RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW
NAME: XXXXXXXXXXXXXXXXX	CASE: PD-2020-00063
BRANCH OF SERVICE: NAVY	SEPARATION DATE: 20060317

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Information Systems Technician, medically separated for “post concussive syndrome” and “left hip pain,” rated 10% each, with a combined disability rating of 20%.

CI CONTENTION: “I was incorrectly rated for TBI and other injuries.”

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 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 - 20051117	VARD - 20060615	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Post-Concussion Syndrome	8045	10%	Post-Concussion Headaches	8045-8100	0%	20050906	
Cognitive Disorder, Not Otherwise Specified (NOS)	Cat II	Ongoing Cognitive Changes…	8045-9304	30%	20050909	
Left Hip Pain	“5299-5003”	10%	Osteoarthritis…Left Hip	5252-5010	10%	20050909	
Acetabular Chondromalacia	Cat II					
COMBINED RATING: 20%	COMBINED RATING OF ALL VA CONDITIONS: 50%	

ANALYSIS SUMMARY:

Post-Concussion Syndrome. According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI sustained a closed head injury in April 2002 as a passenger of a rollover motor vehicle accident (MVA). He experienced a loss of consciousness for an unknown duration, was amnesic for the event, and hospitalized for 10 days during which he reported persistent right frontal headaches. A brain CT scan on 30 April 2002 demonstrated a small right frontal contusion focus and an incidental finding of a pineal cyst. In May 2005, MRI results suggested a diffuse axonal injury in a subcortical distribution predominantly frontal in nature. An additional brain MRI on 21 November 2002 revealed the disappearance of the right frontal region contusion seen on the April CT scan, but the cyst remained undisturbed. There was no subsequent brain X-ray or MRI in evidence proximate to separation.

The 30 June 2005 MEB neurology addendum, 9 months prior to separation, noted CI complaints of right frontal area headaches which were aggravated by bright light. The headaches were mostly relieved by over-the-counter pain medication but occasionally required a narcotic analgesic. Physical examination showed a small, healed right temporal laceration scar but neurological findings were “entirely normal.” The examiner opined that the CI appeared “to be fit for full duty without any residual neurologic deficits with headaches that are not disabling and are under good control with his present medication program.”

At the 5 July 2005 MEB neuropsychological (NP) evaluation, 8 months before separation, the CI reported that although he returned to full duty after his hospitalization, he was later placed on limited duty because of hip pain and severe headaches. The headaches were constant and dull in nature with occasional shooting pains lasting 1-2 minutes. His pain level decreased to 2/10 after taking medication, and he no longer experienced dizziness, however, he had passed out 3 times for unknown reasons and was planning to follow up with a neurologist. The CI also reported memory and word finding problems as well difficulties with sleep and irritability. He was taking a stimulant medication for concentration, and also had a childhood history of stimulant treatment for attention-deficit hyperactivity disorder. The mental status examination (MSE) was unremarkable with the exception of word finding difficulties. Overall, the examiner concluded that the NP tests showed high verbal intelligence and that the CI’s reasoning and problem solving abilities were intact. However, there was likely a decrease from his premorbid functioning in areas of processing speed, concentration, word finding and generation, verbal memory and some aspects of sequencing. The examiner opined that the pattern of decreased functioning was consistent with the head injury and diffuse axonal impairment, and subsequently diagnosed cognitive disorder, NOS. During the MEB examination (recorded on DD Forms 2807- 1 and 2808), 2 days later, the CI reported car sickness, frequent severe headaches, memory loss, frequent trouble sleeping and depression; mental examination was deferred.

At the 6 September 2005 VA Compensation and Pension (C&P) neurological disorder examination, 6 months after separation, the CI complained of short-term memory problems and bouts of headaches. He generally was able to function during these headaches except for a couple of minutes twice a day. He also reported three syncopal attacks in the past but had a full workup which was normal. Neurological findings were unremarkable. During the VA C&P mental disorder examination, 3 days later, the CI reported memory problems but that his irritability and sleep issues were controllable with medication; he had no depression or anxiety symptoms. The examiner diagnosed “ongoing, cognitive changes secondary to closed head injury,” noting that although the CI had cognitive changes by history, he performed well during the MSE with no memory or concentration issues.

The panel directed attention to its rating recommendation based on the above evidence. The reconsideration PEB rated the post-concussion syndrome 10%, dual coded 9304-8045 (dementia due to head trauma-traumatic brain injury (TBI)). The VA rated the post-concussion headaches 0%, dual coded 8045-8100, (TBI-migraine headaches), based on the 6 September 2005 C&P examination, citing no evidence of characteristic prostrating (completely exhausted) attacks occurring over several months prior to the examination, nor significant functional impairment due to the headaches. The VA also rated “ongoing cognitive changes” 30%, dual coded 8045- 9304, based on the 9 September 2005 C&P examination, citing short-term memory problems, sleep impairment, and a Global Assessment of Functioning score of 55 (moderate symptoms).

