RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2014-01863
BRANCH OF SERVICE:  Army	BOARD DATE:  20141216
SEPARATION DATE:  20061011

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-1 (Metal Worker) medically separated for headache and right (non-dominant) shoulder conditions which could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty.  She was issued a permanent P3U3 profile, which authorized an alternate aerobic event and referred for a Medical Evaluation Board (MEB).  Two conditions, characterized as “right shoulder pain, status post injury” and “intractable headaches” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other conditions were submitted by the MEB.  The PEB adjudicated “post-traumatic headaches” and “post-traumatic right shoulder pain” as unfitting, each rated 0%, citing criteria of the US Army Physical Disability Agency (USAPDA) pain policy for the shoulder rating.  The CI made no appeals and was medically separated.

CI CONTENTION:  “Please consider all conditions”

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 IPEB – Dated 20060925	VA - (8 Mos. Post-Separation	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Posttraumatic Headaches	8045-9304	0%	Migraine Headaches (Tension)	8100	0%	20070607	
Right Shoulder Pain	5099-5003	0%	Chronic Right Shoulder Sprain	5201	10%	20070607	
Other x 0  (Not in Scope)	Other x 1 	
Combined:  0%	Combined:  20%	
Derived from VA Rating Decision (VARD) dated 20070918 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Post-Traumatic Headache Condition.  The service treatment record (STR) corroborates the narrative summary (NARSUM) account of a head injury on 15 February 2006 (second week of basic training) when the CI suffered a concussive injury (boot blow to head without loss of consciousness).  She developed persistent headaches; magnetic resonance imaging (MRI) of the brain was normal and, repeated neurological examinations were normal.  A neurology consultant in May 2005 noted daily headaches, associated with light sensitivity, nausea, and dizziness; adding “every other day they become a bit more severe,” and noting that they were responsive to lying down for 10 to 20 minutes.  She was started on medication (Amitriptyline maintenance, Midrin rescue – used to treat symptoms of depression) and, a neurology note 2 weeks later noted that headaches were “slightly less severe” at a frequency of every other day.  The MEB’s DD Form 2807-1, Report of Medical History, dated in July 2001, recorded persistent “severe headaches” without elaboration.  STR documentation of only one unscheduled visit for treatment of headache, an emergency room (ER) encounter on 7 September 2006 (a month prior to separation).  There is no other STR evidence elaborating the severity, frequency or functional consequences of the headaches and, no entries documenting quarters or work loss due to headache.  There is no STR evidence of cognitive complaints or impairment, focal neurological deficits (central), or vestibular abnormality (objective).  There is no commander’s performance statement in evidence.

A neurological addendum to the NARSUM was prepared on 24 August 2006 (7 weeks prior to separation).  The examiner recorded “daily” headaches (no elaboration of severity or duration) accompanied by light sensitivity, nausea and dizziness, “worse with stress,” and sometimes interfering with sleep.  It was noted that “medication initially helped her headaches but they have again worsened”; and, concluded, “At this point the headaches have been refractory to medical management.”  The neurologist recommended PEB referral with a notation that a trial of new medication (Neurontin) was being initiated.  There is a cursory neurology entry in the STR after that (3 weeks prior to separation) noting “varying severity” of headaches.

General and neurological VA Compensation and Pension (C&P) examinations were conducted on 14 May 2007 (8 months after separation).  The VA general examiner, with regards to headache complaint, noted “good [quoting CI] relief with current treatment regimen”; and, documented employment “part time without restrictions as a pharmacy tech.”  The VA neurological examiner reported an earlier course of “5-10 minute” headaches every other day, which had improved with medication changes to a frequency of twice per week but “remained brief”; and, diagnosed two types of “non-prostrating” headaches (“migraine-type” related to the head injury, and “tension-type” related to stress), stating, “Neither headache type is long-lasting or incapacitating.”

