RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01908
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20091126

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Cannon Crewmember, medically separated for “residuals of traumatic brain injury (TBI)” and “left (non-dominant) shoulder pain,” rated 10% and 10%, respectively, with a combined disability rating of 20%.

CI CONTENTION:  The CI listed multiple conditions rated by the VA, some of which he did not receive a rating for from the Service.  He also indicated he subsequently received higher ratings by the VA approximately 3 years after separation.  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 - 20090818	VARD - 20100323	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Residuals of Traumatic Brain Injury	8045	10%	Tension…& Migraine Headaches	8100	0%	20091211	
			TBI Residuals	8045	NSC		
Left (Non-Dominant) Shoulder Pain	5099-5024	10%	Left Shoulder Tendinitis	5299-5203	10%	20091102	
Left Knee Pain	Not Unfitting 	Left Knee PFS	5299-5260	0%		
Neck Pain		Cervicalgia	5237	20%		
Alcohol Related d/o NOS		No VA Placement	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

Residuals of TBI.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM) in December 2007, the CI was the driver of a HUMVEE that struck an improvised explosive device (IED) blast.  He sustained a concussion with loss of consciousness at the blast site.  The CI was able to remain in-theater, but was unable to perform all of the duties of his military occupational specialty (MOS) secondary to left shoulder injury.  The CI was exposed to additional IED blasts and sustained 2 additional concussions.  He developed chronic daily headaches diagnosed as post-concussion headaches.  The CI was followed by the TBI clinic for treatment of his headaches.  Brain magnetic resonance imaging (MRI) in March 2009 was normal. Despite treatment, the condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty, so he was referred for a Medical Evaluation Board (MEB).  The MEB forwarded “post-concussive headaches” for PEB adjudication.

At the time of neurology clinic follow-up appointment on 2 July 2009, 4 months prior to separation, the CI noted that he was able to make it through the typical headache day if he was only doing clerical work.  He had severe headache once a month or so with vomiting and photophobia, which required him to lay down. 

During the neurology NARSUM examination on 27 July 2009, 4 months prior to separation, the CI reported that his headaches began in the summer of 2007 and they occurred greater that 50% of the days of the month.  He indicated that his Kevlar helmet triggered severe headaches.  He had tried multiple medications with little effect.  At the time of the NARSUM, he was taking headache prevention and abortive medications.  The neurological examination recorded normal mental status examination (MSE) that included normal memory, attention, concentration and knowledge appropriate to educational history.  There was no evidence of impaired cranial nerve function, or impaired motor function of the upper or lower extremities.  The examiner noted that his present condition allowed performance of desk duties, but any required field equipment or environment would trigger headaches to the point that it interfered with mission readiness, effectiveness, and completion.  It was noted that the headache condition was stable but interfered with the performance of military duties in his MOS.  The diagnoses of post-traumatic headache disorder and tension type headache, chronic, were assessed.  Psychiatrist treatment entry dated 6 days prior to separation indicated the CI’s headaches were controlled with the recent change of medication (Topiramate).

The 11 December 2009 VA Compensation and Pension (C&P) neurological examination, performed 2 weeks after separation, noted that the CI was seeking employment as an administrative assistant but was not working.  The examiner noted that his condition was stable.  The CI reported his headache prevention medication had significantly decreased headache frequency.  He reported some mild memory problems, and difficulty with problem solving during his headaches.  The neurological examination was normal.  The Assessment of Cognitive Impairment and other residuals of TBI documented daily mild to moderate headaches, and hypersensitivity to sound and light that mildly interfere with his daily activities, and mild memory and sleep problems.  The neurologist opined that there was no evidence of significant head trauma to consider his headaches as post-traumatic and that the CI’s difficulty with sleep and memory were more likely than not related to his psychiatric diagnosis.

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB rated the condition at 10% coded 8045 (residuals of TBI) and indicated the facet related to subjective symptoms was met at the 10% level (total facet of 1) for headaches.  The VA did not service-connect the condition of TBI residual due to the C&P examination that recorded absence of residuals.  However, the VA granted a 0% disability rating for tension and migraine headaches coded 8199-8100 (migraine).  The Board undertook a careful review of the record in evidence for support of a rating higher than the 10%.  