The VARSD in effect at the time of separation captured brain injuries under the generic category of brain disease due to trauma (code 8045). There are two different scenarios for rating under this code: analogously with purely neurological deficits, or based on purely subjective symptoms. In the absence of associated neurological disabilities (seizures, nerve paralysis, etc.), rating under 8045 is limited to 10%, and cannot be combined with any other rating for a disability due to brain trauma. Therefore, a higher rating is not possible under this code. The panel also considered

whether a higher rating was possible under code 8100 for migraine headaches, with rating options relying on the frequency of “prostrating” attacks. While VASRD §4.124a does not define prostrating, the panel’s precedence has relied on the English dictionary definition of extreme exhaustion, or powerlessness reduced to extreme weakness. Panel members carefully considered the frequency and nature of the CI’s headaches, including objective and corroborating subjective evidence, and agreed they did not meet the definition of prostrating headaches; thus, a higher rating was not warranted under this code.

The panel then considered a rating under VASRD §4.130 (mental disorders) to include the Category II cognitive disorder, NOS. At the time of separation, the CI continued to complain of memory and sleep difficulties as well as irritability, but these problems were mitigated by the use of medication. While the NP evaluation documented some deficits, objective clinical evidence was minimal. Additionally, the commander’s statement did not mention a cognitive problem. While panel members agreed that a 10% rating was warranted for “occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication,” this provided no benefit to the CI. 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 post concussive syndrome.

Left Hip Pain. According to the STR and MEB NARSUM, the CI sustained a left hip injury during the April 2002 MVA and underwent surgeries on 1 March and 22 April 2004 which showed an anterior superolateral tear but essentially normal articular joint cartilage.

The 28 June 2005 MEB NARSUM, 9 months prior to separation, noted CI complaints of very limited walking distances using a cane, and left hip pain with prolonged sitting or standing. Physical examination showed a very antalgic gait, severely favoring the left hip.   Left hip range of motion (ROM) demonstrated flexion to 120 degrees (normal 125), external rotation to 50 degrees (normal 60), and abduction to 40 degrees (normal 45); painful motion was elicited.

At the 6 September 2005 VA C&P general examination, 6 months after separation, the CI reported left hip pain after prolonged sitting and standing, and the inability to walk more than two blocks with a cane or crutches. Physical examination revealed a significant limp, use of crutches, and mild left hip tenderness. Flexion was to 120 degrees with the knee flexed, and 80 degrees with the knee straight; external rotation was to 45 degrees and painful motion was noted in all planes.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the left hip condition 10%, analogously coded to code 5003 (arthritis, degenerative), and listed “acetabular chondromalacia” as a Category II condition which contributed to the left hip pain. Panel members agreed that this related diagnosis was not a separate condition which could be reasonably justified as separately unfitting; nor was a separate rating achievable without violation of VASRD §4.14 (avoidance of pyramiding). The VA rated the left hip condition 10%, analogously coded 5252-5010 (arthritis, due to trauma), based on the C&P general examination, citing painful motion. The panel agreed the CI’s post-operative left hip impairment supported a 10% rating IAW VASRD §4.59, 4.40 and 4.45 (painful motion and functional loss), however, there was no limitation of motion which supported a higher rating under the diagnostic codes for limitation of thigh flexion, extension, or thigh impairment (5251, 5252, and 5253); and no evidence of a pelvic fracture for an alternative fracture rating. 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 hip condition.

BOARD FINDINGS: In the matter of the post concussive syndrome and IAW VASRD §4.124a, the panel recommends no change in the PEB adjudication. In the matter of the left hip condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication. 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.

The following documentary evidence was considered:

DEPARTMENT OF THE NAVY
SECRETARY OF THE NAVY COUNCIL OF REVIEW BOARDS 720 KENNON STREET SE STE 309
WASHINGTON NAVY YARD, DC 20374-5023

IN REPLY REFER TO
6040
CORB:003 14 May 21

From: Director, Secretary of the Navy Council of Review Boards To:	XXXXXXXXXXXXXXX

Subj:	Physical Disability Board of Review Determination Ref:	(a) 6040.44(Series)
1.	The Physical Disability Board of Review (PBDR) reviewed your case in accordance with reference
(a) and forwarded their recommendation for action.

2.	On 23 April 2021 the Assistant Secretary of the Navy (Manpower and Reserve Affairs) accepted the PDBR’s recommendation of no change to your characterization of separation or disability rating assigned.

3.	The PDBR determination is final and not subject to appeal or review.