RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXXX	 CASE:  PD-2014-00464	
BRANCH OF SERVICE:  Army 	 SEPARATION DATE:  20060705		 

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an activated National Guard E-4 (Small Arms Repairer) medically separated for neck pain.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS) or satisfy physical fitness standards.  He was issued a permanent P3L3 profile and referred for a Medical Evaluation Board (MEB).  The “cervocogenic headaches, chronic”, was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other conditions were submitted by the MEB.  The Informal PEB adjudicated the neck pain as unfitting, rated 10%, with application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The CI made no appeals and was medically separated.  

CI CONTENTION:  He was given a higher rating for his condition by the VA.  His complete submission is at Exhibit A.

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 when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting.  Any conditions outside the Board’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.  Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the VASRD standards to the unfitting medical condition at the time of separation.  The Board 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, operating under a different set of laws.  The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation.

RATING COMPARISON:  
   
IPEB – Dated 20060614	VA* - (~1 Mo. Pre-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Neck Pain with Minor C6-7 (Right) Foraminal Osteophytic Narrowing…	5242	10%	Cervical Spine Sprain	5299-5237	10%	20060605	
			Cervicogenic Headaches Associated with Head Trauma	8045-9304	10%	20060605	
Other MEB/PEB Conditions x 0  (Not in Scope)	Other x 2	
RATING:  10%	RATING:  30%	
*Derived from VA Rating Decision (VARD) dated 20061023 (most proximate to date of separation [DOS]).   

ANALYSIS SUMMARY:  

Neck Condition.  The service treatment record (STR) documents that the CI sustained an injury during close quarter combat training.  He was picked up by his training partner and dropped on the left side of his head, neck, and shoulder.  A head CT was normal.  At an acute care encounter, the CI complained of ongoing left neck, shoulder, and upper arm pain since his neck strain and head trauma.  Symptoms were characterized as burning pain in the supraclavicular area at the neck border.  The CI was evaluated by a civilian neurologist and treated for presumed headaches secondary to trauma and a possible axillary nerve/C5 radiculopathy (injury or irritation of a nerve root).  A cervical spine X-ray showed straightening of the lower cervical curvature suggesting muscle spasm.  A cervical spine MRI showed possible minor narrowing around the C6-7 nerve root.  A left shoulder X-ray was unremarkable.  The CI transitioned to a military neurologist for headache syndrome and left shoulder strain.  The neurologist stated “I suspect shoulder pain and headaches are secondary to chronic myofascial pain, with several prominent trigger points [tender areas which refer pain to another part of the body].  We discussed options at this point, to include a trial with Botox injections.”  The headaches were treated with daily preventive therapy and the shoulder strain with trigger point injections of BOTOX (botulinum neurotoxin [neuromuscular blocker agent] used for muscle inactivation treating focal muscle spasticity).  Cervical spine range-of-motion (ROM) was measured by physical therapy (PT) for the MEB.  Repetitive (X3) active ROM values, measured with a goniometer, are listed in the chart below.  In the narrative summary (NARSUM) by a military neurologist, the CI complained of persistent left-sided upper shoulder pain.  The pain radiated to the neck and scapular regions and was described as a constant aching and burning sensation.  Symptoms were exacerbated by raising or rotating the left shoulder or turning the head.  There were no sensory changes or paresthesias (abnormal sensation, tingling, burning, and prickling).  The CI complained of associated near daily headaches, which could gradually worsen during the day, and lasted all day.  Headaches and were exacerbated by light, noise, and physical activity.  Severe episodes were associated with nausea and were relieved by lying down in a dark room for up to several hours.  The physical exam documented a normal posture and gait.  The neck was supple with tenderness in the left upper trapezius, scalene, and sternocleidomastoid muscles.  There was no muscle atrophy or weakness.  Tone, bulk, strength, sensation, and deep tendon reflexes (DTRs) were normal.  The neurologic exam was reported as normal, with no evidence of radiculopathy or neuropathy (injury or irritation of a peripheral nerve).  The neurologist documented the symptoms of the chronic, post-traumatic, left shoulder strain remained essentially unchanged despite multiple medication trials, BOTOX trigger point injections, and multiple PT modalities (stretching, heat, and ultrasound).  The chronic cervicogenic headaches (neck/cervical spine pain referred to the head) did not improve in frequency or intensity despite a preventive medication trial or BOTOX injections.  

