RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	     CASE:  PD-2014-01665
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20091027

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E5, Forward Signal Support NCO, medically separated for “chronic low back pain with myofascial pain syndrome,” with a disability rating of 20%.  

CI CONTENTION:  He makes no specific contention in his application.  His complete submission is at Exhibit A.

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44.  It is limited 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 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 Veterans Affairs Schedule for Rating Disabilities (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:  

SERVICE PEB - 20090706	VA - 20100408	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain (LBP) with Myofascial Syndrome	5299-5243	20%	Degenerative Disc Disease Lumbar Spine	5243	10%	20100310	
			Myofascial Pain of Right Scapula	5099-5021	0%	20100310	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:   

Chronic LBP with Myofascial Syndrome. The service treatment record and the Medical Evaluation Board (MEB) narrative summary (NARSUM) dated 18 December 2008 indicated upper back pain began in 1998 when the CI lifted sections of an armored vehicle.  That pain, which was determined to be muscle strain, was treated with heat and nonsteroidal anti-inflammatory drugs (NSAIDs), but despite treatment, the CI had difficulty lifting for one month thereafter.  The CI returned to service in 2003 and upper back pain developed in March 2003 near the medial border of the scapula (shoulder blade).  Treatment consisted of Indocin (indomethacin, an NSAID).  X-rays of the thoracic spine were normal in March 2004.  Pain persisted and involved the lower back secondary to compensation for the upper back pain.  Treatment consisted of Motrin (ibuprofen, an NSAID).  Evaluation by a physical medicine and rehabilitation (PM&R) specialist noted taut bands in the right rhomboid muscle(s) areas, which connect the scapula to the spinal vertebrae, with some radiation to the left when palpated.  Myofascial pain (sensitive points on a muscle and its covering tissue—“trigger points”) of the right rhomboid area was suspected.  Mobic (meloxicam, an NSAID) was started for the pain and trazodone (an antidepressant for sleep) was prescribed along with a referral for chiropractic manipulation.  The CI discontinued the medication when he felt better, but still complained of LBP.  Regular chiropractic treatments began in June 2004.  An MRI [magnetic resonance imaging] dated 30 July 2007 revealed a disc herniation at L4-5 resulting in at least moderate compression of the spinal canal along with a disc protrusion centrally at L5-S1 that caused a mild compression of the spinal cord.  Additionally, there was disc degeneration at L4-5 and L5-S1 levels.  Chiropractic treatments continued through June 2008 when physical therapy treatment commenced.  Thereafter, both physical therapy and chiropractic treatments were carried out.  Vicodin (hydrocodone, a narcotic and APAP (acetaminophen, a pain reliever)) was prescribed in September 2008.  An MRI of the thoracic spine was normal in November 2008.  Pain increased as duty requirements changed and the CI was prescribed morphine (a narcotic) in December 2008.  The NARSUM indicated that the CI’s back pain increased when he was deployed because he constantly wore body armor and a Kevlar helmet and was unable to get regular chiropractic care.  Once he returned to his home base and resumed chiropractic treatments he improved.  However, after again being unable to obtain chiropractic care due to training requirements, pain increased and he had difficulty wearing body armor and climbing in and out of vehicles to perform his job.  Walking then became painful.  He denied radicular symptoms or bowel and bladder dysfunction.  A pain management evaluation in April 2009 revealed a normal gait and station with a full range of motion (ROM) of the thoracic spine with T8-9 spinous process tenderness to palpation and a lumbar flexion of approximately 60 degrees.  The upper and lower extremities were normal. Medications including Mobic, Elavil (amitriptyline, for nerve pain), narcotics (OxyContin (oxycodone) and Percocet (oxycodone and acetaminophen), and Flexeril (cyclobenzaprine, a muscle relaxer) were continued.  Despite many treatment interventions pain flared from 3-4/10 (10 being the worst pain) to 8-9/10 during activities including walking, running, wearing body armor and Kevlar, heavy lifting, pushups or sit-ups. 

