RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	 CASE:  PD-2013-00095
BRANCH OF SERVICE:  Army 	 BOARD DATE:  20140729
SEPARATION DATE:  20030815

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SGT/E-5 (74B20/Information Systems Operator Analyst) medically separated for low back pain and myofascial pain syndrome.  The conditions could not be adequately rehabilitated to meet the requirements of his Military Occupational Specialty (MOS) or satisfy physical fitness standards.  He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The pain conditions, characterized as “mechanical low back pain secondary to sacroiliac joint dysfunction” and “chronic myofascial pain syndrome” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded four other conditions (see rating chart below) for PEB adjudication.  The Informal PEB (IPEB) adjudicated “left sacroiliac joint dysfunction” and “myofascial pain syndrome” as unfitting rated 10% and 0%, respectively.  The remaining conditions were determined to be not unfitting.  The CI appealed to the Formal PEB (FPEB) which adjudicated “mechanical low back pain secondary to sacroiliac joint dysfunction” and “myofascial pain syndrome” as unfitting and rated them at 10% and 0%, respectively citing criteria of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The remaining conditions were again determined to be not unfitting the CI made no appeals and was medically separated.

CI CONTENTION:  “There were conditions rated with a 0% that were more severe than they suggested for example my bilateral knee conditions that impaired me from running and marching, also my left shoulder injury that Impaired me from carrying heavy objects.  Also my back conditions was rated with just a 10% when the condition as they know is more severe than they way the rated it; in the morning I cannot just jump off bed, I have to give time until my back and knees can respond.  Which are exacerbated by my myofascial pain syndrome in my neck, shoulder, and gluteal muscles.  Also my headaches where made severe and chronic then the 0% got rated by the Med Board, and the other conditions.  There’s also a hearing condition due to 2 grenade simulators exploded near me on a field exercise and other condition army related granted by the VA.  My hearing problem is rated with a 30% (Tulios Syndrome, with hypersensitivity to high pitch and vertigo (inner ear disorder).”   

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 ratings for the unfitting low back and myofascial pain conditions are addressed below; additionally, the contended bilateral knee, headaches and neck pain conditions are also addressed.  The contended conditions of Tulio’s Syndrome, vertigo, hearing condition and left shoulder were listed by neither the MEB nor the PEB and therefore are not in the 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.

The Board acknowledges the CI’s contention for ratings of the various conditions noted above that were determined to be not unfitting by the PEB.  Disability compensation may only be offered for those conditions that cut short the member’s service career based on the severity at the time of separation.  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, operating under a different set of laws. 

RATING COMPARISON:  

Service FPEB – Dated 20030501	VA - (2 Mos. Pre-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Mechanical Low Back Pain Secondary to SIJ Dysfunction…	5294-5299-5295	10%	Lumbosacral Strain	5295	10%	20030610	
Myofascial Pain Syndrome of Trapezii, Levator Scapluae and Scalene Muscles	5099-5021	0%	Myofascial Pain Syndrome of Bilateral Gluteal, Trapezius Levator, Scapulae, and Scalene Muscles	5320-5021	10%		
Chronic Headaches	Not Unfitting	Muscular Tension Headaches	8100	0%		
Carpal Tunnel Syndrome…		CTS, Left Wrist	8515	0%		
		CTS, Right Wrist	8515	0%		
Bilateral Knee Pain		Bilateral Retropatellar Pain Syndrome	5260-5024	10%		
Mild Neck Pain		Chronic Neck Pain		NSC		
No Additional MEB/PEB Entries	Other x 9 		
Combined:  10%	Combined:  40%	
Derived from VA Rating Decision (VARD) dated 20030729.

ANALYSIS SUMMARY: 

