RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00242
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070623

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a National Guard E3, Supply Specialist, medically separated for “chronic left knee pain,” “chronic shin splints,” and “migraine headaches,” rated 20%, 0% and 0%, respectively, with a combined disability rating of 20%.

CI CONTENTION:  The CI referenced an attachment to explain her contention. It was not in the file. Her 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 on 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 - 20070425	VARD - 20070614	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Left Knee Pain	5099-5003	20%	Left Knee Condition	5257	10%	20060717	
Chronic Shin Splints	5022	0%	Bilateral Shin Splints	5299-5262	30%	20060617	
Migraine Headaches	8100	0%	Migraine Headaches	8100	50%	20060617	
Chronic Neck Pain	Not Unfitting 	Cervical Spine Condition	5237	NSC	20060617	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  70%	

ANALYSIS SUMMARY:  

Chronic Left Knee Pain and Chronic Shin Splints.  It is clarified that, although the PEB adjudicated the left knee and shin splints as separate conditions, the clinical and disability features of this case are coalesced such that a single narrative for the evidence and analysis is the most practical presentation.

According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI was first seen for bilateral knee pain on 31 October 2003.  She reported a history of pain for the past week.  No trauma was recorded and she was noted to have full range of motion (ROM) and to be non-tender.  The next record in evidence was a primary care note dated 9 April 2004 when the CI was seen for a viral infection and also reported knee pain.  On examination, the knees were noted to have “no abnormalities” and there was no tenderness from shin splints.  On a follow-up for hypertension 3 days later, she was noted to have no knee or leg symptoms and to have a normal musculoskeletal examination.  The CI requested a return to full duty the next day.  The CI was released from active service on 8 June 2004.  The next record in evidence was dated 12 July 2005.  The CI was seen in family practice for high blood pressure and reported ongoing knee pain and shin splints.  She was noted to be in no acute distress.  On examination, the knees were tender above the kneecap, but the examination was otherwise unremarkable.  No comment was made on the shins.  An X-ray of the left knee was normal.  She was next seen on 23 September 2005, by the same examiner who noted that the CI was seeking disability insurance.  The back of both knees were tender as were the shins.  The examination was otherwise unremarkable.  Another X-ray of the left knee was normal.  The CI was seen for the initial VA Compensation and Pension (C&P) evaluation on 27 September 2005.  She was noted to use crutches bilaterally.  She reported that her shin splint symptoms began on 29 April 2004 while running.  This is not consistent with contemporaneous records.  She also reported pain in the left knee, but denied swelling, fluid in the joint, or redness.  There was no instability or locking.  She used crutches and could not rise on her toes, but could rise on her heels.  She reported pain with light touch over the left knee and severe pain over the left shin to a superficial touch.  She reported severe pain over the right shin before she was actually touched.  There were no objective findings of pathology otherwise.  X-rays of the leg bones (tibiae and fibulae) were normal as were X-rays of the left knee.  A bone scan on 6 October 2005 showed stress-related changes in both knees and ankles (which were not symptomatic).  

