RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03492
BRANCH OF SERVICE:  aRMY 	SEPARATION DATE:  20080520

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an activated National Guard E5, Food Service Specialist, medically separated for “neck pain,” “major depression disorder,” and “migraine headaches,” rated 10%, 10%, and 0%, respectively, with a combined disability rating of 20%.

CI CONTENTION:  “Please 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 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 - 20080422	VARD - 20091001 	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Neck Pain	5237	10%	Degenerative Disc Disease of Cervical Spine	5242	20%	20081106	
Major Depression Disorder	9434	10%	Post-Traumatic Stress Disorder, Depressive Disorder	9411	30%	20081117	
Migraine Headaches	8100	0%	Migraine Headaches	8100	50%	20081106	
Left Shoulder Pain	Not Unfitting	Left Shoulder Injury	5203	10%	20081106	
Plantar Fasciitis, Mild Pes Planus, Achilles Spur and Mild Degenerative Changes of the First Metatarsophalangeal Joints	Not Unfitting	Numbness, Left Foot	8520	10%	20081106	
Atypical Chest Pain	Not Unfitting	Chest Pain	5399-5321	0%	20081106	
Varicose Veins	Not Unfitting	No VA Placement	
Contact Dermatitis	Not Unfitting	No VA Placement	
Hypertension	Not Unfitting	No VA Placement	
Bartholin Duct Cyst	Not Unfitting	No VA Placement	
Diffuse Meibomitis	Not Unfitting	No VA Placement	
Left Temporomandibular Joint Pain Dysfunction Syndrome	Not Unfitting	No VA Placement	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  90%	

ANALYSIS SUMMARY:  

Neck Injury.  According to service treatment records (STRs) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s neck condition began in 2003 after carrying heavy kitchen equipment, which resulted in temporary profiles for 6 months.  In March 2005, the CI indicated that while deployed, the vehicle she was riding in ran over an Improvised Explosive Devise (IED) and she sustained a neck injury, which caused headaches (see below).  The neck pain persisted through May 2005 when she re-injured her neck.  In July 2005 she was medically evacuated out of the combat zone because of a brachial plexus issue as well as neck pain, which failed to improve with medication and physical therapy.  Despite treatment, the cervical spine condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for MEB.  The MEB forwarded “neck pain” for PEB adjudication. 

At the NARSUM examination on 11 December 2006 the CI reported constant dull pain in her lower cervical spine at a pain level  of 6-7 (10 being the worst pain) that worsened with nodding her head, walking down steps, using the rear-view mirror in her vehicle, wearing a backpack, or wearing body armor.  The pain improved with warm compresses, ice packs, and Vicodin (hydrocodone, a narcotic and APAP (acetaminophen, a pain reliever)).  She had scalp tenderness over the greater occipital notch with no reproduction of her headache symptoms.  There was no physical evidence of a head injury.  However, there was tenderness to palpation over the lower cervical spinous muscles with no muscle spasm noted.  Cervical spine range of motion (ROM) measurements are in the chart below.  

At the MEB examinations (28 and 17 months prior to separation), the CI reported “I can’t turn my head (neck) to my left side, always painful.”  Physical examination revealed decreased ROM with tenderness to palpation over the left cervical musculature and bilateral upper extremity strength 3/5.  Magnetic resonance imaging (MRI) in December 2006 showed C5-6 disk protrusion indenting the spinal cord underlying the C5-6 and C6-7 disks and uncovertebral joint (located most often between C3 and C7 vertebrae) degeneration which caused mild bilateral foraminal (spaces where nerves pass through the vertebral column) narrowing.  

Neurosurgical evaluation on 8 January 2007 noted the CI struck her head on the vehicle she was riding.  A cervical spine MRI showed a degenerative disc at C5-6 and an EMG (electromyogram) showed no radiculopathy.  Despite extensive physical therapy the CI had no improvement of the neck pain and there were minimal radicular symptoms at the time of examination.  The examiner’s diagnoses were cervical disc degeneration C5-6 and cervical disc degeneration C6-7 with chronic neck pain without radiculopathy.  Surgery was not indicated.  Physical therapy and the use of a transcutaneous electrical nerve stimulation (TENS) unit were carried out for many visits in January 2007.  The NARSUM dated 20 February 2007 indicated the CI’s final diagnosis was neck pain secondary to a herniated disk at C5-6.  An MRI of the brain (see below) and cervical spine dated 4 February 2008, ordered for a 5-day history of left face/arm/leg paresthesia/numbness to rule out demyelinating disease, ischemia, mass, etc. demonstrated a few subcortical and deep white matter foci, which could represent chronic microvascular ischemic changes, vasculitis, or demyelinating disease and multilevel degenerative disk disease of the cervical spine, worst at C5-C6.  

At the 6 November 2008 VA Compensation and Pension (C&P) examination, performed 6 months after separation, the CI reported daily tightness stated to be 8/10 and an inability to lift more than 5 pounds because of neck pain and left arm numbness; however, she had no incapacitating episodes.  Examination of the neck revealed no tenderness of the spine or in the paraspinal musculature.  The ROM measurements are in the chart below.  Reflexes were 2+ and symmetrical in the upper extremities and motor strength was 5/5 bilaterally.  Pinprick sensation was minimally decreased in the ulnar nerve distribution of the left hand.

The ROM examinations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.  