Mechanical Low Back Pain Condition.  According to service treatment records, the CI experienced recurrent/chronic low back pain since basic training in February 2000 with complaint of radiation of pain into the leg.  A bone scan in March 2001 demonstrated increased activity in the left sacroiliac joint.  Magnetic resonance imaging (MRI) of the lumbar spine on 27 November 2001 demonstrated early facet joint degenerative changes without intervertebral disc herniation, protrusion, or nerve impingement.  Physical therapy (including osteopathic manipulation) and a left sacroiliac joint injection provided temporary relief.  Electrodiagnostic testing completed on 11 June 2002, was negative for evidence of radiculopathy.  During a physical medicine and rehabilitation clinic visit on 19 June 2002, after three separate field duty exercises (one week at a time), he noted that wearing his ruck had increased his low back symptoms.  The physiatrist identified gluteal trigger points which improved after dry needling.  At a follow up physical medicine and rehabilitation clinic appointment on 10 September 2002, the examiner noted that the low back pain symptoms persisted at the same level or worse.  On examination the examiner noted the following: gait was normal and back active range-of-motion (ROM) was normal; straight leg raise was negative for radicular signs.  MRI of the lumbar spine taken on 12 September 2002, showed a small central protrusion at L4-5 without evidence of nerve impingement.  A repeat bone scan of the spine taken on 28 September 2002 was normal.  During a clinic appointment on 20 January 2003, the examiner noted persistent back pain for 12–24 months and indicated referral for MEB.  A repeat MRI of the lower back dated 2 March 2003, showed mild arthrosis of the facets; with a small posterior sub annular defect at L5-S1, although the radiologist found no significant disc disease, central canal narrowing or spinal nerve root outlet narrowing.  The MEB physical therapy ROM examination dated on 6 March 2003, recorded trunk (thoracolumbar) flexion of 80 degrees (normal 90), extension 35 degrees (normal 30), right/left lateral bending 30 degrees (normal 30), right rotation 35 degrees and left rotation 40 degrees (normal 30).  The CI sought care in the emergency department on 8 March 2003, for exacerbation of back pain that morning while pounding with a hammer while bending over.  The MEB orthopedic surgery consultation on 12 March 2003 recorded the CI’s report of chronic low back pain for 2 years exacerbated by physical activity.  The CI reported tingling and warm sensations down the back of both legs and into the feet without weakness.  On examination of the back, there was pain reported at extremes of motion indicated as normal.  There was tenderness of the bony spinous processes but the paraspinous muscles were non-tender.  The CI reported pain with examination maneuvers not expected to cause pain.  Straight leg raises was negative for radicular signs and strength and reflexes were normal.  The orthopedic examiner cited the recent physical therapy ROM examination.  The surgeon diagnosed mechanical low back pain that met retention standards but would benefit from a permanent profile with a grade of two with an alternate aerobic event and 2.5 mile marching restriction.  The MEB NARSUM dated 14 April 2003 noted persistent low back pain preventing military duties (such as wear of a rucksack, prolonged marching, running and lifting no more than 20 pounds repetitively).  On examination, there was tenderness of paraspinal muscles.  Two sets of “lumbar” ROM were recorded, one consistent with prior examinations showing slight limitation of flexion (flexion 80 degrees, extension 35 degrees, side bending 30 degree, right rotation 35 degrees and left rotation 30 degrees) but also included a second set with limited motion (flexion 20 degrees).  Muscle strength, reflexes and sensation were intact and straight leg raises was negative for radicular signs.

At the VA Compensation and Pension (C&P) examination performed 10 June 2003, 2 months before separation, the history of chronic low back pain aggravated by activity was summarized.  On examination, the CI was described as lean and muscular with a normal gait and “unremarkable” spinal curvature without muscle spasms.  The lumbar spine ROM was forward flexion of 45 degrees, extension 20 degrees, lateral bending of 30 degrees to the right/left and rotation to both right/left of 30 degrees.  There was report of pain with all motion.  The C&P examiner diagnosed lumbosacral strain with moderate functional impairment.

The Board directs attention to its rating recommendation based on the above evidence.  The FPEB rated mechanical low back pain secondary to sacroiliac joint dysfunction, lumbar facet arthrosis, with local referred pain in the gluteals with no neurological impairment at 10% (coded 5294-5299-5295), sacral-iliac injury rated as lumbosacral strain.  The FPEB in finding mechanical low back pain with local referred pain in gluteals subsumed the myofascial pain of the bilateral gluteal from the MEB condition two into the mechanical low back pain condition.  The VA rating decision dated 29 July 2003 adjudicated a 10% rating for lumbosacral strain condition using code 5295 (lumbosacral strain), citing characteristic of painful or limited motion.  In accordance with DoDI 6040.44, the Board is required to recommend a rating IAW the VASRD in effect at the time of separation.  The Board notes that the 2002 Veteran Administration Schedule for Rating Disabilities (VASRD) standards for the spine, which were in effect at the time of separation, were changed to the current §4.71a rating standards in September 2003.  The Board must correlate the above clinical data with the 2002 rating schedule applicable diagnostic codes include: 5292 (limitation of lumbar spine motion); 5293 (intervertebral disc syndrome based on incapacitating episodes) and 5295 (Lumbosacral strain).  The Board noted the physical therapy MEB ROM examination reported “trunk” ROM which correlates with the combined thoracolumbar ROM used under the current VASRD.  The MEB NARSUM noted “lumbar” motion with results similar to the physical therapy examination.  The trunk motion limitation was slight in flexion and would support a conclusion that the lumbar limitation of motion was also slight supporting a 10% rating under the VASRD guidelines for limitation of lumbar motion in effect at the time of separation.  These ROMs examinations are also consistent with a previous examination several months before in September 2002 reporting normal back ROM.  The second MEB NARSUM set of ROM values are inconsistent with prior examinations.  The VA C&P examiner reported lumbar spine ROM with a flexion of 45 degrees.  The Board noted that at the time of the VA C&P examination, the VASRD provided separate rating codes for the dorsal spine (thoracic) and lumbar spine and considered that the C&P examination was compliant with the reporting of lumbar motion separately from thoracic motion.  A normal lumbar flexion is approximately 60 degrees indicating a slight limitation.  Otherwise, there was no intervening injury to explain the difference in ROM results from the MEB physical therapy examination.

