RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02278
BRANCH OF SERVICE:  AIR FORCE  	SEPARATION DATE:  20090729

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Vehicle Operations Craftsman, medically separated for “right shoulder pain associated with neck and back pain,” and “migraine headaches,” rated 20% and 0%, respectively, with a combined disability rating of 20%.   

CI CONTENTION:  The CI’s conditions were rated higher by the VA.  The CI’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 based upon a 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 - 20090319	VARD - 20100827	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Shoulder Pain Associated with Neck and Back pain	5237	20%	Right Shoulder Strain…	5201	30%	20100329	
			Chronic Thoracolumbar Strain…	5237	10%		
			DDD of the Cervical Spine…	5243	10%		
Migraine Headaches	8100	0%	Daily Headaches…	8199-8100	30%		
PTSD	Cat II	Dysthymic Disorder with Chronic PTSD…	9411	30%		
Personality Disorder, NOS	Cat III					
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  100%	

ANALYSIS SUMMARY:  

Right Shoulder Pain Associated with Neck and Back Pain Condition.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s right shoulder condition was first evaluated on 14 March 2007 after a traction injury during physical fitness training.  The right dominant CI was evaluated in a local emergency room (ER).  He reported that it had dislocated and that had he reduced it himself, which he had been doing for several years.  In orthopedics 1 week later, he was noted to have mild instability and signs of tendinitis of the rotator cuff.  He was treated with medications, duty limitations, and physical therapy, but had persistent pain.  On 17 October 2007, electrodiagnostic testing was normal and without evidence of injury to a peripheral nerve or radiculopathy.  On 11 January 2008, the CI had surgical repair of a tear to the rotator cuff and also to the cartilage lining of the shoulder joint (labrum).  Following surgery, he underwent rehabilitation in physical therapy and showed steady improvement in the range of motion (ROM) of the shoulder.  In orthopedics on 8 May 2008, 4 months after the surgery, the shoulder was stable.  The ROM was limited by apprehension and guarding.  Two weeks later in the ER (for chest pain), he was noted to have normal motor function and ROM of the extremities.  The ROM of the neck was also normal and an “inspection” of the back was normal.  The MEB forwarded “right shoulder, neck and middle/low back pain” for PEB adjudication.  The MEB NARSUM examination was performed on 8 September 2008, 11 months prior to separation and 7 months after surgery.  He reported he injured his arm doing push-ups.  He was limited to driving general vehicles and perform administrative duties.  He could not operate heavy machinery or do maintenance.  He continued to work with physical therapy and an exercise physiologist.  On examination, his neck was supple and neurological examination was normal.  The ROM of the shoulder was limited with 30 degrees abduction (180 is normal), extension of 85 degrees (this might be referring to flexion) and he could reach behind himself to his mid back.  The CI was evaluated in rheumatology on 27 October 2008 for persistent and vague neck and back pain since his accident as well as diffuse and vague joint symptoms.  There were no symptoms of a radiculopathy or of a systemic rheumatologic illness.  On examination, X-rays of the neck showed mild degenerative disc disease (DDD).  The right shoulder, neck, and trapezius muscle were mildly tender.  The neurological examination was normal.  His symptoms were consistent with as myofascial pain syndrome.  In a follow-up examination in neurology on 2 December 2008, the CI reported pain in the shoulders, elbows, hips, and knees.  It was noted that MRIs of the neck and lumbo-sacral spine were “unrevealing.”  On examination, the neurological examination was normal.  Neither muscle atrophy nor fasciculations were present.  His gait and arm swing were normal.  The neck was supple and provocative testing for lumbo-sacral nerve root irritation was negative.  A finger to nose test (begun with the arms outstretched in 90 degrees of abduction) was normal (as it had been on multiple prior examinations).  He complained of moderate pain with movement of all joints and activity.  His skin was painful to touch at every location the examiner touched.  Electrodiagnostic testing of both upper extremities was normal on 3 December 2008.  On 16 December 2008, he was again seen in neurology and noted to have a normal neurological examination including the gait.  He was evaluated for fainting in the ER on 25 March 2009, 4 months prior to separation.  He was noted to have a normal neurological examination as well as normal ROM of both shoulders.  A follow-up appointment in rheumatology on 18 May 2009, 2 months prior to separation, noted tenderness of the para-lumbar muscles, decreased neck rotation, and “somewhat limited” ROM of the shoulders due to pain.  In neurology on 15 June 2009, 1 month prior to separation, the CI had a normal neurological examination and gait with normal coordination of the arms and legs.  At the VA Compensation and Pension (C&P) evaluation, performed on 29 March 2010, 8 months after separation, the CI reported that he had injured his arm doing pull-ups.  He reported continued decreased ROM and difficulty with overhead work.  He endorsed giving way, instability, and locking.  Diffuse tenderness was present on examination.  The neurological examination and gait were normal.  The ROM was reduced to 80 degrees of flexion and 65 degrees of abduction (normal is 180 for both).  X-rays were normal.  The CI also reported a history of neck and thoracolumbar pain since he was thrown back in an explosion; corroborating evidence was not found in the records in evidence.  He stated that he was neither seen nor evaluated for this.  He reported pain down both arms and legs in a non-dermatomal pattern.  Walking was limited to ¼ mile.  Spasm was present of both the neck and lower back muscles; atrophy was absent.  The neurological examination was normal.  The ROM was reduced for both the neck and back.  X-rays showed cervical DDD at C5-6, thoracic kyphosis (an abnormal curvature of the spine), and a metallic artifact over the pelvis on the lumbar X-rays.  Old wedge fractures of the thorax were also noted.  