Cervical ROM
(Degrees)	MEB ~17 Mos. Pre-Sep	VA C&P ~6 Mos. Post-Sep	
Flex (45 Normal)	Full	20	
Combined (340)	210	75	
Comment	Painful motion	Pain at the maximum ROM; no loss of ROM with repetition	
§4.71a Rating	10%	20%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under the 5237 code (cervical strain), citing “neck pain resulting from several episodes of neck strain over 2003 to 2004 time period, attributed to strain plus degenerative disc disease at the C5/C6 level that is not amenable to surgery.”  The VA deferred a rating using the 5242 code (degenerative arthritis of the spine) based on the VA C&P examination 6 months after separation, citing degenerative disease of the cervical spine.  The VA Rating Decision (VARD) dated 1 October 2009 indicated a 20% rating using code 5242 for cervicalgia superimposed on multilevel degenerative disc disease of the cervical spine.

The Board initially discussed that a 10% rating, but no higher, could be justified for limitation of flexion (greater than 30 degrees but not greater than 40 degrees) and combined ROM (greater than 170 degrees but not greater than 335 degrees) reported on the MEB examination.  There was no muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour, thus the next higher 20% rating was not justified on this basis.  However, although the VA examination was 6 months after separation, it was more proximate to separation and more quantitatively precise since the MEB examination indicated the flexion was “full” whereas at the VA examination flexion measurement of 20 degrees (greater than 15 degrees but not greater than 30 degrees) and the combined ROM of 75 degrees warrants a 20% rating.  Board members did note that there was no significant reported trauma, injury or surgery in the 23-month interval between the MEB examination and the VA examination to explain the disparity between the measurements; however, the CI did have many visits in the interim where she consistently was treated for the neck pain and shoulder pain (see below) and took medication including prescribed narcotics to relieve the pain, which based on MRI findings included both disc herniation and degenerative disc disease.  

There was no documentation of intervertebral disc syndrome with incapacitating episodes which would provide for a higher rating under that formula, or evidence of ratable peripheral nerve impairment which would provide for additional rating.  The Board also considered whether an additional disability rating was justified for peripheral nerve impairment due to radiculopathy.  Radiographic studies supported some level of radicular nerve irritation or involvement, but physical examinations (MEB, NARSUM, and VA C&P) proximate to separation revealed no objective findings of radiculopathy that would impact duty performance.  While the CI may have suffered additional pain from the nerve involvement, this is subsumed under the general spine rating criteria, which specifically states “with or without symptoms such as pain (whether or not it radiates).”  Therefore, the critical decision is whether or not there was a significant radiculopathy which would impact military occupation-specific activities or functionally impairing.  The Board, therefore, concluded that additional disability rating was not justified on this basis.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 20% for the neck injury condition, coded 5237.  

Major Depressive Disorder.  According to STR and the MEB NARSUM, the CI’s mental health condition began during deployment in 2004-2005 after a series of events including the neck injury previously discussed while riding in a vehicle that went over an IED, an encounter with “guys” starting to jump over concertina wire near a dining facility for which she was providing security and her firing her weapon to repel them, being evacuated from her office prior to a bomb explosion, and having had food poisoning.  While still deployed she underwent psychiatric evaluation in August 2005 and was diagnosed with an adjustment disorder with an anxious mood.  After 5 months home she reported symptoms of nightmares of the events, hearing noises of the event, having intrusive memories and thoughts of deployment, hypervigilance, poor sleep and an exaggerated startle response.  She was initially started on prazosin (an alpha blocker usually used to treat high blood pressure) for nightmares, but it made her heart race and caused chest pain.  On mental status examination, she was noted to be anxious.  She attended a post-deployment adjustment group a couple of times, but did not continue.  She then followed-up with a behavioral health counselor and had many visits from January 2006 through February 2007 and was given several diagnoses including adjustment disorder, posttraumatic insomnia, and chronic posttraumatic stress disorder.  

At the MEB examination the CI checked 'yes' to nervous trouble, loss of memory, frequent trouble sleeping, received counseling, depression or excessive worry, and been evaluated or treated for a mental condition.  The examiner checked normal for the psychiatric clinical evaluation.

A psychiatry mental status examination in January 2007 revealed the CI had normal grooming and walked with a cane.  She was pleasant, cooperative and polite.  Her speech was normal in quality and quantity.  Her affect appeared full and appropriate, although she appeared distressed at times.  Mood was somewhat depressed and anxious.  Thought processes were generally linear and logical although she appeared to lose her train of thought on at least three different occasions.  She reported concerns about her cognitive abilities and poor sleep.  She denied suicidal or homicidal ideation and there was no evidence of psychotic though processes or content.  She was alert and fully oriented.  Memory appeared grossly intact as were insight and judgment.  Neuropsychological testing revealed her scores on cognitive testing were spuriously low for someone with a college degree, pursuing pharmaceutical courses, and constructive civilian work history as a corrections officer.  The diagnosis of an anxiety disorder NOS, as manifested by post-deployment stress symptoms of insomnia, nightmares, intrusive memories of deployment, social withdrawal, and difficulty concentrating, was made.  The Global Assessment of Functioning (GAF) score was 65 (some mild symptoms).  

The CI was evaluated at the VA in June 2007 and diagnosed with posttraumatic stress disorder (PTSD) and underwent supportive psychotherapy thereafter.  A MEB NARSUM Addendum dated 14 November 2007 indicated the examiner did not diagnose PTSD without collateral information to confirm the stressful events.  On 28 August 2007, the CI was admitted to an inpatient unit for suicidal ideation as a result of being distressed about the denial of compensation and her mother’s unexpected death.  Over the prior month the CI experienced daily tearfulness, anhedonia, guilt, hopelessness, insomnia, decreased appetite, problems with memory and concentration and suicidal thoughts.  She was diagnosed with rule out (r/o) major depression with psychotic features, r/o mood disorder, psychotic disorder secondary to a generalized medical condition traumatic brain injury (TBI) and PTSD and she was discharged from the hospital on 31 August 2007.  Treatment consisted of fluoxetine (an antidepressant medication).  In a therapy visit on 9 November 2007 she spoke about her “increased ability to manage her pain and emotional issues and described multiple instances where she said to herself, ‘this will not stop me.’”  Her mood was more stable with less discussion of pain and a positive outlook.  The examiner added major depressive episode in partial remission.  She continued psychotherapy at the VA through separation and beyond.  

