304-8045, brain disease due to trauma.  In the matter of the early degenerative lumbar disc disease condition, the Board unanimously recommends a disability rating of 40%, coded 5295 (lumbosacral strain), IAW VASRD §4.71a.  In the matter of the right ankle post-traumatic arthritis condition, the Board unanimously recommends a disability rating of 10%, coded 5099-5003, IAW VASRD §4.71a and §4.59.  In the matter of the contended sensation of anxiety, lumbar facet arthrosis, mechanical LBP and FHL tendonitis conditions, the Board unanimously recommends no change from the PEB determination as Category II conditions.

RECOMMENDATION:  The Board recommends that the CI’s prior determination be modified as follows and that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective as of the date of his prior medical separation:

UNFITTING CONDITION	VASRD CODE	RATING	
Headache Syndrome Condition	9304-8045	10%	
Degenerative Lumbar Disc Disease	5295	40%	
Right Ankle Posttraumatic Arthritis	5099-5003	10%	
COMBINED	50%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20130114, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR COMMANDER, NAVY PERSONNEL COMMAND
DEPUTY COMMANDANT, MANPOWER & RESERVE AFFAIRS

Subj: PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS

Ref: (a) DoD I 6040.44

(b) PDBR ltr dtd 1 Jun 15 ICO XXXXXXXXXXXXXXXXXX
(c) PDBR ltr dtd 1 Jun 15 ICO XXXXXXXXXXXXXXXXXX
(d) PDBR ltr dtd 8 Jun 15 ICO XXXXXXXXXXXXXXXXXX
(e) PDBR ltr dtd 19 May 15 ICO XXXXXXXXXXXXXXXXXX
 
1. Pursuant to reference (a} I approve the recommendations of the Physical
Disability Board of Review set forth in references (b) through (d).

2. The official records of the following individuals are to be corrected to
reflect the stated disposition:

a. XXXXXXXXXXXXXXXXXX former USN: Entitlement to disability
severance pay with a disability rating of 10 percent (increased from 0 (zero)
percent) effective date of discharge.

b. XXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability
severance pay with a disability rating of 20 percent (increased from 10
percent) effective date of discharge.

c. XXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability
severance pay with a disability rating of 20 percent (increased from 0 (zero)
percent) effective date of discharge.

d. XXXXXXXXXXXXXXXXXX, former USN: Placement on the Permanent
Disability Retired List with a 50 percent disability rating (increased from
20 percent) effective date of discharge.

3. Please ensure all necessary actions are taken to implement these
decisions, including the recoupment of disability severance pay, if
warranted, and notification to the subject members once those actions are
completed.