RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-02306
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070920

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Unit Supply Specialist, medically separated for “chondromalacia patellae, bilateral” and “migraine,” rated 10% each, with a combined disability rating of 20%.

CI CONTENTION:  “Review all conditions.”  The complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The panel’s scope of review is defined in DoDI 6040.44.  It is limited to review of disability ratings assigned 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 Medical Evaluation Board (MEB), but determined by the PEB to be not unfitting or non-compensable.  Any conditions outside the panel’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.  The panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections when appropriate.  The panel’s assessment of the PEB rating determination is based on review of medical records and all available evidence relevant to application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards for the unfitting medical condition(s) at the time of separation.  The panel 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, which operates under a different set of laws.  The panel gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of disability at the time of separation.  

RATING COMPARISON:  

SERVICE PEB - 20070808	VARD - 20080530	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chondromalacia Patellae, Bilateral	5099-5003	10%	Chondromalacia, Bilateral Knees	5014-5010	10%	20080422	
Migraine	8100	10%	Migraine Headaches	5237	10%		
Asthma	Not Unfitting	Asthma	6602	10%		
Sinusitis		No VA Placement	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Chondromalacia Patellae, Bilateral.  The PEB combined the right and left knee conditions under a single disability rating of 10%, coded 5099-5003 (analogous to degenerative arthritis).  This 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 panel noted that “bundling,” the combining of two or more major joints, may be permissible under the VASRD 5003 rating requirements, and that this approach does not compromise the VASRD §4.7 directive to choose the higher of two valid ratings.  The panel’s initial charge in this case was therefore directed at determining if combining conditions under a single rating was justified in lieu of separate ratings.  When considering a separate rating for each condition, the panel 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 DES or be found unfit because of physical disability.  When the panel recommends separate fitness recommendations in this circumstance, its recommendations may not produce a lower combined rating than that adjudicated by the PEB.  The evidence for the right and left knee conditions is presented together, with attendant recommendations regarding separate unfitness, and separate rating if indicated.  

According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI experienced a gradual onset of bilateral knee pain in 2004 attributed to military training.  This was diagnosed by radiographic studies as chondromalacia patella (damage to the cartilage under the knee cap).  Menisci, ligaments and remaining joint structures were normal by imaging.  Provider entries in the STR documented a normal gait and the absence of an effusion or instability.  There were no entries that noted any limitation of range of motion (ROM) or that indicated the presence of painful motion for either knee.  There was no STR documentation of meniscal impingement (objective locking) or other VASRD-ratable criteria for either knee.

The MEB NARSUM was not directly probative to the knee conditions, but a 10 April 2007 MEB orthopedic addendum to the MEB NARSUM, 5 months prior to separation, documented nonspecific bilateral anterior knee pain “worse with stairs and sitting” that prohibited running and multiple general soldiering requirements.  The physical examination recorded (all findings bilateral) patellar compression tenderness and crepitus, but no effusion, instability or meniscal impingement.  The ROM study showed “full” ROM without painful motion.  The orthopedic addendum made no differentiation of right versus left clinical severity or functional limitations.  The MEB’s DA Form 3947 submission and the profile designated a bilateral condition.  The commander’s performance statement was not probative to separate fitness implications of either knee.

At the 22 April 2008 VA Compensation and Pension (C&P) examination, 7 months after separation, the CI reported bilateral knee pain (no differentiation of right versus left severity) rated 5/10 with subjective “locking” that was aggravated by prolonged walking or standing and by stairs.  The physical examination recorded (all findings bilateral) a normal gait without tenderness, effusion, instability or meniscal impingement.  Measured ROM was flexion to 100 degrees right and 110 degrees left (normal 140) with bilateral extension to 0 degrees (normal), specifying the absence of painful motion for each knee.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB’s bilateral 10% rating (see above) cited “two or more major joints with radiographic evidence and without loss of motion.”  The VA also conferred a combined 10% rating under code 5014-5010 (osteomalacia - arthritis due to trauma), based on the C&P examination, citing “painful or limited motion of a major joint or group of minor joints, and may also be applied once to multiple joints if there is no limited or painful motion.”  

With regards to the panel’s recommendation as to whether each knee was separately unfitting, it had to be considered that there was no ratable criterion that would support a minimum 10% rating for either knee (as elaborated and justified below).  Thus, a combined minimum compensable rating was favorable, and arguably obligatory in this case to avoid lowering the PEB rating.  Members further agreed that, based on the clinical and functional evidence, it was reasonable to conclude that the performance limitations confined to either knee alone would not have rendered the CI incapable of continuing military service; and, that more likely it was the combined effect of the bilateral condition which rendered her unfit.

With regard to potential individual rating of either knee (in justification of the above conclusion that combined rating was favorable), members agreed that there was not satisfactory evidence of painful motion for either joint to support a minimum 10% rating IAW VASRD §4.59.  There was no indication of painful motion by any STR provider or in the orthopedic addendum, and painful motion was specifically addressed and negated by the VA C&P examiner.  There was no evidence for minimum compensable ROM limitation (codes 5260 or 5261), persistent effusion or locking (code 5258), or fracture with nonunion or malunion (code 5262) to support a minimum 10% rating for either knee.  There were no other applicable coding or rating options.  Members thus agreed that a minimum 10% rating was supported only by satisfying the 5003 criterion of “2 or more major joints.”  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded that there was insufficient cause to recommend a change in the PEB adjudication for the bilateral knee condition.

