RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX		CASE:  PD-2014-00589
BRANCH OF SERVICE:  Army		SEPARATION DATE:  20060520

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Cannon Crewmember, medically for “frequent episodes of unsteadiness (right vestibular hypofunction),” “chronic low back pain” and “chronic right trapezius myofascial pain (neck and right shoulder)” rated 10%, 10%, and 0%, respectively; with a combined disability rating of 20%.

CI CONTENTION:  The applicant contends that his unfitting neck and back condition should have been rated higher.  Additionally he contends TBI.  The applicant’s complete submission is at Exhibit A.

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44.  It is limited to those conditions determined by the Physical Evaluation Board (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 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 PEB - 20060420	VARD – 20070621	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Episodes of Unsteadiness (Right Vestibular Hypofunction)	6299-6204	10%	Residuals of Closed Head Injury (to include Headaches, Vertigo)	6204-8045	10%	STR	
Post Traumatic Headaches	Not Unfitting					
Tinnitus	Not Unfitting	Right Ear Tinnitus	6260	10%	STR	
Chronic Low Back Pain	5299-5237	10%	Lumbarization…Upper Sacrum, Compression Fracture L1…(Low Back Strain)	5299-5237	10%	20070109	
Chronic Right Trapezius Myofascial Pain (Neck/Right Shoulder)	5099-5021	0%					
COMBINED RATING:  20%	COMBINED RATING FOR ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY
Frequent Episodes of Unsteadiness.  The first record in evidence for the “unsteadiness condition” is an internal medicine (IM) note dated 3 June 2004.  The CI had reported dizziness to a nurse while in treatment for his shoulder.  The CI reported a constant sensation of lightheadedness over the past few days.  His evaluation was unremarkable and he denied hearing loss or difficulties.  Laboratory studies were normal.  The CI was seen 5 days later on 8 June 2004 and endorsed both ringing in his ears (tinnitus) and hearing loss.  He felt unsteady, but not lightheaded (which he had previously reported).  He was referred to otolaryngology (ENT) with the note of a unilateral (right) hearing loss and right > left tinnitus.  It was not noted that he had been evaluated for the unilateral hearing loss 3 years earlier.  At the ENT evaluation on 22 June 2004, the CI reported right > left hearing loss associated with lightheadedness which was without a motion component (inconsistent with vertigo).  He attributed these to a blow to his head while deployed, but denied loss of consciousness (LOC).  He was thought to have noise induced loss (the diagnosis given in ENT 3 years earlier), but an evaluation to rule out pathology was begun.  At an audiology evaluation on 15 June 2004, the CI reported that he had struck the right front of his head when he fell and injured his right shoulder.  An MRI on 27 June 2004 did not show pathology of the auditory system.  At vestibular (balance system) testing on 2 August 2004, the CI reported that his lightheadedness and headaches began after hitting his head while deployed and that he also injured his right shoulder.  He reported that quickly turning his head could reproduce his symptoms (the opposite of what was reported to ENT 6 weeks earlier).  Testing showed borderline right vestibular hypo-functioning which “may be contributing to the patient’s symptoms.”  Continued vestibular rehabilitation in PT was recommended.  He was evaluated in neurology on 12 August 2004 and reported continued lightheadedness after quick head movements as well has headaches.  The neurological examination was normal.  He was referred to pain management for a nerve block, which provided only 10% relief of his headache.  At a follow-up pain management appointment on 24 August 2004, the CI report that his symptoms started after a fall to his head and right shoulder in March 2004 with sustain decreased right hearing and bilateral changes in vision.  He endorsed constant neck pain on the right and a headache around both eyes.  His examination was significant for tenderness of the neck, but the neurological and ROM were normal.  At a neurology follow up on 14 April 2005, for the Traumatic Injury Soldiers’ Insurance Program (TIGLI), the CI reported that he had a LOC (less than 2 minutes) after his fall the previous year.  His examination remained unremarkable other than some limitation in movement of the right shoulder away from the body.  He was diagnosed with post-concussion syndrome.  At an ENT follow-up on 26 August 2005, the CI reported right hearing loss, tinnitus, and vertigo.  He stated that he fell while chasing an insurgent and sustained a concussion with spine and shoulder injuries.  He also reported paroxysmal vertigo and lightheadedness with sudden movement, constant tinnitus, and headaches.  The ENT addendum for the narrative summary (NARSUM) was dated 02 September 2005, 9 months prior to separation.  It recorded that he fell in March 2004 and sustained injuries to his back, shoulder, and head.  His physical examination was unremarkable.  Testing had showed “borderline abnormal right vestibular hypofunction which would be consistent with possibly an incompletely compensated right unilateral vestibular weakness.”  It was noted that the vestibular rehabilitation had not been sufficient for him to meet retention standards.  An MRI of the neck on 28 November 2005 showed minimal degenerative disc disease (DDD) of the cervical spine as well as a congenital cerebellar (part of the brain) finding.  While this can be linked to balance problems, the symptoms reported by the CI were not associated with this by his clinicians during the evaluations.  The neurological addendum for the NARSUM was dated 26 January 2006.  The examiner noted that the CI fell while running during an enemy engagement and sustained a LOC of less than 2 minutes.  The Board noted that this is not consistent with the contemporaneous records and that the CI had specifically denied LOC at the initial ENT evaluation.  The CI endorsed episodic lightheadedness.  The neurological examination was essentially normal.  The NARSUM was dated 10 February 2006, 3 months prior to separation.  A brain MRI, for reported “passing out”, on 9 May 2006 was normal.