At a 24 August 2008 VA C&P examination, the CI reported occasional auditory hallucinations of her late mother and suicidal ideation without plan or intent.  Her mood was depressed and her affect was anxious.  Her immediate memory was good, but her recent memory was impaired as was her abstract thinking.  Her judgment was intact and her insight was fair.  Her diagnoses were PTSD and major depressive disorder and her GAF score was 48 (serious symptoms).

At the 17 November 2008 VA Compensation and Pension (C&P) examination, performed 6 months after separation, the CI reported she experienced the explosion of an IED and hit her head on top of the vehicle’s cab with more of a dazed feeling than a total loss of consciousness, which took about 2 hours to come fully back to her senses.  She sometimes felt like as if she were floating off into space and at other times had dissociative reactions while driving.  She complained of many symptoms suggestive of PTSD including nightmares, painful recollections of events, and other phenomena.  She also complained of symptoms often associated with pregnancy, although she was told she was not pregnant (pseudocyesis).  Additionally, she had chronically disturbed sleep and took Ambien (zolpidem, a sedative for treatment of insomnia) and Zoloft (sertraline, an antidepressant).  She admitted to depressive symptoms some of which related to the loss of her fellow soldiers, which was intensified by the deaths of her mother and her brother.  

However, throughout her mental status examination the CI wore a smiling face, but was also evidently anxious at times.   She was well oriented to time, place, person and process of the examination and did no show gross signs of a cognitive disorder or difficulty with concentration.  She offered no homicidal or active suicidal ideation, plans or intentions.  There were no signs of a psychotic process.  Her affect seemed somewhat inappropriate to her mental content, which appeared to be a façade of happiness against inner depression.  She reported occasionally hearing voices related to her deployment, but the examiner felt this was not uncommon in severe PTSD, and would not, in itself, represent a psychotic disorder.  The examiner opined that as a result of being injured in an IED explosion she met the criteria for PTSD and a post-concussion syndrome and she manifested a depressive disorder, although the content highly resolved around events when deployed and it was inseparable from her PTSD.  Her GAF score was 45 (serious symptoms).  The examiner continued that the psychiatric difficulties alone would appear to preclude the sort of endurance, perseverance, and concentration required for fulltime competitive employment as would her impairment of interpersonal relationships and a depressive mood would further impact her ability to concentrate, learn new material, and adjust to the workplace or other stressors.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under the 9434 code (major depressive disorder), citing “major depressive disorder, onset due to multiple stressors while Soldier was in medical hold.  Command indicates Soldier has no difficulties with assigned duties.”  The VA deferred a rating using the 9411 code (posttraumatic stress disorder) based on the VA C&P examination 6 months after separation, citing PTSD, depressive disorder NOS, cognitive disorder NOS, somatoform disorder not otherwise specified.  The VARD dated 1 October 2009 indicated a 30% rating using code 9411, citing post-traumatic stress disorder with depressive disorder not otherwise specified.   

The Board considered whether the provisions of VASRD §4.129 (mental disorders due to traumatic stress) were applicable.  In accordance with VASRD §4.129, when a mental disorder that develops in service as a result of a highly stressful event is severe enough to bring about the CI’s release from active military service, the rating agency should assign an evaluation of not less than 50% and schedule an examination within the six month period following the veteran’s discharge to determine whether a change in evaluation is warranted.  While the deployment stressors played a role in the evolution of the CI’s psychiatric disorder, overall evidence points to a combination of both combat stress as well as injuries sustained and other medical conditions as well as exacerbation by the loss of the CI’s family members.  However, the Board majority agreed that the conditions of §4.129 were not met in this case.  The Board majority then discussed whether the CI’s major depressive disorder warranted a rating higher than 10%.  After discussing the lack of evidentiary documentation or corroboration to support the CI’s report of having been involved in an IED blast or having encountered “guys” at the line of concertina, the majority felt that the PEB rating of 10% was appropriate.  Therefore, after due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board majority concluded that there was insufficient cause to recommend a change in the PEB adjudication for the depression condition.  

Migraine Headaches.  According to STR and the MEB NARSUM, the CI’s reported her headaches condition began in November 2004 during deployment when the vehicle in which she was riding ran over an IED and she was ejected from the vehicle and injured her neck, which caused the severe headaches three times a week.  On examination after the injury the CI’s scalp showed tenderness over the left greater occipital notch, with no reproduction of her headache symptoms.  There was no evidence of a head injury.  Eye examination was normal; mental status was appropriate and normal; and cranial nerves were intact.  

At the MEB examination the CI reported monthly headaches with fainting and dizziness.  The examiner noted a decreased ROM of the cervical spine and tenderness to palpation over the left cervical musculature.  A neurology note dated 10 February 2006 indicated the CI had features of classical migraine which were intractable.  Prophylactic low dose nortriptyline (an antidepressant medication also used for nerve pain) was instituted to try to reduce the number and frequency of her migraines and was increased based on increasing severity of symptoms.  Computerized tomography (CT) of the CI’s head showed mild asymmetry on the left hemisphere and mild atrophy and an MRI of the brain was normal.  