Migraine.  The CI had a chronic history of migraine headaches (including pre-service) that escalated in 2006 with discontinuation of her medications during pregnancy and post-partum.  A brain MRI and all neurological examinations were normal.  A review of STR provider notes showed that she was seen every few months for routine follow-up of the headaches and medication adjustments.  There were two primary care entries that documented emergent treatment for headache, one in July 2006 (14 months before separation) and another in March 2007 (6 months before separation).  Although there were records for emergency department treatment of headache more remotely (2001 and 2004), there were none in evidence more proximate to separation.  Provider notes indicated that the headaches were frequent (some noting daily occurrence), but none that characterized them as prostrating (or equivalent description as elaborated below).  Although there was no STR corroboration of any duty excuse or quarters assignment due to headache, the commander’s performance statement recorded that the CI “has had to leave work on numerous occasions” for the headaches.   

There was a neurology consult on 24 January 2007 that was referenced by the MEB NARSUM.  This documented headaches “almost every day or every day” with “a more severe headache that comes once a week ... may last for hours.”  The neurologist diagnosed “chronic daily headache – migraine type” and started the CI on a prophylactic medication (Topamax) in addition to the rescue medications (Fioricet and Relpax) that she was already taking.  A follow-up note by the neurologist on 14 March 2007 (6 months before separation) stated, “There are no problems with medication.  The headaches are not as bad as before and Relpax helps during the severe attack ... Impression: migraine headache, improved.”

The 25 April 2007 MEB NARSUM examination, 5 months prior to separation, documented “a lifelong history of migraines” that were “gradually getting worse.”  The frequency and severity of headaches was not elaborated, although the pain rating was “slight and occasional.”  The examiner stated that the CI did not “frequently visit the Emergency Room nor has an extraordinary number of doctor's appointments to cover this issue,” and opined that the headaches “do not appear to be severely prostrating based on lack of Emergency Room usage and longstanding job performance for a number of years.”  

The VA C&P examination (same as above for the knee condition) documented a history of migraine headaches since childhood that had been aggravated by the military, but did not address the frequency or severity of headaches.  The examiner opined that the condition imposed a “significant” effect on usual occupation (no elaboration), but noted that the CI was employed full time as an insurance adjuster and work loss was attributed non-specifically to “medical appointments.”  

The panel directed attention to its rating recommendation based on the above evidence.  The VASRD §4.124a rating guidance under code 8100 (specific to migraine headaches) is based on the frequency of “prostrating attacks” over the “last several months.”  The 10% rating is for an average frequency of “one in two months;” that for 30% is “once a month;” and, for 50% “very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability.”  The VASRD does not define prostrating attacks, however commonly accepted (and court sanctioned) 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).  

Both the PEB and the VA conferred 10% ratings under the solely applicable code 8100, and both cited the above 10% criterion.  The PEB opined that the headaches were improved and rarely prostrating, but were still frequent and severe enough to interfere with duty performance.  The VA decision rested more heavily on the STR evidence than that from the VA C&P, and opined that the former indicated that the CI experienced headaches approximately every other day and “severe migraine headaches nearly every other month.”

The panel agreed that the above 50% criteria were not supported by the evidence, and then deliberated whether the 30% criteria were supported.  Members ultimately concluded that there was insufficient evidence to satisfy the 30% criteria.  The statement by the commander that the CI had left work on numerous occasions because of the headaches was carefully weighed, but members agreed that these episodes were too arbitrary and uncorroborated to justify characterizing them as prostrating.  Evidence from the STR, MEB neurologist (especially the final follow-up note), MEB NARSUM and post-separation VA C&P, portrayed a severity that was better aligned with the 10% criteria than with those for 30%.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded that was insufficient cause to recommend a change in the PEB adjudication for the migraine condition. 

Contended PEB Conditions:  Asthma and Sinusitis.  The panel’s main charge is to assess the fairness of the PEB determinations that the above conditions were not unfitting.  The CI had been treated for asthma flares in her early training period, but there was no evidence of any acute attacks or significant clinical activity for the condition during the pre-separation period.  Pulmonary function testing was essentially normal.  The NARSUM noted only a history of asthma with no evidence of any current clinical acuity.  There was no STR provider evidence for treatment of acute sinusitis.  The MEB NARSUM mentioned only a history of sinusitis.  The post-separation VA C&P examination documented no asthma flares since separation and no episodes of sinusitis in the last 12 months.  Both of these conditions were judged by the MEB to meet retention standards.  Asthma was listed with migraines on the permanent P3 profile in effect at separation, although the NARSUM provider opined that asthma would “in and of itself” rate only a P2 (not mandating MEB referral and not typically imposing unfitting limitations).  Neither condition was implicated in the commander’s performance statement.  The panel found no performance-based evidence from the record that either of the contended conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded there was insufficient cause to recommend a change in the PEB fitness determinations for the asthma and sinusitis conditions, so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the bilateral knee condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the migraine condition and IAW VASRD §4.124a, the panel recommends no change in the PEB adjudication.  In the matter of the contended asthma and sinusitis conditions, the panel recommends no change from the PEB determinations as not unfitting.  There are no other conditions within the panel’s scope of review for consideration.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170223, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs 

AR20190007575, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found your separation disability rating and your separation from the Army for disability with severance pay to be accurate.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed), and I accept its recommendation.  I regret to inform you that your application to the DoD PDBR is denied.  

	This decision is final.  Recourse within the Department of Defense or the Department of the Army is exhausted; however, you have the option to seek relief by filing suit in a court of appropriate jurisdiction.

Sincerely,					      
Enclosure