At an audiology VA Compensation and Pension (C&P) examination on 9 January 2007, 7 months after separation, the CI reported that he had been medically evacuated from theater for a head injury after a fall in combat.  The Board again noted that this is contrary to the actual medical evacuation documentation.  He also reported a significant history of noise exposure as a police officer for 7 years prior to service and also from recreational weapons use.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the CI for frequent episodes of unsteadiness associated with tinnitus at 10%, for occasional dizziness, coded 6299-6204 (analogous to peripheral vestibular disorders).  The VA rated the CI at 10%, coded 6204-8045 (residuals of TBI).  The Board observed that a head injury was not recorded in the initial evaluations and was first reported on 22 June 2004, over 2 months after his initial evaluation.  The evidence does not support the presence of an unfitting head injury for rating purposes.  The Board concurred with the use of the code 6204 and found no route to a rating higher than the 10% adjudicated by the PEB for the unsteadiness condition.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends no change in the PEB adjudication for the unsteadiness condition.

Chronic Low Back Pain.  Review of the records shows that the CI was first seen for LBP during officer candidate school in 2001 and was administratively separated.  He had recurrent LBP during basic training, but completed it as noted above.  No comment was made regarding LBP on multiple evaluations for the shoulder until 8 July 2004, when the CI was seen in physical therapy for vestibular rehabilitation and also noted the LBP.  He attributed the latter to the fall months earlier.  The initial NARSUM was dated 29 July 2004.  He reported an 11-month history of LBP aggravated by the demands of infantry work while deployed (although he was noted to be an artilleryman).  The LBP was not attributed to a fall while deployed (as the CI reported on some histories).  On examination, he had a normal gait and neurological examination.  The ROM was full for active and passive maneuvers.  His left leg pain was reproduced by stretching the piriformis muscle (causing compression of the sciatic nerve in the buttock).  An MRI on 20 August 2004 showed degenerative joint disease (DJD) and DDD at L4-5 and L5-S1 without nerve root compromise.  Electrodiagnostic studies were “suggestive of a possible left S1 radiculopathy” although parts of the examination were normal and inconsistent with the diagnosis.  An examination on 26 August 2004 documented a normal neurological examination.  During these evaluations, he was noted to have a 2cm leg length discrepancy as well.  ROM testing in physical therapy was done on 11 July 2004 with an inclinometer.  Flexion was 25 degrees (normal 90) and the combined ROM 105 (normal 240).  Passive flexion was less than active flexion.  All measurements were limited by pain.  A repeat MRI on 20 July 2005 showed no significant interval change from the prior study in August 2004.  At the MEB examination on 17 October 2005, lumbar area was tender to palpation.  The neurological examination was normal.  No comment was made on the ROM or gait, implying no significant abnormality.  