RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00669
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070109

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E2, Cavalry Scout Trainee, medically separated for “atypical non-prostrating headaches” and “chronic left hip pain,” rated 0% and 0%, respectively,  with a disability rating of 0%.

CI CONTENTION:  “My hip is injured and still causes problems walking and working to this day.  I also suffer from seizures whenever I get stressed.  I am taking medication, however from time to time I still have them.  I am having difficulty finding long term employment as a result.  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 - 20070110	VARD - 20070409	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Left Hip Pain	5099-5003	0%	Left Hip Strain	5099-5024	10%	20070026	
Atypical Non-Prostrating Headaches	9499-9422	0%	No VA Placement	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Atypical Non-Prostrating Headaches.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s headaches began in October 2005.  He was initially seen for a 1 week history of dizziness on 13 October 2005.  He was initially thought to have vertigo (an inner ear problem) and treated with medications.  This was ineffective and when seen 4 days later, he also reported constant headaches.  A CT scan of the skull on 25 October 2005 was normal.  The CI was then empirically treated for sinusitis without improvement.  A brain MRI dated 10 November 2005 was normal other than a mucosal cyst in the left maxillary sinus of no clinical significance.  The CI was then referred to otolaryngology noting constant vertigo since mid-October 2005 without response to treatment.  At the initial evaluation on 5 December 2005, the CI reported vertigo 4-5 times a day lasting 5-20 minutes.  It was intermittent and non-positional.  No ear symptoms, including tinnitus, were reported.  The examination was normal and further testing was recommended.  On 9 December 2005, and ECOG [electrocochleogram] was normal (making Meniere’s disease, a cause of vertigo, less likely).  The same day, ENG [electronystagmogram] testing showed difficulty tracking and vertical nystagmus (a rapid up and down beat of the eyes), suggestive of a central lesion.  It was noted that the CI had a history of a “lazy left eye” and further evaluation with neurology was recommended.  The CI was evaluated in neurology on 2 March 2006.  He reported dizziness since October which was aggravated by any level of exertion even if his head remained stationary.  He had no improvement with treatment and only had relief with inactivity.  His examination was normal other than an abnormal gait due to left hip pain (below).  The evaluation by otolaryngology was not available for review.  An alternate medication and a possible referral to a neuro-ophthalmologist were recommended for consideration.  The CI was evaluated in optometry 4 days later and noted to be free of nystagmus and to have “unremarkable” ocular health.  The CI was then seen by a second (civilian) neurologist on 29 March 2006.  The CI reported dizziness with exertion and with a change in position.  He also noted daily headaches present for “a long time.”  The neurological examination was normal other than one maneuver which induced (benign positional) vertigo on the left.  Treatment was recommended (a series of extinguishing maneuvers).  He was also noted to have frequent headaches, possibly migrainous, and prophylaxis was noted to possibly be indicated.  He was again seen in neurology on 17 May 2006 and reported no change in his symptoms.  The neurologist wrote “He expressed his desire to get out of the Army and wants my help to give a recommendation.”  On follow up on 16 June 2006, the neurologist recorded that the CI again expressed his desire to be discharged from the Army.  The CI continued to complain of dizziness and headaches. The neurologist noted that he was uncertain of the prognosis and that “it could be related to other factors.”  The final neurology note, dated 28 June 2006, documented “I doubt that the headache and dizziness with improve while undergoing review by the Medical Board.”  At the MEB examination (recorded on DD Forms 2807 and 2808) dated 7 August 2006, 5 months prior to separation, the CI reported frequent dizziness and constant headaches.  The neurological examination was checked “normal”.  The MEB NARSUM examination on 9 November 2006, 2 months prior to separation, noted complaints of “highly atypical dizziness with headaches.”  The latter was aggravated by activity.  The headaches were noted to be non-prostrating.  The neurological examination was normal.  An exaggerated limp was present on inspection, but the gait was normal when the CI was observed from behind.  Review of the record does not show that the CI was placed on quarters or left the work place due to headaches in the final 6 months of service.  The commander made no mention of the headache condition in his assessment dated 27 June 2006.  At the 26 February 2007 VA Compensation and Pension (C&P) evaluation, performed 6 weeks after separation, the CI denied dizziness.  The headaches were non-prostrating and associated with maxillary sinusitis.  The neurological examination was normal other than an abnormal left gait.  Neither headaches nor dizziness were listed as active problems.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the CI at 0% for atypical non-prostrating headaches accompanied by dizziness, coded 9499-9422 (analogous to a pain disorder, a mental health somatoform disorder), noting that the industrial impairment was mild to none.  The VA did not rate the CI for headaches or dizziness and made no comment on either in the rating decision dated 9 April 2006, 3 months after separation.  The Board noted that the CI did not appear to miss work due to this condition other than for appointments.  It also noted that the commander made no mention of it in his assessment.  Six weeks after separation, the CI denied dizziness on the VA C&P and noted headaches only in association with sinusitis.  The Board considered the code 9499-9422 under VASRD §4.130 and 8100 (migraine headaches) under VASRD §4.124a and found no route to a rating higher than the 0% 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 atypical non-prostrating headaches accompanied by dizziness condition.  