The Board directed attention to its rating recommendation based on the above evidence.  The Informal PEB rated right shoulder pain associated with neck and back pain at 20%, coded 5201 (limitation in motion).  The CI non-concurred and demanded a Formal PEB (FPEB).  This convened on 5 February 2009 and upheld the PEB adjudication for the right shoulder, but added migraine headaches and PTSD (post-traumatic stress disorder) as Category II conditions and a personality disorder NOS (not otherwise specified) as a Category III condition.  The PTSD condition was determined to be an existed prior to service [EPTS] and not permanently service aggravated [PSA] condition as well.  The medical member dissented and thought that the PTSD condition was unfitting and service aggravated.  The CI again appealed the decision (for the migraines and PTSD), but concurred with the 20% adjudication for the shoulder condition.  The case was then forwarded to the USAF Personnel Council for review.  It concurred with the CI and the FPEB that the shoulder was properly adjudicated at 20%.  The remainder of the discussion addressed the 2 Category II conditions (below).  The VA rated the right shoulder condition 30%, also coded 5201, based on the VA C&P examination 8 months after separation, citing limitation in motion between the side and shoulder level for the dominant arm.  The Board noted that the actual description for this rating is “limitation of motion” to “midway between the side and shoulder level” which is 45 degrees, not the 65 degrees noted on the C&P examination.  The VA also rated the back at 10%, coded 5237 (lumbosacral strain) and the neck at 10% coded 5243 (intervertebral disc disease).  

The Board first considered if the neck and back were separately unfitting conditions.  The CI was consistently considered for right shoulder pain with neck and back pain which were not identified as separate conditions.  The CI had a U4 profile, but only the right arm was specifically cited.  The limitations noted by the commander were non-specific.  The NARSUM noted the right shoulder pain in the discussion of conditions for the MEB.  The evidence does not support the addition of either neck or low back pain as separately unfitting conditions.  The Board then considered the right shoulder pain rating.  The Board noted that while limitation in the ROM was documented on the NARSUM and VA C&P examinations, numerous neurology evaluations documented a normal finger to nose test which is begun at 90 degrees flexion.  An ER visit proximate to separation noted normal ROM.  A rheumatology evaluation 2 months prior to separation noted that the ROM was “somewhat limited.”  The limitation documented on the NARSUM and VA C&P examinations, both done for rating purposes, was significantly worse without a recorded explanation for the deterioration.  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 right shoulder pain associated with neck and back pain condition.  

