RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-04010
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20090526

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Aerospace Warning Systems Craftsman, medically separated for “chronic pain syndrome associated with back and pelvic pain,” with a disability rating of 10%.

CI CONTENTION:  The CI made no specific contention.  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 - 20090109	VARD - 20091127	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Pain Syndrome associated with Back and Pelvic Pain and Headaches	9499-9422	10%	Degenerative Changes Lumbar Spine	5242	10%	20090910	
			Pelvic Pain Syndrome with Possible Endometriosis, Regular Menses and a History of Ovarian Cysts	7629	10%	20090910	
			Migraine Headaches	8100	30%	20090910	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  70%	

ANALYSIS SUMMARY:  

Chronic Pain Syndrome.  The PEB combined the degenerative changes lumbar spine, pelvic pain syndrome and migraine headache conditions as a single unfitting condition coded 9499-9422 analogously to pain disorder and rated 10%.  The approach by the PEB not uncommonly reflected its judgment that the constellation of conditions was unfitting, and there was no need for separate fitness adjudications.  The Board’s initial charge in this case was therefore directed at determining if the PEB’s approach of combining conditions under a single rating was justified in lieu of separate ratings.  When considering a separate rating for each condition, the Board considers each bundled condition to be reasonably justified as separately unfitting unless a preponderance of evidence indicates the condition would not cause the member to be referred into the Disability Evaluation System or be found unfit because of physical disability.  When the Board recommends separate fitness recommendations in this circumstance, its recommendations may not produce a lower combined rating than that of the PEB.  The evidence for the back pain, pelvic pain and migraine conditions are presented separately, with attendant recommendations regarding separate unfitness, and separate rating if indicated.  

Migraine Headache.  According to service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s migraine headache condition began in April 2006 after being reassigned to Korea.  A primary care clinic examination dated 22 July 2008 (10 months prior to separation) noted complaints of debilitating headaches lasting 1 to 3 days every few weeks.  Physical examination showed a normal neurological evaluation.  

The initial VARD referenced a VA C&P evaluation, performed 4 months after separation.  The CI reported two incapacitating headaches per month lasting 2 days each. Physical examination showed a normal neurological evaluation.

The Board directed attention to its rating recommendation based on the above evidence. As noted above, the PEB combined migraine headache condition under a single disability rating, coded analogously to 9422 (pain disorder).  The VA rated the migraine headache condition 30% coded 8100 (migraine headaches), citing prostrating attacks occurring monthly over the past several months.  The Board first considered if migraine headache condition was reasonably justified as separately unfitting.  Member consensus was that the evidence supports the conclusion that the functional limitations of the migraine headaches could be reasonably justified as separately resulting in the CI’s inability to perform her military occupational specialty (MOS); and a separate rating is recommended.  The CI had a 3-year history of severe, prostrating headaches that were only partially responsive to treatment supporting a 30% rating.  The CI did not have very frequent completely prostrating and prolonged attacks that produced severe economic inadaptability and therefore not substantiating a 50% rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a separately unfit determination with a disability rating of 30% for the migraine headache condition, coded 8100.  

Low Back Pain.  According to STR and the MEB NARSUM, the CI’s low back pain condition began in January 2004 during pregnancy.  The MEB NARSUM examination on 13 October 2008 (7 months prior to separation) noted complaints of daily low back pain with severe exacerbations approximately 5 days per month with radiation to her right calf.  Physical examination showed forward flexion to 75 degrees, extension to 5 degrees, and tenderness with palpation of the right paraspinous muscles without spasm.  The initial VA Rating Decision (VARD) dated 27 November 2009 references a VA C&P examination, performed 4 months after separation.  Physical examination showed flexion was 80 degrees (90 normal) and extension was 30 degrees.   Lateral flexion was 20 degrees and rotation was 20 degrees with painful motion.