The ROM was repeated in physical therapy on 5 November 2005 and was limited in flexion to 10 degrees and a combined ROM of 70.  The CI was then referred for chiropractic treatment.  On 9 January 2006, he was noted to have full motion without pain after treatment.  On 18 January 2006, he reported very little back pain and that after treatment he had full pain-free motion.  This was noted on multiple additional treatment notes.  The PEB NARSUM was dated 10 February 2006, 3 months prior to separation.  It was noted that signs of non-organic pain were present and that the LBP was secondary to mild DJD, leg length asymmetry, and left piriformis syndrome.  It was noted that “despite two attempts to obtain a validated ROM on his spine by physical therapy providers, we have been unable to obtain what we believe to be a truly validated ROM.”  The author also noted “This Soldier has displayed an unusual propensity to develop new issues just as his MEB is being completed, as he did in 2004 and in 2005, and as he is doing in 2006.”  On 13 February 2006, he reported a 50% reduction in pain after chiropractic treatment, but did have full ROM.  Again, multiple treatment notes documented full motion after treatment and either no pain or a reduction in discomfort.  The CI again had ROM testing in physical therapy on 13 April 2006 and had flexion of 30 degrees and a combined ROM of 115, limited by pain.  A note by the chiropractor on 19 April 2006 recorded that the CI had been injured in combat when he tripped and fell while carrying an 80 pound radio on his back.  He fell onto the side of his face and his legs came up over his head and he was “knocked unconscious.”  This is not consistent with the history in contemporaneous records.  A chiropractic note dated 5 May 2006 noted that the CI had pain free motion and no muscle spasm; however, painful motion was documented on 17 May 2006. The CI was separated on 20 May 2006.

A primary care note at the VA dated 7 September 2006 recorded that the CI had a normal gait and muscle tone.  X-rays of the back on 9 January 2007 documented a compression fracture of L1 with a volume loss of 30%.  The VA C&P examination was on 9 January 2007, 8 months after separation.  The CI denied symptoms prior to service.  He did not use an assistive device and had a normal gait.  The neurological examination was normal.  Flexion was 70 degrees and the combined ROM was not available as lateral bending was not recorded.  Motion was pain free and there was no further loss of motion with repetition.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition at 0%, coded 5299-5237 (analogous to lumbosacral strain).  The VA rated the back at 10%, also coded 5299-5237.  The Board considered the evidence.  The NARSUM author specifically noted that the physical therapy ROM values were considered unreliable.  The Board noted that the VA values, which support a 10% rating, were consistent with the pathology and the findings documented on multiple chiropractic treatment visits.  It is therefore assigned highest probative value for rating purposes.  The back pain clearly existed prior to service (EPTS), but he was able to complete basic and advanced training.  This is consistent with service aggravation and a ratable condition.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends no change in the PEB adjudication for the back condition.