Migraine Headaches Condition.  According to STR and the MEB NARSUM, the CI’s headache condition began in childhood.  The first record in evidence is a MRI report dated 19 December 2006 which noted a history of migraines.  It was normal as were a CT scan and MRA (MRI angiogram).  The CI was seen in neurology on 24 October 2007 and reported daily headaches which were bad 1-2 times a week.  Over the course of the next few years, he was tried on various medical regimens.  There was no record that he was placed on quarters for the headaches.  At the MEB NARSUM examination, the CI reported that his headaches began about 1 month after he injured his right shoulder.  In fact, the CI had the MRI 4 months prior to the shoulder injury and he reported that they dated to childhood.  The examiner did not attribute lost duty time to the headache condition.  The MEB did not forward the headache condition for PEB adjudication.  A neurology evaluation on 15 June 2009, 6 weeks prior to separation, noted that the CI was on prophylactic medications and “very happy with the beneficial effects of Depakote.”  He was thought to be doing quite well and no change in his medical management was recommended.  At the VA neurology C&P evaluation, the CI reported daily headaches which lasted 2 hours and had been present since 2004-2005 (again, inconsistent with the initial history).  It was noted that less than half of the headaches were prostrating.  

The Board directed attention to its rating recommendation based on the above evidence.  The IPEB adjudicated the migraine headaches as a Category II condition and did not assign a rating.  The code for migraine headaches, 8100, was used.  This was upheld by the FPEB.  The SAF Personnel Council found that the headaches were unfitting, but noted that there was an absence of prostrating headaches found in the medical records and that a 0% rating was appropriate.  The VA rated the daily headache condition 30% coded 8199-8100 (analogous to migraine headaches), based on the VA C&P examination.  The rater noted that the headaches were daily and lasted for up to 2 hours with nausea and sensitivity to light.  Prostration was not recorded as present though.  The Board considered the evidence.  It shows that the CI had the onset of headaches in childhood prior to service although the history of onset varies considerably between examiners.  The Board found no evidence that the CI had been placed on quarters and the commander made no mention of impairment from the headaches.  The Board noted that the final note regarding headaches prior to separation documented good control.  The evidence does not support the presence of prostrating headaches while in service.  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 migraine headache condition.  

Contended PEB Conditions: PTSD and Personality Disorder, Not Otherwise Specified (NOS).  The Board’s main charge is to assess the fairness of the PEB’s determination that these conditions were not unfitting.  The personality disorder is a condition which not ratable IAW DoDI 1332.38 E.5.1.2.9.2.  The MEB did not forward PTSD and the IPEB did not list it.  The FPEB listed PTSD as a Category II condition (not currently compensable or ratable, but one which can be unfitting).  However, the minority voter considered it unfitting and ratable.  The SAF Personnel Council noted that it was an EPTS condition which was not permanently service aggravated.  The Board reviewed the records.  The CI first came to mental health attention on 16 July 2002, when the commander requested an evaluation due to unacceptable behavior both at his home station and while at a technical school.  The Personnel Council also noted that this behavior “may have manifested itself at basic training…”  Subsequent evaluations revealed significant issues with the family of origin with emotional, physical, and sexual abuse.  The CI also reported military sexual trauma, several years after accession and engagement with the mental health services, which was not otherwise documented in the records.  The Board noted that there was one hospitalization while in the MEB process.  The mental health addendum to the NARSUM, dated 22 January 2009, 6 months prior to separation, noted that his primary problems were from PTSD and the personality disorder, both of which were secondary to events which transpired long before he joined the military.  Neither condition was listed by the MEB.  Subsequently, the CI was issued an S4 profile, but prior to the FPEB and SAF Personnel Council review.  The commander noted that the CI performed administrative duties.  The final EPR, which closed out 22 March 2009, documented average performance and that he met standards in all categories rated.  There was no performance-based evidence from the record that either condition interfered with satisfactory duty performance at separation to the level of being unfitting.  In addition, the Board did not find evidence to overcome the SAF Personnel Council adjudication that the PTSD was an EPTS condition without permanent service aggravation.  After due deliberation, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for contended conditions and so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the right shoulder condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the migraine condition and IAW VASRD §4.124a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended PTSD conditions, the Board unanimously recommends no change from the PEB determination as Category II.  In the matter of the contended personality disorder, NOS, condition, the Board unanimously recommends no change from the PEB determination as Category III.  In the matter of the implied contended neck and back pain conditions, the Board unanimously agrees that it cannot recommend either for an additional disability rating.  There were no other conditions within the Board’s scope of review for consideration.  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 20140521, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAF/MR
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD  20762

Dear XXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2014-02278.

After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was appropriate.  Accordingly, the Board recommended no re-characterization or modification of your separation.

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding and their conclusion that re-characterization of your separation is not warranted.  Accordingly, I accept their recommendation that your application be denied.

Sincerely,

Attachment:
Record of Proceedings