The Compensation and Pension (C&P) exam recounted the history and interventions.  It documented neck symptoms as “… he has suffered from pain located at neck … The pain occurs constantly.  The pain travels to neck, shoulder, back.  The characteristic of the pain is crushing in nature, burning in nature, aching in nature, sharp in nature, sticking in nature and cramping in nature.  From 1 to 10 (10 being worst pain) the pain level is at 7.  The pain can be elicited by physical activity.  It is relieved by rest.  At the time of pain he can function without medication.”  It documented headache symptoms as “The claimant reports having reoccurring headaches which are migraines.  The attacks are very troublesome, occurring with photophobia [light sensitivity], phonophobia [sound sensitivity], nausea, throbbing, pressure sensation retro-orbitally, with pounding and sometimes with vertigo, thus far unable to be successfully treated with medication.”  The examiner cited medications previously taken, but reported current treatment for all conditions as “none.”  The physical exam documented a normal posture and gait and no use of an assistive device.  The spine exam revealed normal head position and normal spinal curvatures.  The neck was supple with normal, but guarded, motion.  There were no signs of intervertebral disc syndrome with chronic and permanent nerve root involvement.  Sensation, DTRs, and strength (5/5) were normal, except for 4/5 left shoulder strength.  The cervical ROM values are listed in the chart.  The PEB proceedings were discontinued because there was a diagnosis of shoulder pain, but there was no real evaluation of the shoulder.  The physician officer in charge of the MEB process concluded that the CI had myofascial type pain involving the trapezius muscle.  The trapezius myofascial pain extended from his neck to shoulder and was related to his neck pain and headache symptoms.  The physician opined that the CI did not have a shoulder joint problem and removed the diagnosis from the MEB proceedings (DA Form 3947).

The goniometric ROM evaluations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.

Cervical ROM
(Degrees)	PT for MEB ~2.5 Months Pre-Sep
(20060417)	VA C&P ~ 1 Mo. Pre-Sep
(20060605)	
Flex (45 Normal)	45 (60/60/60)	Normal	
Extension (45)	35 (35/35/35)	Normal	
R Lat Flexion (45)	30 (25/30/30)	Normal	
L Lat Flexion (45)	40 (35/35/40)	Normal	
R Rotation (80)	45 (40/40/45)	Normal	
L Rotation (80)	45 (40/40/45)	Normal	
Combined (340)	240	#	
§4.71a Rating	10%	0%	

The Board directed attention to its recommendations based on the above evidence.  The PEB rated the neck condition 10% (coded 5242).  The PEB cited foraminal narrowing without neurologic deficit, tenderness, and ROM limited by pain.  While the cervicogenic headache condition was implicated in the profiles, commander’s statement, and MEBs, it was not individually addressed as a distinct condition the PEB.  The physician officer in charge of the MEB deemed the cervicogenic headache symptoms, shoulder symptoms, and neck symptoms were components of a myofascial pain syndrome.  The PEB consolidated the separate anatomical components of the myofascial pain syndrome under a single neck condition.  It is clear that the PEB subsumed the myofascial type pain symptoms of the trapezius, shoulder, cervicogenic headaches, and neck in its rating under 5242.  The VA, citing the C&P exam a month before separation, rated the neck condition 20% with 10% as cervical spine sprain (coded 5299-5237) plus 10% as cervicogenic headaches (coded 8045-9304).  The VA cited painful neck motion and subjective headaches symptomatic of trauma.  The Board agreed a 10% rating was supported based on VASRD §4.40 (functional loss) or §4.59 (painful motion).  The ROM in the C&P exam was normal and did not attain the minimum 10% rating based upon the general rating formula for diseases and injuries of the spine.  The ROM in the PT for MEB exam was consistent with the 10% rating (flexion of greater than 30 degrees but not greater than 40 degrees; or a combined ROM of greater than 170 degrees but not greater than 335 degrees of the C-spine).  The higher 20% rating would require (flexion of greater than 15 degrees but not greater than 30 degrees; or a combined ROM of not greater than 170 degrees of the C-spine).  The Board considered the relative probative value of the proximate exams (NARSUM and C&P).  The NARSUM represented the synthesis of findings, from a continuum of care, by serial neurologists.  The C&P exam reflected the isolated observations and findings of a family medicine generalist.  The Board assigned greater probative value to the neurology findings because the symptom complex/diagnoses represent pathology specific to their core area of expertise, and the chronicity of care.  There are no §4.71a spine criteria in evidence which would support a rating higher than 10%, and no documentation of incapacitating episodes which would provide for a higher rating under that formula.  The Board carefully considered whether the associated cervicogenic headaches warranted additional disability rating, noting that the VA rated the headaches separately.  Recognizing that the headache symptoms probably represented referred myofascial pain, the Board concluded that the evidence did provide sufficient grounds for recommending a separate headache disability ratings in this case.  A rating of 10% for the cervicogenic headaches coded 8045-9304 is a good analogy to both the pathology and disability.  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 neck condition and 10% for the cervicogenic headache 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.  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 neck condition, by a vote of 2:1 the Board recommends a disability rating of 10%, coded 5242 IAW VASRD §4.71a.  In the matter of the cervicogenic headache condition, by a vote of 2:1 the Board recommends a disability rating of 10%, coded 8045-9304 IAW VASRD §4.71a.  The single voter for dissent did not elect to submit a minority opinion.  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:  

CONDITION	VASRD CODE	RATING	
Chronic Neck Pain with Minor C6-7 (Right) Foraminal Osteophytic Narrowing	5242	10%	
Cervicogenic Headaches	8045-9304	10%	
RATING	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140116, 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 XXXXXXXXXXXXXXXXXXXXXXXX, AR20160002064 (PD201400464)

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, accept the Board’s recommendation to modify the individual’s disability rating to 20% without re-characterization 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:

CF: 
(  ) DoD PDBR
(  ) DVA