The Board concluded that the preponderance of evidence of the service treatment records in the time leading into and through the disability evaluation process indicated a limitation of lumbar motion that was more nearly slight (10%) than moderate (20%) under the code for limitation of lumbar motion (5292).  Both the PEB and the VA rated 10% under the VASRD code for lumbosacral strain (5295) citing characteristic pain on motion.  There was no muscle spasm with extreme forward bending noted on examinations, or unilateral loss of lateral bending to support the next higher rating.  Examinations also did not support consideration of the 40% rating under this code for severe impairment.  Although the service treatment record reflected periodic care for acute exacerbations of low back pain there were no incapacitating episodes due to intervertebral disc syndrome.  There no such episodes requiring bed rest prescribed by a physician to support a minimum rating under 5293.  There was no evidence of peripheral nerve impairment for consideration of separate unfitting determination.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the mechanical low back pain condition.

Myofascial Pain Condition.  According to service treatment records and the MEB NARSUM, the CI developed pain in the upper back and neck muscles in June 2002 after field training.  At a physical medicine clinic evaluation dated on 19 June 2002, the CI described a pinched neck muscle after three field exercises with wearing a ruck.  The physiatrist identified a right levator scapulae muscle trigger point on examination.  An 18 December 2002 clinic appointment recorded treatment with transcutaneous electrical nerve stimulation improved the lower neck / upper back myofascial symptoms however the neck started hurting again after additional military training.  The MEB physical therapy ROM examination dated 6 March 2003, recorded cervical spine flexion of 50 degrees (normal 45), extension 30 degrees (normal 45), lateral bending 30 degrees to both sides (normal 45) and rotation to both sides of 70 degrees (normal 80).  The MEB orthopedic consult dated 25 March 2003, recorded report of lower neck pain in between the shoulders aggravated by extreme motion of the head and neck.  There were no complaints of associated upper extremity numbness or weakness.  On examination there was tenderness to palpation of the bony spinous processes but not the paraspinous musculature.  There was report of pain at extremes of neck motion.  The orthopedic surgeon cited the recent physical therapy ROM examination.  Upper extremity strength reflexes and sensation was intact and provocative maneuvers for nerve impingement were negative.  The orthopedic surgeon concluded with diagnosis of mild neck pain that met retention criteria.  The MEB NARSUM dated 14 April 2003, noted inability to lift more than thirty-five pounds (or 20 pounds repetitively), unable to wear a fully loaded rucksack, wear a helmet or body armor (but indicated due to back pain).  On examination, cervical spine active flexion was 50 degrees, side bending 30 degrees and rotation 70 degrees.  There were trigger points in the right trapezius, levator scapulae and posterior scalene muscles.  His final profile prepared on 17 April 2003 did not include his myofascial neck muscle condition as a limiting condition.

At the time of the VA C&P examination on 10, June 2003, 2 months before separation, the examiner noted the curvature of the spine was unremarkable and without muscle spasm.  There was “minor tenderness” over the cervical spine area.  Cervical spine ROM was flexion 45 degrees, extension 30 degrees, lateral bending 30 degrees both sides and rotation 75 degrees both sides.  There was discomfort in the scalenes and cervical musculature with neck movement.  He had normal trapezius muscular tone without point tenderness.