The CI presented to the Emergency Room in May 2006, where a head CT was normal, and she was admitted 2 days later for persistence of the headache post-lumbar puncture with associated hypertension.  The headache and hypertension improved with a blood patch (to treat a cerebrospinal fluid leak).  A note in August 2006 indicated the CI had received morphine (a narcotic) and meclizine (for dizziness and nausea) for headache symptoms control.  In December 2006 she reported the headaches decreased from daily severe headaches to 3 days a week of moderate headaches and indicated she was able to take a break from work and rest or take Tylenol (a pain reliever) to relieve the pain.  However, four times per month she had “severe and prostrating 10/10 (10 being the worst pain) left side throbbing headaches that required her to stop duty, seek solitude in a quiet dark room and go to sleep.”  Atenolol (a beta blocker) was added for blood pressure management and she was prescribed zolmitriptan for abortive therapy.  

According to the NARSUM dated 20 February 2007 the CI had stabbing headache pain three times a week in the left temple and occiput that radiated from the back of her neck at a pain level of 10/10 that required her to leave work area and lie down for 3-4 hours at a time. The headaches seemed to be triggered by her neck pain and were relieved by sleep and Vicodin.  The CI was on a prophylactic beta blocker, which did not help. Amitriptyline (an antidepressant and for nerve pain) did help the headaches, but was discontinued due to drowsiness.  The zolmitriptan was not picked up according to a neurology note on 28 September 2007 at which time she was started on Topiramate for migraine prophylaxis and Zomig (zolmitriptan) as needed, but it was discontinued when she felt a choking and swollen sensation in the throat.  Narcotics, which she was using for cervical pain, may have contributed to her headache syndrome.  Depakote (divalproex, a seizure and headache medication) and Imitrex (sumatriptan, a migraine abortive medication) were started in December 2007, but she did not tolerate the Depakote.  An MRI of the brain and cervical spine dated 4 February 2008 ordered for a 5-day history of left face/arm/leg paresthesia/numbness to rule out demyelinating disease, ischemia, mass, etc. demonstrated a few subcortical and deep white matter foci, which could represent chronic microvascular ischemic changes, vasculitis, or demyelinating disease and multilevel degenerative disk disease of the cervical spine, worst at C5-C6.  

A note dated 27 February 2008 indicated the CI never had quarters for the headache condition; however, she missed 0630 formations in the prior 2 months due to headaches.  The CI received facial Botox (botulinum toxin type A) injections to treat the migraine headaches in April 2008, while in May 2008 she reported a left parietal headache, which was throbbing, prostrating, and occurred several times each week with a headache calendar showing 16 days of migraines in March, 12 in April, and 10 in May as of 20 May 2008 that were not relieved by medication and were associated with nausea and vomiting.  The CI was referred for acupuncture and biofeedback as well as an echocardiogram to rule out a patent foramen ovale (PFO) in the heart.  The neurologist noted the examination, which elicited no deficits, was strongly suggestive of a somatoform disorder.  

At the 6 November 2008 VA Compensation and Pension (C&P) examination, performed 6 months after separation, the CI reported migraines two to four times a week with a visual aura followed by pounding, nausea, vomiting, photophobia, and phonophobia along with left side numbness with severe headaches.  She used Imitrex, which was approximately 50% effective and had Botox injections every 3 months.  On examination there was evidence of bidirectional lateral nystagmus and the motor and sensory examinations were normal other than a decrease in pinprick sensation in the left hand ulnar nerve distribution and in the left lower extremity in the L4-L5 nerve root distribution.  The examiner noted the CI needed to be followed up for the nonspecific findings on the MRI from February 2008 because of the possibility of vasculitis or demyelinating disease. 

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 0% rating under the 8100 code (migraine), citing ”migraine headaches two to three times weekly, treated with Amitriptyline 50 mg daily, prevents full duty function but does not meet the criteria for prostrating headaches.”  The VA assigned a 50% rating using the 8100 code (migraine) based on the VA C&P examination 6 months after separation, citing migraine headaches).  Board members noted the PEB may not have taken into account the many visits and treatments the CI had for the migraine headaches after the NARSUM was written.  The Board members did note that the CI kept a migraine headache calendar as directed, which indicated 16 headaches in March 2006, 12 headaches in April 2006, and at least 10 headaches in May 2008 that were not relieved by medication and were associated with nausea and vomiting.  The Board members also noted that while an examiner suggested a somatoform disorder, the CI’s MRI of the brain demonstrated findings that warranted follow-up, the results of which were not in the record.  

However, despite the fact that the CI had migraine headaches, the Board majority felt the CI did not have documented characteristic prostrating attacks or completely prostrating attacks necessary for a rating of 10% or more.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board majority concluded that there was insufficient cause to recommend a change in the PEB adjudication for the migraine headaches condition.  

Contended PEB Conditions:  Left Shoulder Pain, Varicose Veins, Contact Dermatitis, Hypertension, Foot Conditions, Bartholin Duct Cyst, Chronic Diffuse Meibomitis, Left Temporomandibular Joint Pain, and Atypical Chest Pain.  The Board’s main charge is to assess the fairness of the PEB’s determination that left shoulder pain, varicose veins, contact dermatitis, hypertension, foot conditions, Bartholin duct cyst, chronic diffuse meibomitis, left temporomandibular joint pain, and atypical chest pain conditions were not unfitting.  The left shoulder pain, varicose veins, contact dermatitis, hypertension, foot conditions, Bartholin duct cyst, chronic diffuse meibomitis, left temporomandibular joint pain, and atypical chest pain conditions were not permanently profiled, but temporary profiles were issued for left shoulder pain, leg pain from venous disease of both legs, right foot pain from tendonitis, and chest wall strain and muscular pain.  The commander’s statement did implicate left shoulder pain and left chest pain based on her temporary profiles and noted her profiles allowed her to wear alterative footwear and she was being seen for her high blood pressure.  However, the commander noted the CI drove a Sports Utility Vehicle (SUV) with no observed difficulty and ambulated without the use of crutches or cane in and out of the vehicle.

