[AR Number], XXXXXXXXXX

XXXXXXXXXX
XXXXXXXXXX
XXXXXXXXXX

Dear XXXXXXXXXX:

I accept the recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) to re-characterize your separation as a disability retirement with the combined disability rating of 40% effective the date of your medical separation for disability with severance pay.  Enclosed is a copy of the Board’s recommendation and record of proceedings for your information.

	The re-characterization of your separation as a disability retirement will result in an adjustment to your pay providing retirement pay from the date of your original medical separation minus the amount of severance pay you were previously paid at separation.
 
	The accepted DoD PDBR recommendation has been forwarded to the Army Physical Disability Agency for required correction of records and then to the U.S. Defense Finance and Accounting Service to make the necessary adjustment to your pay and allowances.  These agencies will provide you with official notification by mail as soon as the directed corrections have been made and will provide information on your retirement benefits.  Due to the large number of cases in process, please be advised that it may be several months before you receive notification that the corrections are completed and pay adjusted.  Inquiry concerning your correction of records should be addressed to the U.S. Army Physical Disability Agency, (AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557.

	A copy of this decision has also been provided to the Department of Veterans Affairs.

		

			      
Enclosure

RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXX	CASE:  PD-2017-04825
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20061231

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Patient Administrative Specialist, medically separated for “left wrist pain” and “migraine/analgesic rebound headaches,” rated 10% and 0%, respectively, with a combined disability rating of 10%.

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 - 20060912	VARD - 20070529	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Wrist Pain	5099-5003	10%	S/P Left Wrist Surgery for Torn Ligament	5215	10%	20070417	
Migraine/Analgesic Rebound Headaches	8100	0%	Migraines	8100	50%	20070417	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  80%	

ANALYSIS SUMMARY:  

Left Wrist Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI underwent left wrist surgery in June 2001 for exploration of the left extensor carpi ulnaris tendon sheath and debridement of the left distal radial ulnar joint (DRUJ).  During deployment, she had increasing left wrist pain related to lifting activities and repetitive motion of the wrist.  Post-deployment, she had decreased range of motion (ROM) of the left wrist.  At an occupational therapy visit on 7 February 2006 the CI had tenderness of the left forearm to the distal forearm near the DRUJ, reduced pinch strength and decreased grip strength.  At an orthopedic clinic visit the same day, the CI had no swelling or tenderness and was able to actively extend and ulnarly deviate at the left wrist.  There was no appreciable instability.  The examiner’s assessment was wrist sprain with minimal symptoms.  

At an occupational therapy visit on 6 March 2006, the CI reported left wrist pain worsening, with lifting.  Wrist extension was 55 degrees (normal 70) and flexion was 55 degrees (normal 80), each with tenderness of the forearm to the left distal forearm.  Pinch strength and grip strength were reduced on the left, although grip strength was improved from 1 pound to approximately 20 pounds.  

The 10 May 2006 MEB NARSUM examination, 8 months prior to separation, noted complaints of left wrist pain.  Physical examination showed a well-healed scar over the dorsal ulnar aspect of the left wrist.  There was no edema, erythema or ecchymosis (black and blue discoloration), but there was diffuse tenderness over the dorsal ulnar aspect of the wrist with no crepitation (grinding sensation).  Provocative testing to detect instability or carpal tunnel syndrome were negative.  Active ROM of the left wrist was 20 degrees of extension, 25 degrees of flexion, 15 degrees of ulnar deviation (normal 45), 10 degrees of radial deviation (normal 20) and 90 degrees of pronation and supination.  Sensation was intact to light touch distally over the radial, ulnar and median nerve distributions.

At the 17 April 2007 VA Compensation and Pension (C&P) examination, 3 months after separation, the CI reported pain at the left wrist.  Physical examination showed tenderness of the left wrist.  The ROM examination showed dorsiflexion (extension) of 50 degrees, palmar flexion of 50 degrees, radial deviation of 10 degrees and ulnar deviation of 30 degrees with pain at the end of all planes of motion.  Joint function was not additionally limited after repetitive use.  X-rays of the left wrist revealed normal mineralization, no fractures or osseous abnormalities and well-maintained joint spaces.