The CI was seen on 26 April 2006 for a “fit for duty” evaluation.  She reported an initial injury to her knees and shin in March 2004 during a run.  The Board noted that in April 2004 the CI reported no symptoms and requested a return to duty.  She reported that she was seen by her primary care provider in August 2004 and placed on crutches for shin splints.  She continued to use these without resolution of her pain.  On examination, she was noted to be tender below the kneecap.  She was noted to have full and pain-free motion of the knees, but also to have 180 degrees extension and 75 degrees of flexion (normal is 140).  She also had tenderness along the shins bilaterally, but the appearance was normal.  The CI was referred for an MEB.  She was seen in orthopedics the same day.  It was noted that there was no fluid (effusion), locking, or instability of the knees.  She was noted to have diffuse discomfort about both lower extremities.  The ROM of the knees was 0-20 initially, but 0-130 when the CI was distracted.  The examination was otherwise normal and atrophy absent.  The CI did use a crutch for ambulation.  The orthopedist noted that there was not a clear etiology for her pain and that she did not have a disqualifying condition.  She was diagnosed with leg pain and it was specifically noted that the diagnosis of shin splints was not supported by the bone scan or the examination.  A neurology evaluation on 17 April 2006 noted normal muscle tone and slight weakness of the left thigh and hip, but was otherwise unremarkable.  Sensation and gait were normal.  Neither the use of crutches nor a brace was recorded.  The CI underwent another VA C&P examination on 17 July 2006 for an increase in the rating for her left knee and bilateral shin splint conditions.  She reported ongoing shin pain if she walked over 50 feet and left knee pain associated with stiffness and swelling.  She denied instability.  She used crutches and a left knee brace.  The ROM was limited to 90 degrees flexion and painful.  Diffuse tenderness was present, but the knee was otherwise normal.  The shins were tender bilaterally, but without other signs of pathology.  X-rays were not repeated.  She was thought to have moderately severe left knee patellofemoral syndrome (PFS) and moderately severe bilateral shin splints.  At the MEB examination on 30 October 2006, 7 months prior to separation, the CI reported pain aggravated by cold weather, daily activities, and weight-bearing.  The physical examination showed left knee tenderness to palpation on both sides of the kneecap as well as below the kneecap.  Motion was painful but full.  The shins were tender to palpation.  
At the MEB NARSUM examination on 27 December 2006, 6 months prior to separation, the CI noted complaints of sharp to moderate pain in left knee.  It was noted that a recent bone scan dated 29 December 2006 (not otherwise in evidence) was normal.  On examination, there was tenderness about the knee as described above and exquisite tenderness of the shins from mid-shin to the ankles bilaterally.  Full motion was recorded although flexion was limited to 130 degrees (140 normal).  Painful motion was not recorded, but this appears to by a typographical error.  The CI had another VA C&P examination on 9 May 2007, less than 2 months from separation.  This was accomplished by the same examiner who did the 17 July 2006 evaluation.  She reported that she had used crutches and a left knee brace for 2 years and that she could not walk over 50 feet without a flare of pain.  The bilateral shins remained tender without signs of inflammation.  The left knee was not evaluated as the CI reported severe pain.  

The Board directed attention to its rating recommendation for the chronic left knee pain based on the above evidence.  The PEB initially rated the CI at 10% for neck pain coded 5299-5242 (degenerative arthritis of the spine).  The left knee was not separately rated nor was it forwarded by the MEB for PEB adjudication.  The CI requested a Formal PEB (FPEB) which found the left knee unfitting at 20%, coded 5099-5003 (analogous to degenerative arthritis) using the US Army pain policy.  The VA initially rated the knee condition 0%, coded 5257 (knee, other impairment), based on the VA C&P examination dated 27 September 2005.  This was subsequently raised to 10%, based on the VA C&P examination dated 17 July 2006, and coded 5257 (other impairment of the knee).  The VA made no further changes to the left knee adjudication on subsequent VA rating decisions.  Painful motion supports a 10% rating.  The Board found no route, under the VASRD, to a higher rating including the 20% rating adjudication by the PEB using the pain policy.  However, the Board does not recommend a lower combined rating that than adjudicated by the PEB.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the knee condition.  

The Board directed attention to its rating recommendation for the chronic shin splints based on the above evidence.  The IPEB rated the shin splint condition 0%, coded 5022 (periostitis).  This was upheld by the FPEB and also on review by the US Army Physical Disability Agency (USAPDA).  The VA also rated the shin splint condition at 0% initially, coded 5299-5262 (analogous to impairment of the tibia and fibula).  This was subsequently raised to 30% following review by a Decision Review Officer (DRO) and based on the 17 July 2006 examination.  

