XXXXXXXXXX. 

XXXXXXXXXX
XXXXXXXXXX
XXXXXXXXXX

Dear XXXXXXXXXX:

	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.

RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXX.	CASE:  PD-2017-03597
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20080827

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, HUMINT Collector, medically separated for “chronic headaches” and “right cubital tunnel syndrome,” 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 - 20080707	VARD - 20081117	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Headaches	5399-5323	10%	Migraine Headaches	8100	10%	20080731	
Right Cubital Tunnel Syndrome	8516	10%	Paralysis of Ulnar Nerve	8516	10%	20080731	
Left Cubital Tunnel Syndrome	Not Unfitting					
Knee Pain	Not Unfitting	Left Knee Retropatellar Pain 	5019	10%	20080731	
Back Pain	Not Unfitting	Spinal Stenosis	5238	10%	20080731	
Cervicalgia Secondary to Chronic Headache	Not Unfitting	Cervical Strain	5237	20%	20080731	
Seborrheic Dermatitis	Not Unfitting	Exfoliative Dermatitis	7817	0%	20080731	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

Chronic Headaches (and Cervicalgia Secondary to Chronic Headache).  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s headache and neck pain conditions began in April 2007.  Headaches were associated with light-headedness (fell twice).  The CI typically had three or four headaches per week, associated with severe/stabbing pain greater on the left at the base of the skull, and lasting 3-6 hours.  The CI complained of poor sleep, poor concentration and poor memory due to the headaches.  Radiographic studies of the brain and neck were essentially normal.  Treatment with medications, nerve blocks and chiropractic were not successful.  

The 22 May 2008 MEB NARSUM examination, 3 months prior to separation, noted complaints of refractory headaches.  Physical examination showed the head and neck were atraumatic and normocephalic, without lymphadenopathy or rash, and cranial nerves were normal.  The neurologist stated that the CI had “been treated for over a year for frequent and incapacitating headaches that [had] caused him to seek acute and chronic medical treatment extensively over the past year.  When [the CI had] a headache, he [had] significant pain and impaired concentration.  Although his headaches [were] NOT totally disabling (may still function in sedentary occupation such as engineer, architect, clerk or administrative assistant), they will prevent him from meeting physical training standards for the US Army, as well as prevent him from wearing Kevlar, gasmasks or other protective headgear.”  

During the 10 June 2008 MEB examination (recorded on DD Forms 2807-1 and 2808), 3 months prior to separation, the CI reported severe headaches with infrequent dizziness or fainting.  Physical examination showed no cervical spine tenderness or limitation of motion.  

At the 30 July 2008 VA Compensation and Pension (C&P) examination, 1 month before separation, the CI reported headaches occurring an average of three days per week and lasting 3-4 hours per episode, but were not incapacitating.  He denied pre-headache aura or accompanying symptoms.  Treatment consisted of rest and activity modifications as needed along with the use of Robaxin every night and Tramadol as needed for pain which provided some relief without side effects.  Physical examination showed normal cranial nerves.  There was painful and limited cervical spine range of motion (ROM) with flexion to 30 degrees (normal 45) and combined ROM of 230 degrees (normal 340).  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the headaches 10%, analogously coded 5399-5323 (muscle group XXII), citing moderate disability.  The PEB adjudicated the neck condition (cervicalgia secondary to chronic headache) as not unfitting.  The VA rated the headache condition 10%, coded 8100 (migraine), based on the STR and C&P examination, citing characteristic prostrating attacks averaging one in two months over the last several months.  The VA also rated the neck (cervical strain) condition 20%, coded 5238 (spinal stenosis), based on the C&P examination, citing forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees.  

The panel considered the disparate examinations in evidence and the varied coding schema for the related headache and cervical conditions.  Coding under VASRD §4.73 (muscle injuries) and considering §4.55 and §4.56 would be no higher than the 10% adjudicated by the PEB.  Alternative rating under code 8100 (§4.124a - neurological conditions) would likewise rate no higher than 10%.  

There was significant overlap between the chronic headaches and the contended “cervicalgia secondary to chronic headache.”  The panel’s main charge is to assess the fairness of the PEB determination that the contended condition was not unfitting.  No neck condition or cervicalgia was profiled or implicated in the commander’s statement and cervicalgia was judged to be medically acceptable.  There were scant STR entries relating to neck pain and there was no performance-based evidence from the record that the condition 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 determination for the contended cervicalgia, so no additional disability rating is recommended.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded there was insufficient cause to recommend a change in the PEB adjudication for the headaches or the contended cervicalgia.  

Right Cubital Tunnel Syndrome (CTS).  According to the STR and MEB NARSUM, the right-hand dominant CI underwent ulnar nerve transposition surgery on 22 October 2007 (10 months prior to separation).  Surgical follow-up showed good results with normal healing, and electrodiagnostic studies in April 2007 showed some improvement.  However, there was no clinical improvement following occupational therapy or medication therapy with Neurontin (neuroactive medication).  

The MEB NARSUM examination, 3 months prior to separation (7 months after surgery), noted complaints of decreased strength and feeling in the right hand with the hand sometimes locking in position.  Physical examination showed motor weakness of the right intrinsic hand muscles (lumbricles).  There was no pronator drift.  Grip strength was 80 pounds on the right (versus 90 on the left).  No sensory deficit was recorded.  

During the MEB examination, 3 months prior to separation, the CI reported decreased strength and feeling in the right hand with the hand sometimes locking in position.  Physical examination showed decreased right handgrip strength (-4/5).  

At the C&P examination, 1 month before separation (9 months after surgery), the CI reported right greater than left CTS.  He also complained of pain in both elbows with repetitive lifting and movement and residual numbness and tingling of the small and ring fingers bilaterally.  The examiner found grip strength was of good quality and there was no evidence of sensory or motor impairment.  Bilateral elbow, wrist, and finger ROMs were full and symmetric.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right CTS 10%, coded 8516 (ulnar nerve, incomplete paralysis), citing mild incomplete paralysis.  The VA rated the bilateral CTS 10%, coded 8516, based on the C&P examination, citing mild incomplete paralysis of finger and wrist movements.  

The panel considered the disparate examinations in evidence.  The STR documented right grip weakness and hand symptoms approached the “moderate” incomplete paralysis criteria under code 8516; however, by the time of the C&P examination, which was prior to and closer to separation and further from surgery, there was normal strength and decreased symptoms that would rate no higher than “mild.”  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded there was insufficient cause to recommend a change in the PEB adjudication for the right CTS.  

Contended PEB Condition:  Left CTS.  The panel’s main charge is to assess the fairness of the PEB determination that the contended condition was not unfitting.  The left CTS was profiled, implicated in the commander’s statement and judged to fail retention standards.  There was electrodiagnostic evidence of left CTS (much less than the unfitting dominant right side).  Symptoms on the left were intermittent numbness of the fourth and fifth digit during the day, occurring every few days, lasting 30 minutes to 2 hours without weakness.  There was no performance-based evidence from the record that the condition 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 determination for the contended left CTS, so no additional disability rating is recommended.  

Contended PEB Conditions:  Knee Pain, Back Pain and Seborrheic Dermatitis.  The panel’s main charge is to assess the fairness of the PEB determination that the contended conditions were not unfitting.  Although the knee and back conditions were implicated in the commander’s statement, none of the conditions were profiled 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 panel concluded there was insufficient cause to recommend a change in the PEB fitness determination for any of the contended conditions, so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the headaches and IAW VASRD §4.73, the panel recommends no change in the PEB adjudication.  In the matter of the right cubital tunnel syndrome and IAW VASRD §4.124a, the panel recommends no change in the PEB adjudication.  In the matter of the contended left cubital tunnel syndrome, knee pain, back pain, cervicalgia and seborrheic dermatitis, 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.  Therefore, the panel recommends no modification or re-characterization of the CI’s disability and separation determination.