During the 19 December 2007 C&P examination, 12 months after separation, the CI reported pain when it was cold and when lifting heavy objects.  Physical examination showed tenderness of the left wrist without edema, effusion, weakness, redness, heat, guarding of movement or subluxation.  Dorsiflexion was 40 degrees, palmar flexion 30 degrees), radial deviation 10 degrees and ulnar deviation 15 degrees with pain at the end of all planes of motion.  Joint function was not additionally limited after repetitive use.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left wrist condition 10%, analogously coded 5099-5003 (arthritis, degenerative), citing slight and frequent pain IAW the U.S. Army Physical Disability Agency pain policy.  The VA also rated the left wrist condition 10%, coded 5215 (wrist, limitation of motion), based on the April 2007 C&P examination, citing functional loss due to painful motion.

There was no limitation of motion which supported a rating under the diagnostic code for limitation of motion of the wrist (5215) or impairment of supination and pronation (5213).  However, there was evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45) as adjudicated by the PEB.  Additionally, there was no wrist ankylosis (5214) to support a higher rating.  There was therefore no VASRD §4.71a rating higher than the 10% adjudicated by the PEB under any applicable code.  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 left wrist condition.  

Migraine/Analgesic Rebound Headaches.  According to the STR and MEB NARSUM, the CI’s headaches began in 1999, but she was still able to function.  However, after she returned from deployment in December 2005, she reported headaches three to four times a week triggered by running.  Her medication was changed from Maxalt (rizatriptan, a headache abortive medication) to topiramate (anticonvulsant and nerve pain) and nortriptyline (antidepressant and nerve pain) was continued.  On 1 February 2006, the topiramate was reported to have been discontinued and divalproex (anticonvulsant to treat migraines) was prescribed.  During the 14 February 2006 MEB examination (recorded on DD Forms 2807-1 and 2808), 11 months prior to separation, the CI reported migraines during formations (under the sun), workouts and stress at work.  Physical examination was normal.  The commander’s statement dated 2 June 2006, 6 months prior to separation, indicated, “due to the migraines, she has been placed on quarters on a few occasions which caused some scheduling issues.”  At a neurology visit on 9 June 2006, the CI reported the headaches were worse.  She was treated with a prednisone burst and venlafaxine (an antidepressant) was prescribed.  On 12 June 2006, the CI reported stopping the divalproex because she was doing better with the recently prescribed medications.  On 22 June, she reported daily headaches for 2 weeks.  On 6 July, she reported having almost daily headaches for the prior two months, which the neurologist felt was caused by analgesic rebound from overuse of the triptans (Maxalt).  Prednisone was again prescribed.  On 27 July, the CI related the headaches were somewhat better, especially if she stayed inside and avoided heat and sun.  She underwent Botox injections to muscles of the face and neck.  

The 2 August 2006 MEB NARSUM, 4 months prior to separation, provided additional information regarding the migraines, noting complaints of migraine headaches triggered by exercise and exposure to sun and heat, daily frequency and clinical presentation for quarters one to two times per month.  Record review showed ER visits in December 2005 and June 2006 without other clinic visits on record for acute treatment of the headaches.  No physical examination was performed, but neurology determined the CI failed retention standards due to the migraine headaches.  

At the 17 April 2007 C&P examination the CI reported recurrent headaches when stressed or in the sun.  The headaches occurred five times per week and lasted for 4 hours; she was unable to do anything during an attack.  Physical examination showed unremarkable neurologic and mental health evaluations.  At the 19 December 2007 C&P examination the CI reported headaches described as throbbing, persistent and severely painful.  When headaches came on, she had to stay in bed and was unable to do anything.  Neurologic evaluation was within normal limits.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the migraines 0%, coded 8100 (migraine), citing analgesic rebound headaches occurring frequently with noncompliance with therapeutic plan.  The VA rated the migraines 50%, coded 8100, based on the April 2007 C&P examination, citing very frequent, completely prostrating and prolonged attacks productive of severe economic inadaptability. 

Review of the record supported a conclusion that, during the several months prior to separation, the CI experienced prostrating headaches occurring on average once per month.  The NARSUM indicated the CI reported daily frequency and clinical presentation for quarters one to two times per month and received injections in October and November 2006 for severe headaches.  A rating of 30% is therefore justified.  A 50% rating is not appropriate since the STR did not provide evidence of “very frequent, completely prostrating and prolonged attacks productive of severe economic inadaptability.”  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 30% for the migraines, coded 8100.  

BOARD FINDINGS:  In the matter of the left wrist condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the migraines, the panel recommends a disability rating of 30%, coded 8100 IAW VASRD §4.124a.  There are no other conditions within the panel’s scope of review for consideration.  

The panel recommends the CI’s prior determination be modified as follows; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective the date of medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Left Wrist Pain	5099-5003	10%	
Migraine Headaches	8100	30%	
COMBINED	40%	

The following documentary evidence was considered: