RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXXXXX		CASE:  PD-2015-00008
BRANCH OF SERVICE: Army		SEPARATION DATE:  20040420

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5, Financial Specialist, medically separated for “chronic headache,” with a disability rating of 10%.

CI CONTENTION:  The CI submitted a long explanation of his unfitting condition, identifies a number of conditions not mentioned by either the MEB or PEB, and asks for review of his not unfitting bilateral plantar fasciitis.  The applicant’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 - 20031222	VARD - 20080826	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Headache	8199-8100	10%	[Post-Surgical] Residual Headache	8008-8100	10%	20021017	
Bilateral Plantar Fasciitis	Not Unfitting	Plantar Fasciitis, Right Foot	5284	0%	20041027	
		Plantar Fasciitis, Left Foot	5284	0%	20041027	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  90%	

ANALYSIS SUMMARY:

Chronic Headache.  The service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM) documented a diagnosis of a Chiari I malformation (congenital skull defect allowing part of the brain to compress the upper spinal cord) that required surgical decompression in July 2001 (2½ years before separation).  Clinical entries reflected an uncomplicated course, but the CI suffered persistent headaches.  Repeat radiographic imaging (MRI) demonstrated no brain protrusion after the surgery and electrodiagnostic testing (EMG/NCS) was normal.  The headaches did not respond well to initial treatment, were described as daily or constant, and were aggravated by strenuous activities that required profile restrictions.  The only STR documentation of emergent treatment of headache was a clinic visit in January 2002 that resulted in an overnight admission.  The commander’s performance statement from September 2002 (19 months before separation) referenced “headaches and weakness” that “at times” necessitated quarters or release from work, but described overall performance as “satisfactory” and did not elaborate the frequency of any work loss due to headache.

Subsequent STR entries documented a favorable response to medication adjustment as elaborated below.  Additional surgery was not indicated; the headaches were not sufficiently controlled to allow unrestricted duty; and, the CI was referred for MEB which in turn forwarded “Chiari I malformation status-post decompression with residual headaches” to the PEB.

The MEB NARSUM examination on 20 June 2003 (10 months before separation) documented “persistent” headaches rated 5/10 that were not adequately responding to Fioricet (a headache-specific analgesic that by outpatient evidence had already been discontinued) and Imitrex (an injectable medication used to abort headaches).  The examiner noted exacerbation by bending over, running, marching, excessive heat or cold, and helmet wear; but, did not provide evidence probative to the existence or frequency of incapacitating headaches.  The neurological examination was normal.

At an MEB NARSUM Neurology Addendum performed on 8 December 2003 (5 months before separation), documented a favorable response to a prophylactic medication (Neurontin) for pain.  The headaches were “still always present” and rated 3-4/10, with more “severe headaches at least every 4-7 days ... daily or more should he exert himself.”  The MEB neurologist did not characterize the latter as prostrating, and additionally stated that Imitrex for “severe” headaches was used “rarely ... 2-3 times per year.”  A detailed neurological examination was notable only for a “mild” tremor that required provocation to elicit.

There was an additional STR entry from the same neurologist on 17 March 2004 (2 weeks before separation) that documented continued improvement with Neurontin, and a final entry on 8 July 2004 (10 weeks after separation).  The latter documented that the CI was starting school and that “he has not been having severe headaches...has used Imitrex only once in the past several months.”

The VA Compensation and Pension (C&P) examination of 17 October 2002 (18 months before separation) documented only “daily” headaches exacerbated by position change and strenuous activities that were not responding to treatment (Fioricet and Imitrex).  Severity, frequency of exacerbations, or characterization of prostrating episodes were not addressed.  The C&P General examination of 27 October 2004 (6 months after separation) mentioned “takes Neurontin for chronic headaches,” but provided no further elaboration.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the headache condition 10%, analogously coded 8199-8100 (migraine headaches) citing “Imitrex required 2-3 times/year.”  The 2002 VA rating decision (VARD) proximate to separation was unavailable; therefore, the Board referenced the 2008 VARD which continued a 10% rating for the headache condition, analogously coded 8008-8100 (brain, vessels, thrombosis- migraine headaches), based on the VA C&P examination 18 months before separation.

The VASRD §4.124a rating schedule for code 8100 (migraine) rests heavily on the frequency of “characteristic prostrating attacks...over last several months.”  The 10% rating under 8100 is for “prostrating attacks averaging one in 2 months,” a 30% rating for “once a month,” and the highest rating of 50% requires frequency and severity “productive of severe economic inadaptability.”  Members agreed that there was no evidentiary support for the latter rating, and construed the PEB’s rating to reflect its conclusion that only the episodes requiring rescue treatment with Imitrex (from the neurology addendum) were characterized as prostrating.

The VASRD does not provide a definition of “prostrating,” but members agreed that ratable headaches require reasonably convincing evidence that they force the abandonment of work or current activities.  The commander’s statement indicated that there were such events, but no high frequency was stated or implied (the assessment of “satisfactory performance” would not suggest frequent absences); and, the record indicated significant improvement after that evidence which was more probative to the rating interval under consideration.  Outpatient STR clinical entries, which were ample and appeared to represent the complete record, did not capture a need for the CI seek care beyond routine follow-up for over a 2-year interval before separation.  Members agreed, that although such encounters were not necessary to constitute a prostrating event, this level of clinical attention was not consistent with frequent headaches causing significant work loss; and, ultimately agreed that there was insufficient evidence to conclude that there were prostrating headaches beyond those conceded for the enumerated events requiring rescue by Imitrex.  This was especially true given the improving course and the “last several months” criterion of the rating language.  Under that premise, the 30% criteria were clearly not supported and the PEB’s 10% rating was appropriate.

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 of the chronic headache condition.

Contended PEB Conditions:  Bilateral Plantar Fasciitis.  The CI had a chronic history (onset 1994) of bilateral plantar fasciitis treated with orthotics, and other than a podiatry consult for the MEB there was no STR evidence of any ongoing complaints or treatment.  The condition was judged to meet retention standards, was never profiled in service, and was not implicated in the commander’s statement.  It did not receive a compensable rating from the VA.

The Board’s main charge was to assess the fairness of the PEB’s determination that the condition was not unfitting.  Members agreed that there was no performance-based evidence indicating that the condition interfered with duty requirements to an extent that would have prohibited further military service.  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 bilateral plantar fasciitis; thus, it was not eligible for rating.

BOARD FINDINGS:  In the matter of the chronic headache condition and IAW VASRD §4.124a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended bilateral plantar fasciitis, the Board unanimously recommends no change from the PEB determination as not unfitting.  There were no other conditions within the Board’s scope of review for consideration.  The Board, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150106, w/atchs
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 XXXXXXXXXXXXXXXXXXXXX, AR20170002045 (PD201500008)

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