The Board directed attention to its rating recommendation based on the above evidence.  The PEB’s 0% rating was under code 8045-9304 (brain disease due to trauma rated as dementia).  Code 8045, per the VASRD in effect, stipulates, “Purely subjective complaints such as headache, dizziness, insomnia, etc., recognized as symptomatic of brain trauma, will be rated 10 percent and no more under diagnostic code 9304.”  The VA’s 0% rating was under 8100 (migraine), citing the VA neurology opinion that the headaches were non-prostrating.  The Board considered the option of recommending a rating under 8100, specifically considering the latitude offered by VA Training Letter (FAST Letter) TL06-03 (effective on 13 February 2006).  Members agreed that the episode prompting an ER visit could be reasonably characterized as prostrating, thus supporting the 10% criterion of 8100; but, that there was insufficient evidence justifying a conclusion that there were further “characteristic prostrating attacks” as would be required for a higher rating under 8100.  Members agreed, however, that a 10% rating is readily supported under the PEB code and, compliant with the rating language of the VASRD in effect for that code (see above).  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a rating of 10% for the post-traumatic headache condition under 8045-9304.

Right Shoulder Condition.  The CI’s right shoulder and neck were contused in the same basic training accident cited above for the head injury.  She complained of persistent neck, right shoulder pain and pain with numbness and subjective weakness of the right arm.  Shoulder and cervical MRIs were normal, as was an electrodiagnostic study.  The shoulder pain persisted and a course of physical therapy (PT) was pursued.  An early PT note documented shoulder forward flexion and abduction limited to 90 degrees (normal 180 degrees for both), but range-of-motion (ROM) consistently improved over time.  Multiple STR entries confirm joint stability, normal strength and neurological findings, and the absence of atrophy.  Formal ROM measurements for the MEB by PT yielded forward flexion to 145 degrees and abduction to 170 degrees, documenting painful motion.  The NARSUM documented that the CI “still has pain in the anterolateral aspect of her shoulder with any motion or activity ... unable to do pushup.”  The physical exam noted tenderness, “no instability or apprehension,” 5/5 strength, and “full symmetric” ROM with pain at the extremes.  A VA C&P examiner documented (8 months after separation) improving right shoulder pain with flare ups of pain (rated 3-4/10) provoked by “repetitive movements ... and ... lifting over 15 pounds”; specifically annotating no effects on occupation or daily activities.  The VA physical exam recorded tenderness without noting other positive findings, and recorded forward flexion to 175 degrees and abduction to 180 degrees.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB’s 0% rating analogous to 5003 (degenerative arthritis) rested on application of the USAPDA pain policy which circumvents VASRD §4.59 (painful motion); the latter being well documented by the MEB PT and NARSUM examiners.  The VA’s 10% rating under 5201 (limitation of motion) presumptively conceded painful motion, since the minimum rating under 5201, based solely on ROM limitation, requires forward flexion or abduction ≤ 90 degrees.  There is no ankylosis, instability, fracture or other ratable feature in evidence which would support a rating greater than 10% under any available code; but, members agreed that painful motion was supported to achieve the minimum 10% rating.  After due deliberation, considering the total evidence and mindful of reasonable doubt, the Board recommends a 10% rating for the right shoulder condition; preferring code 5099-5010 (traumatic arthritis) for its clinical compatibility.

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 for rating the shoulder condition was operant in this case and it was adjudicated independently of that policy by the Board.  In the matter of the post-traumatic headache condition, the Board unanimously recommends a disability rating of 10% coded 8045-9304 IAW VASRD §4.124a in effect at separation.  In the matter of the right shoulder condition, the Board unanimously recommends a disability rating of 10% coded 5099-5010 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	
Post-Traumatic Headaches	8045-9304	10%	
Traumatic Arthritis, Right Shoulder	5099-5010	10%	
COMBINED	20%	
The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140501, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

XXXXXXXXXXXXXXX
President
DoD Physical Disability Board of Review

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 XXXXXXXXXXXXXXX, AR20150013654 (PD201401863)

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		XXXXXXXXXXXXXXX
			Deputy Assistant Secretary of the Army
			    (Review Boards)

CF: 
(  ) DoD PDBR
(  ) DVA