Left Shoulder Pain.  The CI was evaluated by a physical medicine specialist on 9 January 2007 where it was noted that she was unable to lift the left shoulder much past 90 degrees.  She indicated that she had an impingement that bothered her at times and had significant cervical degenerative disc disease/degenerative joint disease, which occurred as a result of an injury in March 2005.  An MRI a year earlier demonstrated posterior cuff tendonosis.  The examiner opined that she would benefit from massage, exercise, and acupuncture to improve her ROM and reduce pain.  On examination in September 2007 shoulder joint pain was present on the left in the subacromial region and in the supraspinatus region when moved.  There was tenderness to palpation at the rotator cuff with crepitus (grinding) and pain was elicited during an impingement test.  An MRI in October 2007 demonstrated left supraspinatus and infraspinatus tendinosis without high-grade partial tendon tears, subchondral cyst formation of the posterolateral aspect of the left humeral head, and a small focus of possible proteinaceous material just inferior to the acromioclavicular joint of undetermined clinical significance.  An orthopedic surgeon evaluated the CI in December 2007 and noted she reported her symptoms to be primarily anterior chest wall, axillary, and posterior shoulder/paraspinal in nature, which worsened with overhead activities, lifting, and strenuous use of the left shoulder.  On examination she had mild tenderness over the biceps tendon proximately.  The ROM measurements are in the chart below.  While standing her motion was limited by pain only. Strength was 5/5 about the shoulder.  The examiner’s assessment was left shoulder pain, multifactorial.  He opined that “she may have some component of bicipital tendonitis; however, she has a significant, if not, dominant portion of nonorganic etiology of her symptoms.”  She was felt not to be a surgical candidate and continued physical therapy in conjunction with physical medicine and possibly a chiropractor or massage therapist was recommended.  

Left Shoulder ROM
(Degrees)	MEB                          ~15 Mos. Pre-Sep	Ortho                           ~5 Mos. Pre-Sep	VA C&P                                        ~6 Mos. Post-Sep	
Flexion (180 Normal)	107, 106, 108	90	140	
Abduction (180)	127, 127, 127	90	140	
Comments	Limited by pain			
§4.71a Rating	10%	20%	10%	

Varicose Veins.  The CI complained of symptomatic varicose veins and underwent a right endovenous laser ablation of the greater saphenous vein on 25 May 2006 and was healing well 2 weeks postoperatively.   On 15 June 2006, she underwent a left endovenous laser ablation of the greater saphenous vein.  Three weeks postoperatively she still had some residual varicosity in the left popliteal fossa (behind the knee) and posterior lower calf that caused discomfort after standing for more than 2 hours.  On 2 October 2006, the CI underwent ligation of the distal thigh perforating vein and stab phlebectomies of varicose veins of the left lower extremity.  On 24 October 26 she reported pain from both lower legs, right greater than the left; however, operative sites were healing well.  At follow-up on 31 October 2006 the operative sites were healed and pain in the back of the left knee after walking was felt to be a continuation of musculoskeletal pain she had been having.  From a vascular perspective, she was fit to return to duty.  

Contact Dermatitis.  The CI, who had a history of hypertension (see below) and nummular eczema that was treated with Zyrtec (cetirizine, an antihistamine) and tacrolimus (a topical immunomodulatory medication), developed a pruritic, red rash of her arms approximately 1 week earlier.  The diagnosis of a photo allergy secondary to the use of hydrochlorothiazide (a diuretic for high blood pressure) in combination with recent sun exposure.  Treatment consisted of desonide ointment (a topical steroid) and avoidance of excessive sun when taking certain antihypertensive medications containing or related to hydrochlorothiazide.

Hypertension.  The CI had hypertension that was treated with atenolol (a beta blocker) and hydrochlorothiazide; however, she presented to the Emergency Room with a severe headache where her systolic blood pressure was 190, which was treated with intravenous metoprolol (a beta blocker) and the doses of the atenolol and hydrochlorothiazide were increased.  On 18 July 2006 the CI’s BP was 119/70 and the examiner indicated the CI’s essential hypertension was controlled on medication.  

Foot Conditions.  A note dated 6 March 2006 indicated the CI had hammer toes of the left and right fifth toes and painful flat feet.  X-rays demonstrated pes planus bilaterally with retro calcaneal (heel bone) spurring and severe adductovarus rotation (hammer toes) of the fifth toes.  Conservative treatment of the plantar fasciitis was recommended as was surgical correction of the hammertoes.  The examiner indicated the CI met retention standards.  On 26 March 2006 the CI underwent surgical correction of the hammertoes.  In December 2006 the CI had pain at the insertion of the right Achilles tendon and X-rays demonstrated an Achilles spur.  A right foot cast was placed on 19 March 2007 and she was given Vicodin for pain flares.  X-rays and a bone scan in April 2007 demonstrated Achilles spurs bilaterally and focal uptake in the right and left superior calcanei (heel bones) at the site of the Achilles tendon insertion, most likely representing early Achilles tendonitis.  The CI continued to complain of pain of the heels/ankles but clinical findings did not substantiate the complaint.  The CI was seen in June 2007 at which time her symptoms were minimal.  The findings included Achilles tendonitis bilaterally, posterior tibial tendonitis bilaterally, and flexor halluces longus tendonitis bilaterally.  Ankle braces and foot orthoses were ordered and continued conservative care was appropriate.  In October 2007 the CI reported she had a second opinion stating there was nothing wrong with her.  Examination revealed pain with palpation at the sinus tarsi (lateral side of the hind foot) bilaterally that was treated with a steroid injection to each foot.  X-rays of both feet and ankles as well as an MRI of the right ankle revealed no bony pathology, but did show mild tendinopathy of the peroneus longus tendon, but no gross abnormalities to explain the CI’s pain.  A three phase study bone scan demonstrated generalized overuse and/or trauma.  In January 2008 the CI developed decreased feeling in the left distal leg and foot, but denied any lower back pain.  Neurologic examination and electrodiagnostic studies were normal without evidence of a left lumbar radiculopathy, focal femoral or peroneal neuropathy, lumbosacral plexopathy, or generalized polyneuropathy.  

