RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03493
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20030613

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-3 (Light Wheeled Vehicle Mechanic) medically separated for post traumatic headaches.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty. He was issued a permanent P3 profile and referred for a Medical Evaluation Board (MEB).  The “chronic headaches, refractory to treatment status post eye injury” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded two other conditions (refractive error and patella femoral pain syndrome) for PEB adjudication.  The Informal PEB adjudicated “post traumatic headaches” as unfitting, rated 10% citing application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The remaining conditions were determined to be not disqualifying.  An Administrative Corrected PEB made a change in VA code and did not impact the rating.  The CI made no appeals and was medically separated.  

CI CONTENTION:  “Please consider all conditions.”

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e. (2).  It is limited to those conditions determined by the PEB to be unfitting for continued military service and when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting.  Any conditions outside the Board’s defined scope of review and any contention not requested in this application may remain eligible for future consideration by the Board for Correction of Military/Naval Records.  Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the 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 

Admin Corr IPEB - Dated 20030307	VA* - (~3Mos. Pre -Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Post Traumatic Headaches	8199-8100	10%	Migraine Headaches	8100	30%	20030317	
Refractive Error	Not disqualifying	Residuals of Eye Injury	6099-6001	0%	20030317	
Patella Femoral Pain Syndrome						
		Chondromalacia L&R	5099-5019	0%	20030317	
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 15 (equals SC, NSC & deferred)	
RATING:  10%	RATING:  60%	
*Derived from VA Rating Decision (VARD) dated 20030614 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY:  

Headache (HA) Condition.  The narrative summary (NARSUM) noted the CI had a metallic foreign body in the right eye in February 2002, which had apparently spontaneously dislodged at the time of the exam, but a remaining rust ring was removed.  Following this incident the CI developed HAs, which he related to the incident.  The HAs gradually worsened with associated nausea, vomiting, and sensitivity to light and sound.  There were scant notes from the service treatment record (STR) in the record before the Board.  A computed tomography scan of the head 20 August 2002 was normal and the HAs were diagnosed as migraines.  The CI was referred to neurology.  Treatment trials of multiple abortive and preventive migraine medications failed to adequately control the migraine HAs and a MEB was recommended.

At the MEB exam 15 January 2003, 5 months prior to separation, the CI reported migraine HAs.  The MEB physical exam noted the CI had a visual refractive error with normal corrected distance visual acuity bilaterally and otherwise normal eye exam.  The MEB examiner noted that that the CI continued to have daily moderate HAs, aggravated by activity, noise, light, and fumes.  At the MEB neurology consult 16 January 2003, the CI reported chronic daily HAs and three severe HAs per week and the neurological exam was normal.  The MEB neurologist noted that the CI had not been sent home due to the HAs, but they decreased his ability to work.  The commander’s statement 31 January 2003 noted that the CI was “unable to work for extended periods of time,” but also noted he was able “to perform his job to Army standards, however, he is not as efficient and his headaches interfere with day-to-day activities.”  The permanent profile listed physical limitations of no running, marching, or use of protective gear, and physical training and exertion at own pace only.  

At the VA Compensation and Pension (C&P) exam 17 March 2003, 3 months prior to separation, the CI reported daily HAs which could be severe and lasted for variable lengths of time and reported being unable to work when an attack occurred.  The CI reported a HA at the exam and the examiner noted the CI appeared to be in mild distress.  Pertinent exam including the eyes and full neurological exam was normal, except for noted tenderness to palpation (TTP) of the right temple area of the head.

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB rated the HA condition 10%, coded 8199-8100 (analogous to migraines).  The VA rated the HA condition 30%, coded 8100.  The Board considered that VA rating guidance under diagnostic code 8100 (migraine headache) is based on the frequency of “prostrating attacks” over the “last several months.”  The VASRD does not further define prostrating attacks however commonly accepted definitions include "utter physical exhaustion or helplessness" (Webster's New World Dictionary of American English), “complete physical or mental exhaustion” or "extreme exhaustion or powerlessness" (Dorland's Illustrated Medical Dictionary) and the Board unanimously agreed to this general description of prostrating for its deliberations.  

The 8100 criteria for the highest rating of 50% requires HA frequency of “very frequent…and prolonged attacks productive of severe economic inadaptability”; a 30% rating requires “once a month over the last several months”; a 10% rating requires “prostrating attacks averaging one in 2 months,” and a 0% rating, “less frequent attacks.”  The Board engaged in lengthy deliberations regarding whether the CI’s frequent HAs rose to the level of prostrating as defined above.  The Board majority noted that there was no evidence in record of emergent treatment, duty release, or prescribed bed rest for HA.  At the pre-separation C&P exam, the CI self-reported that he was unable to work with severe HAs, which occurred approximately three times per week.  However, the Board considered that the commander noted that the CI was unable to work for extended periods of time,” but did not suggest how frequently this occurred, and also noted that despite this, his job performance was adequate and the MEB neurology consult noted that the CI had never left work due to the HAs.  The Board majority agreed that the evidence did not support that the CI’s HAs were “prostrating” as commonly defined above.  However, IAW DoDI 6040.44 the Board may not recommend a lower combined rating than that conferred by PEB.  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 HA condition.  

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the refractive error and patellofemoral pain syndrome conditions 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.  

Refractive Error.  Following the right eye foreign body incident noted in the discussion of the HA condition, the CI experienced blurry vision and was diagnosed with a refractive error.  An optometry visit 13 February 2002 noted distant visual acuity of 20/25 in the right eye.  The MEB DD Form 2808, Report of Medical Examination, 15 January 2003 noted distant and near visual acuity of 20/30, corrected to 20/20 in each eye, with an otherwise normal eye exam.  The NARSUM noted the refractive error was non-disqualifying.  At the VA pre-separation C&P General Medical exam on 17 March 2003 distance vision was 20/40 in each eye and the CI was noted to wear corrective lenses.  A pre-separation VA eye exam on 27 March 2003 noted uncorrected and corrected visual acuity of 20/20 in each eye, with “mild astigmatism” (abnormal shape of the cornea), with normal exam of both eyes.  The VA examiner noted that there was no evidence of retained metal noted on X-ray.

Patellofemoral pain syndrome.  There was a single treatment note for the knees in the STR dated 11 February 2002, which indicated right knee pain greater than left for a year.  The diagnosis was retropatellar pain syndrome and stretching and strengthening exercises were recommended.  Report of medical examination dated 15 January 2003 noted TTP of both patellae with positive grind tests and no evidence of instability or semilunar cartilage injury. The NARSUM noted that the CI had a history of right knee pain after activity that had been evaluated by primary care and physical therapy and he had no physical limitations due to the condition.  The NARSUM indicated the PFPS was not disqualifying.  The refractive error and PFPS were not profiled or implicated in the commander’s statement and were not judged to fail retention standards.   All were reviewed and considered by the Board.   There was no performance based evidence from the record that that the refractive error or PFPS of either or both knees significantly interfered with satisfactory duty performance.  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 any of the 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 HA condition and IAW VASRD §4.124a, the Board majority recommends no change in the PEB adjudication.  In the matter of the contended refractive error and PFPS conditions, the Board majority recommends no change from the PEB determinations as not unfitting.  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 20140612, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB                              0 6 JUL 2016

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, AR20160003188  (PD201403493)

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: