RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01851
BRANCH OF SERVICE:  Navy 	SEPARATION DATE:  20080615

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Consolidated Automated Support System Test Station Operator/Maintainer, medically separated for “chronic myofascial pain syndrome, right thoracic back,” with a disability rating of 10%.

CI CONTENTION:  “The injury is worse than the Navy doctors let on.  My range of movement and ability to move is severely impacted.  I’m in constant pain.”  The CI’s 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 based upon a 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 - 20080313	VARD - 20081007	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Myofascial Pain Syndrome, Right Thoracic Back	5099-5003	10%	Dysfunctional Thoracic Lumbar Condition, Low/Upper Back and Chronic Sacroiliitis	5237	NSC	20080212	
Bipolar Disorder NOS	-	EPTS	Post-Traumatic Stress Disorder with Bipolar Disorder	9432-9411	30%	20080206	
Cervicalgia	Cat II	Chronic Cervical Strain	5237	0%	20080212	
Right Shoulder Multidirectional Instability	Cat II	Status Post Right Shoulder Dislocation	5201-5024	0%	20080212	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Chronic Myofascial Pain Syndrome, Right Thoracic Back with Associated Cervicalgia, Degenerative Disc Disease in the Lumbar and Thoracic Regions, and Right Shoulder Multidirectional Instability.  According to an orthopedic evaluation dated December 2006, the CI initially dislocated the right shoulder during a deployment.  At the time of the orthopedic evaluation the CI reported right shoulder pain and feeling of instability.  She denied further dislocations.  The physical examination showed anterior instability, tenderness to palpation, and positive testing for a labral tear.  Radiographic evaluation in January 2007 demonstrated acromion pathology indicative of impingement and fluid indicative of a bursitis.  The CI was treated with physical therapy and activity modification.  In February 2007, the CI initially reported mid-back pain after physical therapy and mid-lower back pain after a fall.  At a physical therapy evaluation dated 23 February 2003 the CI reported decreased shoulder pain and increased cervical and thoracic back pain.  The physical examination showed shoulder tenderness to palpation, painful motion, weakness, subluxation, and laxity.  The cervical and thoracic spine examination demonstrated increased curvature of the cervical spinal contour, tenderness to palpation of the thoracic, cervical and neck musculature.  Diagnoses of somatic dysfunction of the thoracic region and joint instability shoulder region were rendered.  An orthopedic note dated July 2007 noted that the right shoulder was well rehabbed, but continued right thoracic back pain with lifting.  Despite treatment, the right shoulder, cervical and thoracic pain conditions could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for a Medical Evaluation Board (MEB).  The MEB forwarded myalgia and myositis and joint derangement shoulder region for PEB adjudication.  

At the VA Compensation and Pension (C&P) examination in February 2008, performed 4 months before separation, the CI reported right shoulder pain radiating down the arm and to the upper back.  She also reported cervical pain.  Physical examination showed right shoulder guarding without tenderness, subluxation or weakness.  The gait was normal and the cervical and thoracolumbar regions were without evidence pain radiating pain on motion, muscle, spasm, or tenderness.  There was no additional limitation of motion with repetition.  The MEB narrative summary (NARSUM) examination on 29 February 2008 (4 months prior to separation and 17 days after the VA examination) noted a diagnosis of chronic myofascial right upper back pain.  Physical examination showed multiple right thoracic paraspinal muscular tenderness to palpation with full lumbar spine motion.  The right shoulder examination demonstrated laxity with full, painless range of motion. 

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic myofascial pain syndrome of the right thoracic back at 10% coded 5099-5021 (analogous to myositis).  The PEB designated the cervicalgia, degenerative disc disease in the lumbar and thoracic regions and right shoulder multidirectional instability as Category II conditions (related to the unfitting condition).  The VA rated right shoulder at 0% coded (5201-5024) and the cervical spine conditions at 0%, coded 5237 (cervical strain).  The VA did not service connect the thoracic and lumbar spine conditions.  There was no evidence of thoracic limitation of motion, muscle spasms or guarding resulting in abnormal spinal contour or gait for a higher than 10% 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 myofascial pain syndrome of the right thoracic back condition.  

The Board also considered whether the right shoulder, degenerative disc disease in the lumbar, and cervicalgia Category II conditions rose to the level of being separately unfitting.  Board members agreed that the evidence did not support separately unfitting determination and that there was there was insufficient cause to recommend a change in the PEB Category II adjudication for the cervicalgia, degenerative disc disease in the lumbar and thoracic regions and right shoulder multidirectional instability conditions.  

Bipolar Disorder NOS.  According to service treatment records (STR) and the MEB NARSUM, the CI sought treatment for her mental health disorder May 2006 after nearly overdosing during a depressive episode.  At the time of initial evaluation there was a prior to service history of traumatic stress.  The CI was diagnosed with posttraumatic stress disorder and possible bipolar disorder.  Despite treatment with medication and psychotherapy, the CI’s bipolar disorder NOS condition did not improve sufficiently to meet the requirements of the CI’s military specialty and she was referred for an MEB.  At the VA Compensation and Pension (C&P) examination on 6 February 2008, performed 4 months before separation, the CI reported low or dysthymic mood a fair amount of the time; sporadic tearfulness "for no reason"; flashbacks to aspects of the 2001 sexual assault when triggered by pertinent sensory stimuli, hypervigilance; a sense of dissociation or "unreality" to her current situation; and passive suicidal ideation.  She reported a 12 year history of bipolar depression with intermittent depression and manic episodes.  She reported discontinuance of her psychotropic medication in spring 2007.  She denied psychiatric hospitalization and post-military traumatic events.  The examiner Physical examination showed disturbance of motivation and mood, constriction in range of affect, heightened anxiety, depressed mood, and low self-esteem. Speech was normal.  Thought processes were “appropriate.”  Cognition and memory, were intact.  The examiner noted passive thoughts of suicide and absent homicidal ideation.  Judgement and insight were noted as impaired as related to moderate alcohol use.  Diagnoses of bipolar disorder Type 1, PTSD, and alcohol abuse were rendered.  The MEB NARSUM examination on 7 February 2008 (4 months prior to separation) noted that the CI had a history of PTSD prior to Service.  The CI reported continued symptoms of decreased motivation, fluctuating appetite, worse insomnia, guilt, decreased energy, anhedonia, and occasional suicidal ideation. These symptoms were present all day long, every day for at least 2 weeks at a time.  She also reported 1-2 week episodes of decreased sleep, increased distractibility, rapid speech, slightly racing thoughts, and an increase in goal-directed activity. She estimated more than 4 mood episodes per year.  She denied any history of psychotic symptoms and current suicidal or homicidal ideation. The mental status examination showed that the CI was pleasant, cooperative with depressed and congruent mood and affect.  The CI denied suicidal ideation.  Speech was fluent, logical and goal directed.  Thought processes were normal.  Cognition, memory, judgment and insight were intact.  The examiner rendered diagnoses of bipolar disorder not otherwise specified and PTSD.  The examiner opined that the chief cause of her PTSD was her history of repeated sexual assault prior to service and that “Overall, she appears to do a very good job when she is not in a depressed mood, but her work clearly suffers when she is.”

The Board directed attention to its rating recommendation based on the above evidence.  The PEB determined that the bipolar disorder NOS condition existed prior to service and was not permanently service aggravated; therefore not rated.  The VA assigned a 30% rating for the condition diagnosed as PTSD with bipolar disorder, coded 9432-9411 (bipolar disorder-PTSD).  The Board considered the evidence presented in the service treatment records, the NARSUM, the C&P examination, and the non-medical asessment.  All Board members agreed that the evidence supported the PEB determination that the bipolar disorder NOS existed prior to service and was not permanently service aggravated.  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 bipolar disorder NOS condition.  

BOARD FINDINGS:  In the matter of the myofascial pain syndrome and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the bipolar disorder, the Board 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 20140429, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR DIRECTOR, SECRETARY OF THE NAVY COUNCIL OF REVIEW
               BOARDS 

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS
 
Ref:   (a) DoDI 6040.44
       (b) CORB ltr dtd 11 Aug 16

      In accordance with reference (a), I have reviewed the cases forwarded by reference (b), and, for the reasons provided in their forwarding memorandums, approve the recommendations of the PDBR that the following individual’s records not be corrected to reflect a change in either characterization of separation or in the disability rating previously assigned by the Department of the Navy’s Physical Evaluation Board:

		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN

						  	XXXXXXXXXXXXXXXXXXXX
	     				  		Assistant General Counsel
						  	(Manpower & Reserve Affairs)