Bartholin Duct Cyst.  The CI had an 8-month history of an odiferous vulvovaginal discharge, which she attributed to a tick bite during deployment.  Examination revealed an abnormal draining Bartholin cyst, which was well epithelialized.  Treatment consisted of metronidazole (an antibiotic) on 24 January 2006.  Because of the recurrent nature of the right Bartholin cyst, definitive surgery (marsupialization) was carried out on 10 March 2006.  On 30 November 2006 the CI reported recurrent pain without discharge, drainage, swelling or mass in the area of the prior surgery.  On examination there was no pain and no evidence of infection at the operative site, just evidence of old marsupialization.  

Chronic Diffuse Meibomitis.  The CI had chronic meibomitis (inflammation of the oil glands along the margins of the eyelids) outbreaks, which were worse when deployed.  Evaluation in May 2006 revealed concretions (accumulation of matter) with neovascularization (small blood vessels) on the right palpebral conjunctiva (inner portion of the eyelid).  Treatment consisted of artificial tears and Laci-Lube ointment (for dry eyes).  In November 2006 treatment included of lid care, erythromycin (an antibiotic) topical ointment and avoidance of oral medication.  In an optometry examination on 6 December 2006 for the MEB the CI had no visual complaints; however, on 14 December 2016 the CI reported blurred vision at near distances.  Examination of the eyelids and conjunctiva showed no abnormalities.  The CI had a small degree of hypermetropia (farsightedness) for which glasses with bifocal lenses were ordered.  

Left Temporomandibular Joint Pain.  The CI complained of an earache in the left ear that was worse with chewing, opening the jaw wide, and sometimes with swallowing.  The diagnosis of temporomandibular joint pain dysfunction syndrome was made and a trial of Mobic (meloxicam, an NSAID) and a soft diet was recommended in January 2006.   There was no evidence of retro cochlear (inner ear) pathology on a MRI of the brain.  A bite guard was added to the treatment regimen. In February 2006.  The CI reported no improvement in February 2008 with the bite guard and medication and was referred to a dentist for fitting with a firm bite guard.  

Atypical Chest Pain.  The CI was evaluated for left chest wall pain in August 2005 and had a cardiac workup including a stress test and pulmonary studies, which were normal.  The CI noted chest pain while driving with shortness of breath in July 2006.  Workup to rule out a myocardial infarction, although she had hypertension as a risk factor, was non-revealing from a laboratory standpoint and was felt most likely musculoskeletal pain increased in intensity from an unknown etiology, although her ECG was reported as anteroseptal infarct, age undetermined.  A chest X-ray was reported as a normal although a subtle increased density projecting over the peripheral left lower lobe was thought to be artefactual.  The CI presented to the Emergency Room with chest discomfort on 31 January 2007.  An ECG dated 31 January 2007 at 21:33:00 noted the anterior infarct, which was cited on or before 10 May 2006, and a sinus rhythm replaced a junctional rhythm noted on another ECG earlier that day.  An angiogram on 31 January 2007 revealed no evidence of pulmonary embolus or lower extremity deep venous thrombosis, but there was bilateral dependent atelectasis (a partial lung collapse) and a left adnexal cystic mass (in the pelvis), which may have been a functional cyst.  Cardiac enzymes were normal and she was scheduled for a stress test, which was reported on 15 February 2007 as no scintigraphy evidence of reversible myocardial ischemia and a normal gated study.   The examiner noted the CI continued to have left parasternal chest pain, which was probably from costochondritis (inflammation of the cartilage where the ribs joint the sternum).  Follow-up was to be on an as needed basis.  On 28 September 2007, the CI reported her chest pain as pain to the left chest wall anteriorly below the clavicle between the second and third ribs and in the left precordium (overlying the heart), which was tender when touched.  
   
There was no performance-based evidence from the record that the conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, and 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 contended conditions; and so, no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the neck injury condition, the Board unanimously recommends a disability rating of 20%, coded 5237 IAW VASRD §4.71a.  In the matter of the major depressive disorder condition and IAW VASRD §4.130, the Board majority recommends no change in the PEB adjudication.  In the matter of the migraine headaches condition and IAW VASRD §4.124a, the Board majority recommends no change in the PEB adjudication.  The single voter for dissent submitted the appended minority opinion for the major depressive disorder condition and the migraine headaches condition.  In the matter of the contended left shoulder pain, varicose veins, contact dermatitis, hypertension, foot conditions, Bartholin duct cyst, chronic diffuse meibomitis, left temporomandibular joint pain, and atypical chest pain conditions, the Board unanimously recommends no change from the PEB determinations as not unfitting.  There were no other conditions within the Board’s scope of review for consideration.  