Chronic Right Trapezius.  The CI was also found unfit for chronic myofascial (muscles and soft tissue) pain of the right trapezius (large shoulder muscle above the shoulder blade) which led to neck and shoulder pain.  The CI sustained a fall onto outstretched hand injury in the spring of 2004 while deployed.  X-rays of the right shoulder on 1 June 2004 were normal, but an MRI showed ACJ arthropathy.  An X-ray of the cervical spine on 16 August 2004 showed mild DJD as did an MRI the next day.  He was treated in physical therapy, but his pain persisted.  An MRI of the brachial plexus (a nerve bundle in the shoulders) on 29 March 2005 was normal.  An MRI of the neck on 28 November 2005 showed minimal DDD of the cervical spine as well as a congenital cerebellar (part of the brain) finding.  The NARSUM attributed the neck and shoulder pain to the right trapezius myofascial pain syndrome.  The VA C&P examination on 9 January 2007 noted reduced ROM in the CI’s neck, but attributed the neck pain to the congenital condition, Chiari I malformation, in a separate note dated 26 February 2007.  The ROM of the shoulder was normal and pain free as was the rest of the examination.  The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the trapezius strain pain syndrome at 0%, coded 5021 (myositis [inflammation of a muscle]).  The VA did not rate the CI for trapezius pain, but did rate the CI at 0% for a right shoulder strain.  The VA denied service connection for the neck.  The Board considered the evidence, but found no route to a rating higher than the 0% adjudicated by the PEB.  The Board considered the coding option 5301, Group I function which includes the trapezius, but a slight impairment supports a 0% rating.  This is a better description of the unfitting condition; however, it provided no rating advantage to the CI and, therefore, no coding change is recommended.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends no change in the PEB adjudication for the right trapezius myofascial pain syndrome.

Contended PEB Conditions.  The CI also contended TBI (traumatic brain injury) and tinnitus.  The PEB did not specifically address TBI nor did the MEB.  However, the MEB did list post-traumatic headaches (migrainous and ice pick) as medically acceptable, implying a head injury.  The Board determined that this was sufficient to bring a possible TBI into scope for consideration.  The Board’s main charge is to assess the fairness of the PEB’s determination that TBI and its manifestations (headaches) were not unfitting.  The Board’s threshold for countering fitness determinations requires a preponderance of evidence, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.

The initial records in evidence do not record the presence of a head injury.  The first record in evidence is an ENT evaluation on 22 June 2004 which noted that the CI had sustained a blow to his head when he fell and injured his shoulder, but did not suffer a loss of consciousness.  A TBI was not recorded as a diagnosis.  On 12 August 2004, the neurological examination was normal.   (2236) An MRI of the brain on 17 September 2004 was normal other than an incidental finding of the Chiari I malformation.  In subsequent clinical encounters, the CI reported that he fell and hit his head with a LOC of up to 2 minutes.  

The MEB noted that the CI had post-traumatic headaches, but determined that these were medically acceptable.  Headaches were noted in the final profile, but the CI retained a P1S1 profile.  The commander’s statement did not address specific medical issues.  The condition was reviewed and considered by the Board.  The earliest records after the fall while deployed are silent for a head injury and the history was noted to evolve over time.  Regardless, even if a TBI occurred, the evidence does not support the presence of unfitting complications from a TBI at separation.  Finally, a VA note dated 24 January 2008 documented that the CI had recently fallen with LOC, vomiting, and cognitive deficits which could, at least partially, account for any post-separation deterioration.  There was no performance based evidence from the record that the headaches 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 any of the post-traumatic headache condition and so no additional disability ratings are recommended.

In a similar fashion, the Board addressed tinnitus which can be a complication of TBI.  This was noted to exist prior to service and the CI needed a waiver for hearing loss, in fact, to join the Navy.  As discussed above, the evidence does not support that the CI had a significant head injury to support the presence of a TBI.  The Board found no evidence in the record to support duty impairment from tinnitus as a separate condition regardless of the presence or absence of a TBI.

BOARD FINDINGS:  In the matter of the frequent episodes of unsteadiness condition and IAW VASRD §4.87, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the back condition, the Board and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the right trapezius myofascial pain condition and IAW VASRD §4.73, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended post-traumatic headache (TBI) condition, the Board unanimously recommends no change from the PEB determination as not unfitting.  In the matter of the contended TBI condition (which includes tinnitus), the Board unanimously agrees that it cannot recommend it for additional disability rating.  The Board, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination.

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140116 w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-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, AR20160006639 (PD201400589)

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 and hereby deny the individual’s application.  
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:

Enclosure

CF: 
(  ) DoD PDBR
(  ) DVA