RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2014-02078
BRANCH OF SERVICE:  Army	BOARD DATE:  20150416
SEPARATION DATE:  20050720

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (Microwave Systems Specialist) medically separated for left knee pain and migraines.  The conditions could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty but he was authorized to perform an alternate physical fitness test (per PROFILE).  He was issued a permanent P3L3 profile and referred for a Medical Evaluation Board (MEB).  The “chronic painful left knee” and “post-traumatic migraine” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501 as medically unacceptable.  Also identified and forwarded by the MEB was an abdominal condition designated as medically unacceptable; and, a mood disorder, designated as medically acceptable.  The Informal PEB adjudicated “left knee pain” and “migraines, posttraumatic” as unfitting, rated 10% and 10%, with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The remaining conditions were determined to be not unfitting.  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 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:

IPEB – Dated 20050404	VA* - (~29 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Knee Pain	5099-5003	10%	PFS Left Knee	5099-5010	10%	20071217	
Migraines, Posttraumatic	8100	10%	Migraine Headaches	8100	10%	20071217	
Chronic Functional Abdominal Pain Syndrome	Not Unfitting	GERD	7399-7346	0%	20071217	
		Status Post Cholecystectomy	7318	NSC	20071217	
Mood Disorder, NOS	Not Unfitting	Posttraumatic Stress Disorder	9411	NSC 	20071120	
Other x 0 (Not In Scope)	Other x 12	
RATING:  20%	RATING:  30%	
*Derived from VA Rating Decision (VARD) dated 20080214 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:  The records in evidence are incomplete and documentation relating to treatment was not available for review.  Multiple attempts to obtain these were unsuccessful.  The Board determined though, that this case could be adjudicated with the information in evidence.

Left Knee Pain.  The only records in evidence regarding the left knee prior to entry into the MEB process are one prior enlistment examination and an orthopedic appointment.  On the history for the 10 March 2000 enlistment onto active duty, the CI denied any knee problems including operations or hospitalizations.  The orthopedic evaluation on 19 July 2004, a year prior to separation, simply noted knee pain.  The range-of-motion (ROM) was recorded as 15-120 degrees, but the examination was otherwise normal including an X-ray.

The narrative summary (NARSUM) was dated 5 August 2004.  It noted that the CI was treated for osteomyelitis at the age of three and wore a brace for about a year and then had knee problems in high school.  He apparently had arthroscopy in basic training in 1991 and again in Advanced Infantry Training in 1992.  In 1994, he cracked his knee cap (patella) and tore ligaments in his knee after a machine gun fell onto it.  He had surgery and was on crutches for 2 years.  His knee became swollen with activity on two additional occasions and arthroscopy was repeated in 1998 and 1999.  He was then referred to Walter Reed Medical Center where he was treated with physical therapy and steroid injections.  The Board noted that none of these surgical procedures were documented on the 10 March 2000 history form.  On examination, he had a mildly antalgic gait (an abnormal gait from or to prevent pain) and well healed arthroscopy scars.  The active ROM was limited to 15 degrees extension and 115 degrees flexion.  The passive ROM was from 0-115 and limited by pain.  He was tender to compression over the patella.  However, there was no atrophy, instability, or signs of meniscal irritation.  An MRI and X-rays in 2002 did not show pathology of the knee.  He reported that he could walk without limitation, but running was limited.  He was thought to have patello-femoral syndrome.  A neurological evaluation for headaches on 17 December 2004, 7 months prior to separation, noted normal strength and gait including toe and heel walk.  The action officer observed that a normal heel walk is not consistent with a significant limitation in extension.  At the MEB examination on 11 May 2005, two months prior to separation, the CI reported four arthroscopies.  The MEB physical examiner only documented decreased ROM and tenderness.

The VA Compensation and Pension examination was not performed until 17 December 2007, 29 months after separation.  The CI reported that he had built pool tables after separation, but was “let go” in September 2007 because he “could not lift anything heavy.”  He was noted to be ambulatory without use of an assistive device.  On examination, his posture and gait were normal.  The patella was tender to manipulation.  The ROM was limited at 0 to 120 degrees, but did not decrease further with repetition.  He was able to squat with pain.  Neither instability nor ligamentous laxity was noted.  No comment was made on the presence of scars.  X-rays were normal.