The Board recommends that the CI’s prior determination be modified as follows; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	RATING	
		PERMANENT	
Neck Injury	5237	20%	
Major Depression Disorder	9434	10%	
Migraine Headaches	8100	0%	
RATING	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140507, w/attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

Minority Opinion.  This is a case about the CI’s credibility and extent of documentation necessary to achieve the standard of preponderance of evidence.  As background the minority voter noted that the CI was medically evacuated from deployment in the theater of operations for a brachial plexopathy and not for any of her other conditions.  Because she was unable to or did not provide credible or corroborated evidence of the IED explosion and subsequent injuries, both the PEB and the PDBR majority did not rate the CI to the extent that the minority voter will demonstrate is realistic, rational and responsible in accordance with the facts and the law.  First and foremost, the CI was noted to be an outstanding performer by her commander.  Furthermore, while deployed as a cook, she assumed additional duties according to her accounts of riding in a vehicle and providing security.  Although cooks are not routinely assigned the tasks, this CI, a mobilized reservist, who worked in corrections security as a civilian, certainly brought a set of skills beyond those of her MOS as a cook.  Her reports were reasonably consistent in regard to the IED exposure, although they varied slightly on whether she banged her head in the vehicle or was thrown from the vehicle, but nevertheless, a person who is dazed and suffers from head trauma with or without loss of consciousness will either not have known the fine details of the event or will have some lapse in memory, which is what she later had—a cognition deficit on neuropsychological testing, which was considered spuriously low by the examiner.  But what if in fact the documentation were lost or misplaced through no fault of the CI?  Well, that is the situation here.  The STR clearly noted that during the medical evacuation flight process the CI received medication that made her drowsy.  A timely note in the STR dated 1 September 2005 indicated that as a result, some of her gear was misplaced.  Medical Hold personnel assisted the CI to contact the Air Evac personnel to attempt to retrieve her baggage in which she indicated “that her orders, medical profile, passport and other important document were in a brief case that is missing.”  The note continued  “One of CIs biggest concerns upon presentation involved finding her medical records; CI believes that her medical records were with her upon arrival and that they have been misplaced her at MAMC.”  “An intensive search was conducted and no records were found . . . all efforts were being made to find her medical records.”  The CI’s loss of medical records was not unique.  An article entitled “Lost to History:  Missing War Records Complicate Benefit Claims by Iraq, Afghanistan Veterans” (https://www.propublica.org/article/lost -to-history-missing-war-records-complicate-benefit-claims-by-veterans accessed 9 September 2016) discusses the issue in much more depth than is required here.  Needless to say, a CI who sustains an injury or illness in a theater of operations has more than sufficient concerns and need not bear the burden to finding lost records whether they are medical or any other type.  To that end the VA regulations clearly and unequivocally address the issue in VASRD §4.3 (38 USC 4.3), which states:  "Resolution of reasonable doubt.  It is the defined and consistently applied policy of the Department of Veterans Affairs to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. See §3.102 of this chapter.  [40 FR 42535, Sept. 15, 1975]."  Note that VASRD §4.3 explicitly refers to VASRD §3.102 (38 USC 3.102), which states:  "Reasonable doubt.  It is the defined and consistently applied policy of the Department of Veterans Affairs to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant. By reasonable doubt is meant one which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. It is a substantial doubt and one within the range of probability as distinguished from pure speculation or remote possibility. It is not a means of reconciling actual conflict or a contradiction in the evidence. Mere suspicion or doubt as to the truth of any statements submitted, as distinguished from impeachment or contradiction by evidence or known facts, is not justifiable basis for denying the application of the reasonable doubt doctrine if the entire, complete record otherwise warrants invoking this doctrine. The reasonable doubt doctrine is also applicable even in the absence of official records, particularly if the basic incident allegedly arose under combat, or similarly strenuous conditions, and is consistent with the probable results of such known hardships.  (Authority: 38 U.S.C. 501)  [50 FR 34458, Aug. 26, 1985, as amended at 66 FR 45630, Aug. 29, 2001]."  The CI’s situation was clearly anticipated by VASRD §3.102, which is on point and critical to the just and equitable adjudication of this case.  

First, the issue of “consideration of all procurable and assembled data” bears comment.  The CI stated her records were misplaced and a search failed to turn up the records.  Therefore, when the regulation calls for “all procurable and assembled data” it is obvious that missing records were reported as soon as the CI’s medical evacuation was completed.  There was not a delay and the CI’s explanation of the misplacement was neither delayed nor embellished.  She was a patient being transported home from the theater of operations who received medication with known sedating effects.  She was not on sentry or courier duty where she had to remain fully and completely vigilant at all times.  Simply stated, her records were lost and neither the PEB nor the PDBR majority could, therefore, assemble a full and complete contemporaneous record, but instead had to rely on the CI’s word, which the VASRD §102 lends credence as follows:  “The reasonable doubt doctrine is also applicable even in the absence of official records, particularly if the basic incident allegedly arose under combat, or similarly strenuous conditions, and is consistent with the probable results of such known hardships.”  With that as a background, pertinent details to justify higher ratings for both the major depressive disorder and the migraine headaches will be discussed.

While still deployed the CI underwent psychiatric evaluation in August 2005 and was diagnosed with an adjustment disorder with an anxious mood.  Multiple examinations thereafter found the CI had a diagnosis of a depressive disorder.  The issue is whether the CI had PTSD and its diagnosis or lack of diagnosis revolved around credible medical evidence.  As discussed the CI was in a designated combat zone.  She reported misplaced records, but nevertheless, she regularly and consistently reported exposure to and injuries from an IED and was treated for the neck injury, which was confirmed by MRI findings of a disc herniation and cervical spine degenerative changes as well as migraine headaches, which although are not visible to an observer, warranted prescription of several migraine specific medications that were not very effective.  Of note and is extremely important to understand is that, if in essence she did experience a traumatic brain injury TBI, she was not evaluated to the extent at that time as one is currently evaluated.  Furthermore, although a CT scan revealed mild asymmetry on the left hemisphere and mild atrophy, an initial MRI did not show brain pathology; however, a later MRI did demonstrate a few subcortical and deep white matter foci, which could represent chronic microvascular ischemic changes, vasculitis, or demyelinating disease.  The record did not address follow-up of those findings.  The record is thus replete with treatments for conditions that presumably occurred as a result an IED explosion or another traumatic inducing event.  Therefore, it is not a quantum leap to consider that acute event to have been partially contributory to the CI’s depressive disorder and presumptive PTSD diagnosis along with the other stressors both when deployed and after returning home.  The Board was offered an opportunity to determine whether the conditions of VASRD §4.129 were met in this case.  Based on the aforementioned facts and law, the minority voter believes the conditions were met.