The Board directs attention to its rating recommendation based on the above evidence.  The FPEB rated the myofascial pain syndrome of the trapezii, levator scapulae and scalene muscles, 0% using code 5099-5021 (rated analogously to myositis).  The FPEB incorporated the pain radiating to the gluteal muscles into the rating for the lumbar strain (in accordance with §4.14, avoidance of pyramiding).  The VA rated the myofascial pain condition 10%, coded under 5320-5021 (spinal muscles, rated analogously as myositis) citing painful motion.  The service treatment records and examinations indicate the myofascial pain condition affected neck motion and function.  Cervical spine ROM examinations reflected slight limitation of motion supporting a 10% rating using the VASRD code 5290 for limitation of cervical spine motion (VASRD in effect at the time of separation, as previously noted).  Both the FPEB and the VA adjudicated a rating analogously using the code for myositis.  The Board agreed that a 10% rating was supported based on painful motion (§4.59).  The Board found no route to a higher rating.  The Board agreed the gluteal myofascial pain was appropriately rated with the lumbar back pain condition in accordance with §4.14 avoidance of pyramiding due to the overlapping symptoms.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the myofascial pain syndrome of the trapezii, levator scapulae and scalene muscles (5099-5021).

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the chronic headaches, bilateral knee pain and mild neck pain were not unfitting.  The Board’s threshold for countering PEB fitness determinations requires a preponderance of evidence.

Chronic headaches.  The service treatment record provided evidence of three headaches (one headache per year prior to separation).  The CI reported to the ear, nose and throat specialist that his headaches were becoming more frequent however there was no documentation within the service treatment record to support an increased need for physician intervention.  The headaches were not included in the profiles written, nor discussed, by the commander in his comments.  After due deliberation in consideration of the preponderance of the evidence, the Board concluded there was insufficient cause to recommend a change in the PEB fitness determination for the contended headache condition and therefore no additional disability is recommended.

Bilateral knee pain.  The CI reported knee issues that began during basic training in February 2000 and was diagnosed as retropatellar pain syndrome.  A MRI of both knees obtained on 27 November 2001 were normal (demonstrated no internal derangement such as torn meniscus, torn ligament or degenerative changes).  X-rays of both knees in February 2002 and repeated February 2003 were normal.  After a year of temporary profiles limiting activity to allow rehabilitation of his knees, the final profiles covering the last 11 months of service did not include his knees as an activity limiting condition.  Both orthopedics and physical medicine noted the CI appeared to have improved with conservative physical therapy and routine pain medications and further intervention was not indicated.   An alternate physical fitness test was authorized to include either the bicycle or walking.  The MEB orthopedic exam found full ROM, with complete stability and strength of both knees during the examination of 13 March 2003.  The commander’s comment did not identify knee pain as a mission limiting medical condition.  Despite the CI’s remarks of pain during portions of flexion of both knees, the VA C&P noted that examination of his knee on 10 June 2003 “was grossly unremarkable” the examiner of on to state that the knee examination revealed “no soft tissue swelling, no point tenderness, or joint effusion and there was no ligamentous instability appreciated.”  After due deliberation in consideration of the preponderance of the evidence, the Board concluded there was insufficient cause to recommend a change in the PEB fitness determination for the contended bilateral knee pain condition neither separately nor together and therefore no additional disability is recommended.

Mild neck pain.  Although the FPEB stated this mild neck pain condition as separately not unfit, the Board noted the neck pain was subsumed in the myofascial pain syndrome of the trapezii, levator scapulae and scalene muscles effectively and practically.  The VA considered the chronic mild neck pain condition and found it not to be a separate entity within the evidence of the service treatment record and thereby determined that it was not service connected.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the mild neck pain condition.

BOARD FINDINGS:  IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication.  In the matter of the mechanical low back pain secondary to sacroiliac joint dysfunction, lumbar facet arthrosis, with local referred pain in the gluteals with no neurological impairment condition and IAW VASRD §4.71, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the myofascial pain syndrome of the trapezii, levator scapulae and scalene muscles condition, the Board unanimously recommends a disability rating of 10%, coded 5099-5021 IAW VASRD §4.71a.  In the matter of the contended chronic headaches, bilateral knee pain and mild neck pain conditions, the Board unanimously recommends no change from the PEB determinations as not unfitting.  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 his prior medical separation:  

UNFITTING CONDITION	VASRD CODE	RATING	
Mechanical Low Back Pain Secondary to Sacroiliac Joint Dysfunction, Lumbar Facet Arthrosis, with Local Referred Pain In the Gluteals with No Neurological Impairment	5299-5295	10%	
Myofascial Pain Syndrome of the Trapezii, Levator Scapulae and Scalene Muscles	5099-5021	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20130214, 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 XXXXXXXXXXXXXXX, AR20140020825 (PD201300095)

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% withhout 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