The Board is required to evaluate cognitive disorder IAW VASRD.  The VA assigns an evaluation based upon the highest level of severity for any facet (there are 10 facets with “3” as highest level of severity) of cognitive impairment and other residuals identified as associated with the condition.  The next higher rating of 40% requires demonstration of impairment level corresponding to level 2; not supported by the evidence.  The record documented no objective findings of memory loss, no evidence of impairment in judgment, inappropriate social interaction, issues with orientation, communication, or behaviors that interfered with workplace interactions. The clinical record did not substantiate clinically significant impairment at the time of separation. 

The commander’s performance statement did not mention any impairment in memory, judgment, or difficulties with the comprehension of language, or identified any impairment in learning.  In fact, retention was recommended.  The Board considered the 8100 code; however, the Board concluded the use of this code provided no additional benefits to the CI.  The Board agreed that a 10% rating, but no higher, was justified for the headache condition under the code 8045, and there was no justification for a higher rating under the 8100 code since prostrating attacks were not present.  There were no additional applicable codes to consider for rating the condition.  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 adjudication of the residuals of traumatic brain injury condition.

Left (Non-Dominant) Shoulder Pain.  According to STR and the MEB NARSUM, the CI, injured his left shoulder in December 2007 after an IED blast.  In theater radiographs were negative for fracture.  Although he was prescribed medication and used a sling, his pain continued.  MRI studies on 12 June 2008 demonstrated rotator cuff tendinitis and degenerative joint disease, osteoarthritis.  

The orthopedic clinic appointment on 17 February 2009 (9 months prior to separation) recorded range of motion (ROM) as “full,” but with pain and weakness in impingement positions (overhead).  The diagnosis of tendonitis rotator cuff and left shoulder impingement were recorded, with the opinion that the condition was refractory to conservative care and failed retention standards.  Despite treatment, the left shoulder condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty, so he was referred for a MEB.  The MEB forwarded “left shoulder pain due to rotator cuff tendonitis” for PEB adjudication.  

At the MEB examination (recorded on DD Form 2807 and 2808) dated 5 March 2009, the CI reported left shoulder pain, and a post injury history of numbness and tingling of one month duration.  The examiner documented “full ROM” in the left shoulder with painful motion.  At the MEB NARSUM examination 21 April 2009 (7 months prior to separation), the CI noted that his pain increased with overhead lifting, and noted that he had pain daily.  The physical examination revealed muscle strength of the left shoulder was “4/5-due to pain,” with normal muscle bulk and tone.  There was tenderness to palpation of the left shoulder and ROM documented normal flexion and abduction of 180 degrees, with pain on motion.  Tests for impingement were negative (Neers, Hawkins).

At the 2 November 2009 VA Compensation and Pension (C&P) examination, performed 3 weeks prior to separation, the examiner recorded left shoulder ROM measurements of flexion and abduction as normal, with pain; and normal strength.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating coded analogously 5099-5024 (tenosynovitis), citing painful motion IAW 4.59.  Likewise, the VA assigned a 10% rating under analogous code 5299-5203 (clavicle or scapula, impairment of), citing painful motion.  The Board considered all applicable coding options and noted the condition was not compensable under any code related to limitation of motion, or dislocation, or malunion.  The VASRD §4.71a threshold for rating for ROM impairment (code 5201, arm limitation of motion) is “at shoulder level” (approximately 90 degrees from the side), and the examinations in evidence demonstrated motion above this level.  Although there was insufficient limitation of motion to support a rating under the 5201 code, Board members agreed that a 10% rating was justified with application of VASRD §4.59 (painful motion).  There was no malunion or recurrent dislocation of the humerus to justify a rating under the 5202 code (humerus, other impairment of); and no nonunion with loose movement of the clavicle to warrant the next higher 20% rating under the 5203 code (clavicle or scapula, impairment of).  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded there was insufficient evidence to recommend a change from the PEB’s adjudication of the left shoulder condition.

Contended PEB Conditions:  Left Knee, Neck Pain, and Alcohol Related Disorder.  The Board’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  None of the conditions were profiled or implicated in the commander’s statement or judged to fail retention standards.  There was no performance-based evidence from the record that any of the conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for any of the contended conditions and so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the residuals of traumatic brain injury condition and IAW VASRD §4.124a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the left (non-dominant) shoulder pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended left knee pain, neck pain and alcohol related disorder NOS conditions, the Board unanimously recommends no change from the PEB determinations 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 20150707, w/attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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 AR20160014401 (PD201501908)

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