Chronic Left Hip Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s hip condition began in early August 2005.  He was thought to have an overuse injury and treated with duty limitations and medications.  The range of motion (ROM) was normal.  A bone scan showed very faint increased uptake at the left femoral neck.  His pain persisted and he was placed on non-weight bearing.  He continued to have pain and was evaluated in physical therapy and thought to have a left hip flexor tendonitis.  The CI was then placed in medical hold and also began the evaluation for the dizziness/headache conditions (above).  A physical therapy note dated 5 January 2006 recorded that the CI had not been seen for the hip since 30 September 2005, but had persistent pain.  Disuse atrophy of the left calf was evident.  An MRI on 26 May 2006 showed non-specific findings with a subtle changed in a left hip muscle and tendon.  A physical therapy appointment one week later noted full ROM of the hip and resolved left hip pain.  At the MEB examination (recorded on DD Forms 2807 and 2808) dated 7 August 2006, 5 months prior to separation, the CI reported left hip pain without further details.  On examination, left hip tenderness was present with a lunging gait.  A sworn statement from an E-7 noted that “On or about 02 October I witnessed PVT Collins walking normally down the hall on both feet for a distance of250 meters without assistance of crutches or any other aid to help him.  I have seen him on two other occasions shortly thereafter walking and in one case running in the barracks when he did not see anyone in the area.”  The MEB NARSUM examination on 9 November 2006, 2 months prior to separation, noted complaints of left hip pain.  On examination, he was noted to walk with an exaggerated limp on inspection.  However, when approached from behind in the hallway, he appeared to have an excellent gait (on 27 November 2006).  At the 26 February 2007 VA C&P evaluation, the CI reported daily left hip pain with was aggravated by activity.  No assistive device was used.  On examination, the 69 inch CI reported a recent 20% weight gait to 214.5 pounds.  The gait was antalgic (limited by pain).  Tenderness of the left hip was present.  Atrophy was absent.  The ROM was limited by pain with flexion of 70 degrees (normal 125); extension of 35 degrees (normal 20); abduction of 43 degrees (normal 45); and adduction of 60 degrees (normal 45).  He could not cross his left leg over his right (even though adduction was greater than normal; the Board could not reconcile these two findings).  There was no additional loss with repetition.  X-rays were normal.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated chronic left hip pain condition at 0%, coded 5099-5003 (analogous to degenerative arthritis) noting a non-physiological exaggerated limp.  The VA rated the left hip strain at 10%, coded 5099-5024 (tenosynovitis), noting pain with motion.  The Board considered the evidence.  Radiographic studies were either normal or showed minimal pathology of uncertain significance.  The ROM was noted to be normal and then later, significantly reduced without explanation for the variance.  The latter examination was 6 weeks after separation.  The gait was typically antalgic (abnormal due to pain) when the CI was under evaluation, but noted by more than one observer to be normal when the CI was not aware he was being observed.  The Board considered the conflicting evidence.  The VASRD requires that the higher of two evaluations be used if the disability picture more nearly approximates the criteria for the rating.  The VA measurements were an outlier from prior measurements which showed a normal ROM.  This reduces the probative value of this examination.  In addition, the Board noted that, 6 days prior to separation, the CI concurred with the PEB assessment which noted “a non-physiological exaggerated limp, full motion, and good stability.”  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 left hip condition.  

BOARD FINDINGS:  In the matter of the atypical non-prostrating headaches accompanied by dizziness condition and IAW VASRD §4.124a and VASRD §4.130, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the left hip pain condition and IAW VASRD §4.71a, the Board majority recommends no change in the PEB adjudication.  The single voter for dissent recommended modification to 10% for the hip coded 5099-5003, but did not elect to submit a minority opinion.  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 20150603, 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, AR20170001036 (PD201500669)

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