The Board directed attention to its rating recommendation based on the above evidence.  As noted above, the PEB combined low back pain condition under a single service disability rating, coded analogously to 9422 (pain disorder).  The VA rated the low back pain condition 10% coded 5242 (degenerative arthritis of the spine), based on the VA C&P examination 4 months after separation, citing limited flexion and painful movement.  The Board first considered if lower back pain condition was reasonably justified as separately unfitting.  Members agreed that the evidence supports the conclusion that the functional limitations of the lower back pain could be reasonably justified as separately resulting in the CI’s inability to perform her MOS; and a separate rating is recommended.  The CI demonstrated a forward flexion of the thoracolumbar spine greater than 60 degrees, but not greater than 85 degrees with painful movement supporting a 10% rating.   A higher evaluation of 20%  was not warranted unless there was flexion of greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion was not greater than 120 degrees or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a separately unfit determination with a separate disability rating of 10% coded 5242.  

Pelvic Pain Syndrome with Endometriosis.  According to STR and the MEB NARSUM, the CI’s pelvic pain syndrome condition began in 1995 (age 12) and coincided with menstrual cycles.  The CI’s condition worsened in October 2006 and she sought care.  The MEB NARSUM examination noted complaints of pelvic pain that had greatly lessened since starting treatment 6 months earlier.  Physical examination showed a normal abdominal evaluation.  At the 10 September 2009 VA C&P evaluation, performed 4 months after separation, the CI reported minor pelvic discomfort (2/10) that did not interfere with her ability to do any activities so long as she continued daily medication.  Physical examination showed no abdominal or pelvic tenderness.  

The Board directed attention to its rating recommendation based on the above evidence.  As noted above, the PEB combined pelvic pain syndrome with endometriosis condition under a single disability rating, coded analogously to 9422 (pain disorder).  The VA rated the pelvic pain condition 10% coded 7629 (endometriosis), based on the VA C&P examination 4 months after separation, citing continuous treatment required to control symptoms.  The Board first considered if pelvic pain syndrome with endometriosis condition was reasonably justified as separately unfitting.  Members agreed that the evidence did not support the conclusion that the functional limitations of pelvic pain could be reasonably justified as separately resulting in the CI’s inability to perform her MOS; and a separate rating is not recommended.  The CI had a previous history of pelvic pain; however, the condition was not profiled, there is no evidence of missed duty due to the condition and it was not implicated in the commander’s statement.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends against a separately unfit determination and a separate disability rating for the pelvic pain condition.  

BOARD FINDINGS:  In the matter of the migraine headache condition, the Board majority recommends a disability rating of 30%, coded 8100 IAW VASRD §4.124a.  The single voter for dissent recommended classifying the migraine headache condition as not unfitting and did not elect to submit a minority opinion.  In the matter of the low back pain condition, the Board unanimously recommends a disability rating of 10%, coded 5242 IAW VASRD §4.71a.  In the matter of the pelvic pain condition, the Board unanimously agrees that it cannot recommend it for additional disability rating.  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	
Migraine Headaches	8100	30%	
Degenerative Arthritis of the Spine	5242	10%	
COMBINED	40%	

The following documentary evidence was considered:

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

PDBR PD-2014-04010

MEMORANDUM FOR THE CHIEF OF STAFF

      Having received and considered the recommendation of the Physical Disability Board of Review and under the authority of Title 10, United States Code, Section 1554a (122 Stat. 466) and Title 10, United States Code, Section 1552 (70A Stat. 116) it is directed that:

      The pertinent military records of the Department of the Air Force relating to be corrected to show that:

                a.  The diagnosis in her finding of unfitness was Migraine Headaches, VASRD code 8100, rated at 30%; and Degenerative Arthritis of the Spine, VASRD code 5242, rated at 10%, with a combined disability rating of 40%.

                b.  On 25 May 2009, she elected child-only coverage under the Survivor Benefit Plan based on full retired pay.

                c.  She was not discharged on 26 May 2009 with entitlement to disability severance pay; rather, on that date she was released from active duty and on 27 May 2009 her name was placed on the Permanent Disability Retired List.