RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	     CASE:  PD-2014-03242
BRANCH OF SERVICE:  Army                                                                 SEPARATION DATE:  20030930

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Telecommunications Operator-Maintainer, medically separated for “migraine headaches” and “chronic diffuse joint pain” rated 10% and 10%, respectively , with a combined disability rating of 20%.

CI CONTENTION:  The CI requests the board consider all conditions.  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 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 – 20030806	VARD - 20040503	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Migraine Headaches	8100	10%	Migraine Headaches	8100	0%	20040323	
Chronic Diffuse Joint Pain	5009-5025	10%	Fibromyalgia	5025	NSC	2004032	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS: 0%	

ANALYSIS SUMMARY:

Migraine Headaches.  The first record in evidence for a headache condition is an emergency room encounter dated 2 March 1999 in which the CI reported a 1 day history of a headache associated with nausea and vomiting.  She was seen periodically over the next few years and treated with both preventive and abortive medications.  Despite treatment, she continued to have headaches and could not meet her duty requirements.  She was then entered into the Medical Evaluation Board (MEB) process.  At the MEB narrative summary (NARSUM) neurology addendum dated 23 April 2003, approximately 5 months before separation, the CI reported headaches beginning in August 2000.  
She had been treated with an anti-depressant which improvement in her headaches to 1 every 3 months, but had stopped it as she and her husband were trying to conceive.  She had been noted to have incidental changes on a brain magnetic resonance imaging (MRI) study, done for evaluation of infertility, which were stable and thought to be secondary to a history of migraines and of no clinical significance.  At the time of the NARSUM, she was off of medications.  A prior neurological work-up had been normal as is typical in migraine headache conditions.  A review of the clinical records for the year prior to separation shows that the CI was on almost continuous quarters for headaches between 30 November 2002 and 12 December 2002.  She was then next sent home on 4 April 2003 after being given medications and was placed on quarters again on 10 April 2003.  She was on quarters once in May 2003 and once in August 2003.  At the VA Compensation and Pension (C&P) examination dated 23 March 2004, approximately 6 months after separation, the CI reported monthly headaches accompanied by light and/or noise sensitivity.  Nausea was infrequent.  She enjoyed relief of her headaches a few hours after taking Fioricet (acetaminophen, a barbiturate, and caffeine) especially if she could rest briefly.  She reported that she was slowly functional during her headaches.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB and VA both coded the headache condition 8100, migraine headaches, but rated it 10% and 0%, respectively.  The latter noted the absence of characteristic prostrating attacks.  The C&P does not support prostrating attacks after separation.  A review of the records shows that the CI was placed on quarters 4 times in the 10 months leading up to separation.  This is roughly once every 2 months.  The Board did note that the CI was on quarters for most of the first 2 weeks of December 2002, but a 30% rating requires “with characteristic prostrating attacks occurring an average once a month over last several months.”  These were 11 months prior to separation and outside the “last several months” timeframe.  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 chronic migraine condition.  

Chronic Diffuse Joint Pain.  Review of the record shows that the CI had a several year history of musculo-skeletal complaints without definitive etiology when she was entered into the MEB process.  Despite this, a family practice referral to physical therapy dated 20 February 2003 noted that she was a ballet dancer.  The NARSUM was dated 29 April 2003 and noted that she was unable to meet full duty requirements and could not accomplish the physical fitness test.  It was noted that she had been treated with physical therapy and medications without resolution of her pain.  Examination of her major joints showed full range of motion (ROM) without documented pain.  An addendum to the NARSUM, done by rheumatology on 1 August 2003 per the clinic note, noted that she had full ROM of all joints without evidence of joint inflammation.  Of 18 trigger points for fibromyalgia, 8 were positive, less than the minimum of 11 needed to diagnosis fibromyalgia.  She was thought to have chronic diffuse joint pain without evidence of synovitis (inflammation of the joint lining) or degeneration on radiographs.  The criteria for fibromyalgia were not met, but a myofascial pain syndrome was possible.  At the VA C&P examination 6 months after separation, the CI reported pain in the neck, both shoulders, hips, knees, and right ankle.  The examinations were essentially normal for all these joints.  X-rays of the hips, knees, and right shoulder were unremarkable.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated chronic diffuse joint pain at 10%, coded 5099-5025 (analogous to fibromyalgia).  The PEB assigned non-compensable ratings to each knee, coded 5099-5024 (tenosynovitis), but did not service connect any of the other joints or fibromyalgia.  The Board noted that there was no pathology on examination or on imaging studies.  It found no route to a rating higher than the 10% adjudicated by the PEB.  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 chronic diffuse joint pain condition.  
BOARD FINDINGS:  In the matter of the migraine headache condition and IAW VASRD §4.124a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the chronic diffuse joint pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  There were no other conditions within the Board’s scope of review for consideration.  The Board, therefore, recommends that there be no recharacterization of the CI’s disability and separation determination.

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140513, with attachments
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 XXXXXXXXXX, AR20160011318 (PD201403242)

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