At the MEB examination, the CI reported on DD Form 2807 dated 21 November 2008, chronic upper and lower back pain and myofascial pain in the upper back as well as disc degeneration and disc herniation in the lower back.  On the DD Form 2808 dated 17 December 2008, the MEB physical examiner noted tenderness from L4-S1 in the midline and tenderness over the rhomboids and thoracic paraspinal muscles.  There was no atrophy or spasm and straight leg raising (to determine nerve root irritation) was negative.  Thoracolumbar ROM measurements performed showed, after repetition, flexion of 55 degrees (normal 90) and combined ROM of 140 degrees (normal 240).  A permanent L3 profile was issued on 9 February 2009 for chronic LBP with limitations of all physical fitness testing and all military functional activities except wearing a protective mask and all chemical protective equipment.  Additional restrictions included no flutter kicks, no running, no ruck marching, or no jumping.  Partial sit-ups were permitted as tolerated and gym physical training was recommended for aerobic and abdominal workouts.  The commander’s statement dated 17 February 2009 indicated the CI was not performing the duties of his military occupational specialty because he was suffering from chronic back pain and profile limitations, and he could not deploy with his unit due to his medical limitations. 

At the VA Compensation and Pension (C&P) examination dated 10 March 2010, performed 5 months after separation, the CI reported the LBP condition started in 2008 and was associated with stiffness.  Treatment consisted of Flexeril and morphine.  On examination the CI had a normal gait and posture.  ROM measurements of the thoracolumbar spine were forward flexion 70 degrees, extension 25 degrees, left lateral flexion 30 degrees, right lateral flexion 30 degrees, left lateral rotation 25 degrees and right lateral rotation 25 degrees with painful motion and a loss of 5 degrees of left lateral flexion on repetition.  There was no muscle spasm, ankylosis, abnormal spine curvature, or bowel, bladder or erectile dysfunction, or incapacitating episodes in the prior 12 months.  Lower extremity motor and sensory functions were normal.  X-rays of the lumbar spine showed mild degenerative changes at L5-S1.  Additionally, the CI had a myofascial pain condition that began in 2003 in the right scapular area that had no functional limitations.   

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 20% rating using code 5299-5243 (Intervertebral disc syndrome) for chronic LBP with myofascial pain syndrome.  The VA assigned a 10% rating using code 5243 for degenerative disc disease of the lumbar spine and a 0% rating using code 5099-5021 (myositis) for myofascial pain of the right scapula claimed as upper back pain.  The Board first discussed the PEB diagnosis of chronic LBP and myofascial pain syndrome.  While on first glance it appears that the two conditions are coupled and should be uncoupled for rating purposes, in essence IAW VASRD §4.71a, the General Formula for Rating Diseases and Injuries of the Spine, rating of the spine in this case is based upon thoracolumbar measurements.  Therefore, the myofascial pain syndrome involving the rhomboid muscles falls predominantly within the thoracic spine domain and does not warrant a separate rating, but is included in a rating based on the thoracolumbar spine ROM.  The Board sought a route to a higher rating, but was unable to find one in the absence of ankylosis, forward flexion of the thoracolumbar spine 30 degrees or less, or episodes of incapacitation having a duration of at least 4 weeks but less than 6 weeks during the past 12 months.  The Board then considered whether an additional rating could be recommended under a peripheral nerve code.    Although the pain component of the neuropathy is appropriately subsumed in the spine rating IAW VASRD §4.71, which states that “rating is performed with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease,” there was no sensory component with any significant functional implications and no motor weakness was in evidence.  Therefore, a radiculopathy could not be recommended for additional disability rating.  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 chronic LBP with myofascial syndrome condition.

BOARD FINDINGS:  In the matter of the chronic LBP with myofascial syndrome condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  There were no other conditions within the Board’s scope of review for consideration.  The Board, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination.

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140414, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB

28 JUL 2016

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 XXXXXXXXXXXXXXXXXXXX, AR20160007463 (PD201401665)

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 and hereby deny the individual's application.
This decision is final. The individual concerned, counsel (if any), and any Members of
Congress who have shown interest in this application have been notified of this decision
by mail.

BY ORDER OF THE SECRETARY OF THE ARMY:

Enclosure

CF:
( ) DoD PDBR
( ) DVA