The Board directed attention to its rating recommendation based on the above evidence.  The orthopedic and MEB examinations were both at the one-year point prior to separation.  The neurology examination, which was the most proximate to separation, noted a normal gait including tandem, heel, and toe walk.  This is not consistent with a significant limitation in motion as was recorded on the MEB examination almost one year prior to separation.  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 left knee condition.

Migraines, Posttraumatic.  There was one record in evidence for migraines prior to entry into the MEB process.  The CI was seen in the emergency room for gastroenteritis and a migraine; he was treated and put on quarters for the former.  The NARSUM documented that he had been hospitalized in 1995 after he fell down some steps with a head injury and secondary post-traumatic headaches.  The 2000 enlistment history did not document this.  The CI denied a head injury, loss of consciousness, or headaches.  He also denied any hospitalization other than for wisdom teeth extraction.  The neurology addendum also recorded a history of hospitalization after a head injury following an altercation with a 3-day loss of consciousness (elsewhere, the CI reported that he fell down stairs while chasing someone as a military policeman.)  He reported that he still had headaches from this which occurred two to three times a week and required him to go to a dark room for an hour.  He reported that he had gone to the emergency room four times the past year.  He stated that he drank eight cups of coffee a day and had headaches if he did not consume caffeine.  The action officer observed that caffeine withdrawal is a common cause of headaches.  On the MEB history, he reported a head injury and headaches, but denied a loss of consciousness.  However, the examiner documented post-traumatic headaches since the head trauma with loss of consciousness in 1996.  Review of the medication profile does show periodic refills of medications used for migraines.  Review of the record showed no out-patient visits for headaches, emergency room visits for headaches (other than that cited above which was for gastroenteritis), or placement on quarters for headaches.  The history of the traumatic event which purportedly caused the headaches is also inconsistent in the records.  The profile issued for the MEB on 25 January 2005 listed traumatic migraines.  The only other profile in evidence, dated 19 July 2004, noted only the left knee.

The Board directed attention to its rating recommendation based on the above evidence.  It noted the inconsistencies in the histories provided to different examiners and the denial of headaches at re-enlistment in 2000 when he otherwise reported a five-year history of headaches.  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 “post-traumatic migraine” condition.

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the contended chronic functional abdominal pain and mood disorder 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.  Neither was profiled or implicated in the commander’s statement (which had minimal information).  The chronic abdominal pain was determined to be medically unacceptable by the MEB.  The mood disorder was not judged to fail retention standards.  Both were reviewed and considered by the Board.  There were two visits in the record for the abdominal condition in the year prior to separation.  The CI had a normal colonoscopy on 23 July 2004.  He was seen in internal medicine on 6 December 2004 after the CI experienced pain during a barium swallow (a radiological procedure to examine the stomach and esophagus).  The pancreas was noted to be enlarged.  The action officer observed that this can be secondary to alcohol abuse and that after separation the record shows alcohol abuse with DUIs (before and after separation) and an admission for substance abuse.  In accordance with DoDI 1332.38 E5.1.3.9.1, a substance abuse disorder (and complications thereof) does not constitute a physical disability.  There was no performance based evidence from the record that either of these conditions significantly interfered with satisfactory duty performance at separation.  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 either  contended conditions and so no additional disability ratings are 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.  In the matter of the left knee and migraine headache conditions and IAW VASRD §4.71a §4.124a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended chronic functional abdominal pain and mood disorder conditions, the Board unanimously agrees that it cannot recommend any additional disability ratings.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  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 20140509, 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, AR20150013717 (PD201402078)

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:

Encl			XXXXXXXXXXXXXXX
				Deputy Assistant Secretary of the Army
				    (Review Boards)
						         
CF: 
(  ) DoD PDBR
(  ) DVA