Therefore, a minimum 50% rating is recommended for a retroactive 6‐month period placement on the Temporary Disability Retired List (TDRL).  If that is the case, then a rating recommendation IAW VASRD §4.130 at the time of placement on the TDRL is warranted.  A 70% rating requires “occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as:  suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships.”  Clearly the CI had occupational and social impairment with suicidal ideation, depression, difficulty with memory, and difficulty adapting to stressful circumstances at work thereby warranting consideration of a 70% rating.   A 50% rating requires “occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships.”  However, a rating more applicable to the CI’s condition at the time of TDRL placement, but for the hospital admission for suicidal ideation, was more consistent with a 50% rating based on her many symptoms including flattened affect, impairment of short term memory, impaired abstract thinking, disturbances of motivation and mood as well as difficulty in establishing and maintaining effective work and social relationships.

A permanent rating recommendation at the time of removal from the TDRL likewise needs to be addressed.  The most proximate source of comprehensive evidence on which to base the permanent rating recommendation in this case is the VA C&P examination performed approximately 6 months after separation from active duty and placement on the TDRL.  In regard to the rating recommendation at the time of removal from the TDRL and permanent disability disposition, the §4.130 threshold for a rating higher than 50% was not applicable and that the criteria for a 10% rating was well‐exceeded.  Therefore, an appropriate deliberation should settle on consideration of a 50% versus a 30% permanent rating recommendation.  A 30% rating requires “occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events).”  While the CI had disturbances in motivation and mood and difficulty in establishing and maintaining effective work and social relationships as markers of a 50% rating, her condition and symptoms were more congruent with a 30% rating since she had been generally functioning satisfactorily, with routine behavior, self-care and conversation normal, although she still had a depressed mood, anxiety, mild memory loss, and chronic sleep impairment. 

While the Board cannot change a diagnosis, since there was a question of PTSD raised, the minority voter notes that the stipulated settlement in Sabo v. United States (102 Fed.Cl. 619) addressed the claims of service members who were discharged with ratings inconsistent with the VASRD.  Therefore, as a Board that performs a de novo review, we are legally required to follow VASRD guidelines; thus, the CI's deployment experience and the resultant mental health disability warrant not only credence, but also a rating of 50% for TDRL placement and 30% for TDRL removal.  

The rating issue for the migraines headaches is whether the CI had prostrating headaches, and if so, to what extent were they disabling.  Once again the question of the CI’s credibility in regard to causation, frequency, and extent was considered by the PEB and the Board majority.   However, not only was the CI forthcoming, consistent and a seemingly accurate responsible historian, but as noted above IAW VASRD §3.105 “Mere suspicion or doubt as to the truth of any statements submitted, as distinguished from impeachment or contradiction by evidence or known facts, is not justifiable basis for denying the application of the reasonable doubt doctrine.”  More importantly, the CI did exactly as she was directed and kept a headache log/calendar, which documented her multitude of migraines on a monthly basis prior to and most proximate to separation, which was after a note in February 2008 indicated the CI never had quarters for the headache condition, but did state that she missed 0630 formations in the prior 2 months due to headaches.  While the accuracy of that observation is not being challenged, it was silent in the critical dimension that was addressed by the NARSUM 1 year earlier, which reiterated a December 2006 report, that indicated the CI had stabbing headache pain three times a week in the left temple and occiput that radiated from the back of her neck, a known site of her disabling condition, at a pain level of 10/10 that required her to leave the work area and lie down for 3-4 hours at a time.  Furthermore, not only did she maintain the calendar, but noted that the headaches, which were associated with nausea and vomiting, were not relieved by either medication or Botox injections.   Certainly, if one were vomiting, the likelihood of incapacitation is realistic and undeniably confirmable by any reasonable person who ever experienced a migraine headache accompanied by vomiting.   The minority voter, therefore, believes that the CI’s migraine headaches occurred with such frequency and severity and were prostrating as well with support in the STR on many occasions were more consistent with a 50% rating (with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability) rather than either a 30% or 10% rating where the average of prostrating attacks is once a month or once every two months respectively.  Thus, the minority voter recommends that considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), a disability rating of 50% for the migraine headaches condition, coded 8100 be assigned.

For all the aforementioned reasons based on the facts, law and policy, the minority voter recommends the Board findings be modified and the CI be granted permanent disability retirement as follows:

In the matter of the major depressive disorder condition, the Board recommends a disability rating of 50%, coded 9434 IAW VASRD §4.129 and VASRD §4.130 for TDRL placement and a 30% rating, coded 9434 IAW VASRD §4.129 and VASRD §4.130 for TDRL removal.  In the matter of the migraine headaches condition, the Board recommends a disability rating of 50%, coded 8100 IAW VASRD §4.124a. 

The Board recommends that the CI’s prior determination be modified as follows; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	RATING	
		TDRL	PERMANENT	
Neck Injury	5237	20%	20%	
Major Depressive Disorder	9434 	50% 	30%	
Migraine Headaches	8100	50%	50%	
RATING	80%	70%	

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, AR20160017497 (PD201403492)

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 reject the Board’s majority recommendation and the Board’s minority opinion.  The applicant’s final Physical Evaluation Board disability rating remains unchanged.  There is insufficient justification to support the Board’s recommendation in accordance with Army and Department of Defense regulations.  

2.  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:

Enclosures

CF: 
(  ) DoD PDBR
(  ) DVA