The Board considered the evidence.  It noted that the onset of the shin splint condition varied in the histories given by the CI and that at times she reported that she was asymptomatic.  The degree of symptoms also varied significantly between examiners and she was noted to have severe pain on one examination with light touch on the left side and before she was touched on the right side.  Two separate bone scans were noted to be negative for shin splints.  The VA C&P examination on 17 July 2006, which the VA used to increase the rating, was between these two studies.  X-rays of the tibiae and fibulae were also normal.  Her pain persisted despite limited activity and the use of crutches and it seemed to increase after she was released from active duty and was not working.  Shin splints are the result of repetitive trauma and typically resolve with reduced activity.  In this case, the opposite seems to have happened.  The Board also noted that the orthopedist documented that there was no atrophy (which would be expected with more than a year of disuse) and that the etiology of the pain was “unclear.”  In fact, atrophy was not recorded on the NARSUM or any of the VA C&P examinations in evidence.  Atrophy would be expected with the degree and duration of limitation of activity reported by the CI.  The Board also noted that weakness of the lower extremities was not documented; this also would be expected with the level of impairment reported by the CI.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the chronic shin splint condition.  
Migraine Headaches.  According to STR and the MEB NARSUM, the CI was first evaluated on 16 December 2003 for a migraine headache associated with sinusitis.  She was next seen for a headache on 9 April 2004.  This was associated with gastroenteritis (nausea and diarrhea).  She was seen several more times over the next few days and remained headache-free.  The next entry was dated 23 August 2005, over one year later.  She reported a 4-day history of right lower quadrant abdominal pain and a headache.  Her examination was unremarkable and the reported pain was noted to be “far out of proportion to exam.”  The initial VA C&P evaluation was on 27 September 2005.  The CI reported headaches 3 times a week which lasted hours to days.  The neurological examination was “unremarkable.”  The MEB NARSUM addendum on 2 April 2006, 14 months prior to separation, noted complaints of migraines that were poorly controlled by medications.  A record review showed the CI sought no medical attention in the ER for headaches over the past year.  There was no documentation that the CI was ever given a profile or even quarters at any time for her headaches.  She was placed on medications for preventative therapy.  It was noted that her headaches were “medically acceptable” (for retention).  The next record in evidence is a neurology evaluation dated 17 April 2006.  The CI reported headaches 4 times a week which lasted 2 days each.  She reported that her headaches began in March 2004 several months after she began birth control pills (BCPs).  She was not able to stop these (she had pain from uterine fibroids if off the BCPs) and was begun on a prophylactic medication.  She was seen for a fit for duty evaluation 1 week later on 26 April 2006 and had a normal neurological examination.  A brain MRI dated 12 May 2006 was normal.  She was again seen in neurology on 15 May 2006 and reported that she had stopped the prophylactic medication as it made her too drowsy.  She reported a headache at the time of the examination.  Her medications were adjusted and she was released without limitations.  The neurology VA C&P evaluation was dated 17 July 2006 and accomplished by a physiatrist.  She reported daily headaches at least 5 times a week.  These lasted at least 24 hours and resulted in diffuse pain.  Prophylactic agents were not helping.  No examination was accomplished.  She was diagnosed with migraine headaches with a worsening course.  The CI was seen in the emergency room on 30 July 2006 for a migraine headache.  She was given a medication for nausea and sent home.  The MEB NARSUM dated 27 December 2006, 6 months prior to separation, noted that the CI had a history of poorly controlled migraines, but did not list this as a diagnosis to forward to the MEB.  A follow-up statement from the treating neurologist on 3 January 2007 again noted that the CI had migraine headaches which were medically acceptable.  The same examiner who accomplished the Neurology C&P evaluation saw the CI for a General C&P on 9 May 2007.  She reported headaches on a daily basis at least 5-6 times a week lasting 24 hours.  No neurological findings were recorded other than a painful gait.  The IPEB determined the headaches to be not unfitting.  The CI contended for the headache condition to be reconsidered and the FPEB then determined that the headaches were unfitting, based on her need for medication and her description of the headaches, her difficulty working on the computer when she last drilled, and the fact that she was deemed non-deployable for this condition in addition to other conditions.  The FPEB noted that the headaches were not prostrating and there was only one emergency room visit in evidence (July 2006, 11 months prior to separation).  The Board also found only one emergency room visit for the migraine headache condition (but noted several evaluations for headaches associated with viral infections; these were remote from separation) and no documentation that the CI had been placed on quarters or released from duty solely due to the headaches.  It also noted that the treating neurologist had opined twice that the headaches met retention standards.  The PEB rated the headache condition 0%, coded 8100 (migraine headaches).  This adjudication was upheld by the USAPDA after review of the evidence following an appeal by the CI.  The VA also initially rated the headache condition 0%, coded 8100, based on the VA C&P examination dated 27 September 2005.  It noted that there was no evidence of prostrating attacks of a frequency sufficient for a compensable adjudication.  This was subsequently raised to 30% and then 50% based, respectively, on the VA examinations on 17 July 2006 and 9 May 2007, 8 months before separation, citing very frequent, completely prostrating, and prolonged attacks productive of severe economic inadaptability.  The Board noted that the frequency cited by the CI at one examination, four times a week lasting for 2 days each, exceeds the number of days in a week implying constant headaches.  Rating guidance under diagnostic code 8100 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).  The VA granted a higher rating than that adjudicated by the PEB based on the CI’s report of the frequency of prostrating headaches at the time of the pre-separation C&P examinations.  This history is not supported by the objective evidence in the record.  In fact, numerous visits for her other medical issues noted that she was in no acute distress when seeking treatment for these conditions.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the headache condition.  

