RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXX	CASE:  PD-2013-00086
BRANCH OF SERVICE:  Army	BOARD DATE:  20141010
SEPARATION DATE:  20030410

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SGT/E-5 (54B/Chemical Operations Specialist) medically separated for myofascial pain syndrome.  The myofascial pain syndrome could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty or satisfy physical fitness standards.  She was issued a permanent U3 profile and referred for a Medical Evaluation Board (MEB).  The cervical and thoracic condition, characterized as “myofascial pain syndrome of paracervical and peri-thoracic musculature,” was the only condition forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The Informal PEB adjudicated “myofascial pain syndrome of the paracervical and peri-thoracic areas w/o any specific history of trauma/injury” as unfitting, rated 0%, with application of the VA Schedule for Rating Disabilities (VASRD).  The CI initially non-concurred and requested a Formal PEB but withdrew her request and was separated.

CI CONTENTION:  The CI writes: “All DoD medical discharge diagnosises (sic) should have been rated over 0% since they were the reason to discharge and happened during military service and also acknowledged and rated by VA.  VA only rates and awards a percentage when it is proven to be service related, which it was.”

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e.(2).  It is limited to those conditions determined by the PEB to be unfitting for continued military service and those conditions identified but not determined to be unfitting by the PEB when specifically requested by the CI.  The rating for the unfitting myofascial pain syndrome condition is addressed below; no additional conditions are within the DoDI 6040.44 defined purview of the Board.  Any conditions or contention not requested in this application, or otherwise outside the Board’s defined scope of review, remain eligible for future consideration by the Board for Correction of Military Records.

RATING COMPARISON:

Service IPEB – Dated 20021104	VA – 11 Mos Post-Separation	
Condition	Code	Rating	Condition	Code	Rating	Exam	

Myofascial Pain Syndrome
	5099-5021	0%	C4-5 Myofascial Pain Syndrome	5237	10%	20040326	
			Thoracic Nerve Damage, Plexus Disease, w/R Upper Neuropathy	8211-8513	20%	20040326	
Other x 0 (Not in Scope)	Other x 4	20040326	
Combined:  0%	Combined:  30%	
Derived from VA Rating Decision (VARD) dated 20040805 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:  The Board acknowledges the CI’s information regarding the significant impairment with which her service-connected condition continues to burden her; but, must emphasize that the Disability Evaluation System has neither the role nor the authority to compensate members for anticipated future severity or potential complications of conditions resulting in medical separation.  That role and authority is granted by Congress to the Department of Veterans Affairs (DVA), operating under a different set of laws.  The Board considers DVA evidence proximate to separation in arriving at its recommendations; and, DoDI 6040.44 defines a 12-month interval for special consideration to post-separation evidence.  Post-separation evidence is probative to the Board’s recommendations only to the extent that it reasonably reflects the disability at the time of separation.

Myofascial Pain Syndrome.  The right handed applicant had a 2-year history of slowly progressive neck and upper back pain.  The first entry in the service treatment record is from a physical therapy consultation on 21 June 2001, referred from primary care for right upper back pain with scapular winging and a positive right Spurling’s maneuver (for cervical radiculopathy) and suspicion of long thoracic nerve injury and possible cervical radiculopathy.  The physical therapy consult documented upper back pain of the right scapula and slight discomfort of the right side of neck.  The CI denied any injury and pain was intermittent for 8 months.  Pain felt like it radiated to mid-back occasionally.  Physical examination revealed normal cervical spine range-of-motion (ROM) and normal bilateral upper extremity ROM.  There was palpable muscle spasm at the right scapula and limited right scapular strength on right of 4-/5.  She was seen by orthopedics on 17 October 2001 for continuing pain and tingling sensation of right upper back sometimes involving the right side of neck.  The orthopedic consult documented pain was worse with heavy lifting without weakness.  X-ray of the cervical spine found inverted lordosis suggestive of muscular spasm, thoracic spine and shoulder X-rays were normal.  The CI was evaluated by neurology for an electromyogram (EMG) study performed on 5 December 2001, performed for hand paresthesias bilaterally and neck pain radiating to the right scapula.  Physical examination during that EMG examination found symmetric reflexes, decreased sensation of second and third right fingers and slightly reduced strength of the right triceps.  The EMG found neurogenic defects of the muscles innervated by C6-7 of the right upper extremity and a magnetic resonance imaging (MRI) study was recommended.  MRI studies of the cervical spine, right scapula, and thoracic spine were normal.  Physician assistant note on 31 July 2002, described full neck and back ROM.

The narrative summary (NARSUM) performed on 21 August 2002, 8 months prior to separation, notes slowly progressing right sided cervical and thoracic back pain.  Pain was described as constant, dull and throbbing.  There were frequent exacerbations reported that intensified the pain to sharp, stabbing and knife-like pain, associated with paresthesias of the right frontal forearm, hand, and severe along the tips of all fingers in the right hand.  She also reported frequent dropping of objects during fine motor activities.  Pain was increased with prolonged standing, lifting, wearing load bearing equipment, flack-vest and the use of Kevlar helmet.  Frequent changes in position partially relieved her symptoms.  The NARSUM documented the CI had tried nonsteroidal anti-inflammatories (Motrin, Naprosyn, Piroxicam), the pain reliever Tylenol and the anti-depressant Elavil, and physical therapy without significant relief of symptoms.  The physical examination found tenderness of the right sided occipital-cervical junction extending along the right cervical and thoracic paraspinal muscles.  There was blunting of sensation to both pinprick and light touch along the entire right hand in a non-dermatomal pattern.  Palpation of the right trapezius muscle reproduced some of the paresthesias of the upper extremity.  There was symmetry of the upper extremities muscle mass, normal strength, negative Spurling’s test, and normal reflexes.  Bubble goniometer ROM was 50 degrees of forward flexion, extension of 60 degrees, right and left lateral flexion of 55 degrees.

At the VA Compensation and Pension exam performed on 26 March 2004, 11 months after separation, the CI reported worsening pain upon lifting arm and unable to hold a pen well to write.  Arm circumference 12 cm above epicondyle was 27 cm on right and 28 on left.  Grip strength was 220 on left and 150 on right.  There was visible winging of the right scapula.  The exam documented avoidance of using right upper extremity, aiding it with left arm when attempting extension or abduction.  There was full ROM with scapular pain upon extremity movement and tender right scapular adductors.  Strength of the left extremity was 5/5 and right was 5-/5 wrist flexion/extension, 4+/5 elbow and shoulder, and 5/5 finger abduction.  The final diagnosis was right upper extremity neuropathy with moderate to severe pain and poor function.  ROM of upper extremities was normal.

The Board directs attention to its rating recommendation based on the above evidence.  The Board considered VASRD diagnostic codes 5099 (rated analogously to) 5021 (myositis) which is rated by ROM of the affected limbs analogously to code 5003 (arthritis) used by the PEB for a zero percent rating.  The Board found no compensable ROMs or radiological abnormalities.  However, the Board did find consistent historical evidence of painful use of the right (dominant) extremity for a 10% rating in consideration of functional loss lAW VASRD §4.10 (functional impairment), §4.40 (functional loss) and §4.59 (painful motion).  The Board considered VASRD diagnostic code 5237 (lumbosacral or cervical strain) used by the VA for a 10% rating for the myofascial pain syndrome condition.  The Board did not find compensable limitations of motion and again in consideration of §4.10, §4.40 and §4.59 found a rating of 10% appropriate by clinical history.  There were no periods of incapacitation for a higher rating.  The Board then considered codes 8211 (eleventh, spinal accessory, external branch, cranial nerve) - 8513 (paralysis of all radicular groups) used by the VA for an additional 20% rating.  The Board found that the abnormal EMG findings of the muscles innervated by C6-7 of the right upper extremity, right upper extremity weakness, scapular winging, numbness, pain upon use, tenderness and poor coordination, was ratable at 20% for slight impairment using this code.  The history and physical findings did not approach a moderate level.  The Board found the neck and upper back pain, tenderness, paresthesias, abnormal EMG findings, and weakness were more compatible with a §4.124a rating for neurological conditions as an alternate code 8513 (paralysis of all radicular groups) and achieved a higher rating.  Discussions then turned to use as an additional code as done by the VA.  The Board found that muscular pain and tenderness are commonly caused by both the neurological condition as well as the musculoskeletal condition and did not overcome the VASRD §4.14 (avoidance of pyramiding) which states that the evaluation of the same disability under various diagnoses is to be avoided.  The muscular pain and tenderness commonly caused by a cervical radiculopathy were subsumed under the 8513 rating.  The Board considered if codes 8519 (paralysis of long thoracic nerve) and 8211 (paralysis of eleventh, spinal accessory, external branch, cranial nerve) could be separately rated.  In view of the EMG evidence of cervical root involvement, the Board determined the peripheral nerve deficits innervated by the cervical roots were also subsumed under code 8513.  There Board did not find a rating advantage for use as alternate codes.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 20% for the cervical radiculopathy condition.

BOARD FINDINGS:  The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised.  In the matter of the cervical radiculopathy condition, the Board unanimously recommends a disability rating of 20%, coded 8513 IAW VASRD §4.124a.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of her prior medical separation:

UNFITTING CONDITION	VASRD CODE	RATING	
Cervical Radiculopathy Condition	8513	20%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20130201, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

SAMR-RB									

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 XXXXXXXXXXXXXXXXX, AR20150003722 (PD201300086)

1.  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 to modify the individual’s disability rating to 20% without recharacterization of the individual’s separation.  This decision is final.  

2.  I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum.   

3.  I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures.

 BY ORDER OF THE SECRETARY OF THE ARMY:

Encl						     

CF: 
(  ) DoD PDBR
(  ) DVA