Contended PEB Condition:  Neck Pain.  The Board’s main charge is to assess the fairness of the PEB’s determination that the contended condition was not unfitting.  The fit for duty evaluation on 26 April 2006 only listed the shin splint condition.  An MRI on 23 May 2006 noted mild degenerative disc disease and degenerative joint disease.  In orthopedics on 7 June 2006, she was noted to have a normal neurological examination and full, pain-free ROM of the neck.  In physical therapy 3 weeks later, she had full but painful ROM and give-way weakness.  This was also the case when seen in physical therapy on 18 July 2006.  The MEB forwarded neck pain as medically unacceptable.  It was profiled U3 on the final profile.  The commander’s statement was not specific and did not address the neck or any other condition separately.  Separate ROM testing done on 3 March 2007 (after the MEB but prior to the PEB) showed flexion limited to 10 degrees and a combined ROM of 85 degrees.  No explanation for the marked limitation in ROM was provided other than pain.  It was noted that the passive ROM measurements were unreliable, that there was not tenderness, spasm, guarding, or abnormal contour.  The Board noted that neck pathology was not noted on any of the four VA C&P examinations prior to separation.  The IPEB determined that the neck was unfitting and rated it at 10%, coded 5299-5242 (degenerative arthritis of the spine).  However, the FPEB noted that the neck pain was an incidental finding and that her description of her pain was not supported by performance data.  Also, it was noted that there was not an LOD (line of duty) for this and that her neck did not compromise her ability to use crutches.  It also noted that there was scant evidence that she sought care for the neck condition.  The FPEB determined that the neck was not unfitting.  This was then considered by the USAPDA which upheld the FPEB adjudication as supported by a preponderance of evidence.  There was no performance-based evidence from the record that the condition significantly interfered with satisfactory duty performance at separation.  The limitation in motion obtained in March 2007 is an outlier from previous examination and inconsistent with the pathology in evidence.  After due deliberation, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the contended condition and so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the knee condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the shin condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the headache condition and IAW VASRD §4.124a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended neck pain condition and IAW VASRD §4.71a, 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 20150325, 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 
XXXXXXXXXXXXXXXXXX, AR20170001286 (PD201500242)

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