RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02084
BRANCH OF SERVICE:  Navy 	SEPARATION DATE:  20090819

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Boatswains Mate, medically separated for “myofascial pain syndrome” and “lumbar lordosis,” rated 10% and 10% respectively, for a combined disability rating of 20%.

CI CONTENTION:   The CI made no specific contention.  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 - 20090709	VARD - 20091210	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Myofascial Pain Syndrome	5237	10%	Myofascial Pain…Neck, Back & Mid Back	5099-5025	0%	20091020	
Chronic Neck/Back Pain	Category II					
Cervical Spondylosis	Category II	Cervical/Neck Condition	5237	0%	20091020	
Lumbar Spondylosis	5237	10%	Chronic Strain, Lumbar Spine	5237	10%	20091020	
Right Sacroiliac Joint Dysfunction	Category II					
Intervertebral Disc Disease	Category II					
Pain Disorder…	Category II	Major Depression	9434	10%	20091006	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

Myofascial Pain with associated Category II (Neck/Back Pain and Cervical Spondylosis).  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI developed low back pain (LBP) after he fell in the scullery aboard ship.  He was noted to have lumbar muscle spasm and reported numbness and tingling of his extremities.  He had a normal neck examination and neurological examination.  He was treated with medications and duty restrictions.  In sports medicine on 3 December 2007, it was noted that the LBP was improving, but that he also had neck and bilateral shoulder pain (shoulder blades) since the fall in September.  He was thought to have a myofascial syndrome.  Over the next year, the CI was seen for multiple complaints including neck pain, back pain, migraine headaches, and an adjustment disorder with depression.  He was evaluated by primary care, physical therapy, neurology, mental health, sports medicine, and orthopedics.  An X-ray and MRI of the neck on 30 September 2008 was normal other than a lateral list of the neck to the right and positional changes.  The range of the motion (ROM) of the neck was full but painful.  Compression of the nerve roots did not elicit pain.  The back evaluation is addressed below.  Multiple trigger points were injected with partial relief of his symptoms.  On 12 January 2009, the CI underwent electrodiagnostic testing (EDX) in physical therapy.  On examination, he had sensory loss (asymmetric) of the right and left upper extremities and asymmetric sensory loss in both lower extremities.  Specific testing was consistent with carpal tunnel syndrome.  The motor and reflex examinations were normal.  The EDX portion of the evaluation showed normal nerve condition velocities with abnormal findings on muscle testing.  The significance of this was unclear, but there was no evidence for pathology of the neck or lumbar nerve bundles (no plexopathy).  It was determined that the CI was not likely to improve sufficiently to return to full duty and he was referred for an MEB.  The MEB forwarded intervertebral disc disease, cervical spondylosis, lumbar spondylosis, myofascial pain syndrome, right sacroiliac joint syndrome, migraine without aura, adjustment disorder with depressed mood, and pain disorder for PEB adjudication.  

The MEB NARSUM examination was dated 12 February 2009, 6 months prior to separation.  The CI reported a 2 year history of neck and back pain with a history of three accidents.  A motor vehicle accident (MVA) in 2006, the year prior to accession, the fall in 2007, and a second MVA in August 2008 which aggravated his symptoms (see the back examination).  The neck pain was sharp and bilateral with radiation down both arms.  The back pain was achy without radiation.  He reported minimal benefit with electrical stimulation (for the neck), Botox (for the headaches) and traction.  On examination, the neck and upper shoulder/neck muscles were tender.  The neck ROM was full but painful.  The neurological examination was normal.  A mental health addendum the same day noted that the CI met retentions standards from a mental health aspect.  

At the MEB examination (recorded on DD Form 2807 Report of Medical History and DD Form 2808 Report of Medical Examination) dated 25 February 2009, the CI reported feeling exhausted, back and neck (pain), migraines, and depressed mood.  The examination was remarkable for tenderness of the lumbar muscles and decreased sensation of the lower extremities.  A neurological addendum to the NARSUM dated 17 March 2009, 5 months prior to separation, noted a normal neurological examination and that the CI had no neurological restrictions (to duty).  

At the VA Compensation and Pension (C&P) evaluation performed on 20 October 2009, 2 months after separation, the CI reported daily pain of the neck, back, and mid back aggravated by activity.  He did not report pain in the lower extremities attributed to the myofascial pain syndrome.  On examination, the gait and posture were normal.  The ROM of the neck was reduced for left and right lateral bending, but otherwise normal.  Sensation was normal, but flexion of the wrist and fingers was slightly reduced without muscle atrophy.  This was thought to be a median nerve dysfunction (carpal tunnel syndrome).  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the myofascial pain syndrome at 10%, coded 5237 (lumbosacral or cervical strain).  Chronic neck and back pain and cervical spondylosis were related Category II conditions.  The lumbar condition is considered below.  The Board noted that while the neck condition could support a 10% rating for painful and limited motion, this would be instead of, not in addition to, the unfitting myofascial pain syndrome.  A dual rating would violate VASRD §4.14 (avoidance of pyramiding).  

The VA rated the myofascial pain associated with neck, back and mid-back condition 0% coded 5099-5025 (analogous to fibromyalgia), based on the VA C&P examination 2 months after separation, that there was not widespread pain above and below the waist on both sides of the body.  This rating was upheld on subsequent VA rating decisions.  

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 myofascial pain syndrome condition.  

Lumbar Spondylosis with associated Category II (Right Sacroiliac Joint Dysfunction, Intervertebral Disc Disease and Pain Disorder).  As noted above, the CI was first evaluated for LBP in September 2007 after he fell.  An MRI on 4 February 2008 showed probable posterior radial annular teats at L1-2 through L5-S1 with mild osteoarthritic changes at L5-S1.  It was otherwise unremarkable.  In physical therapy (PT) on 5 August 2008, he was noted to have a normal gait and posture with the back ROM in normal functional limits.  A repeat MRI on 30 September 2008 showed no interval change.  As noted above, no lumbar radiculopathy was noted on EDX studies on 12 January 2009.

At the MEB examination the lumbar muscles were tender and sensation decreased in the lower extremities.  The MEB NARSUM examination recorded that the CI reported achy lower back pain without radiation to the lower extremities.  Electrical stimulation was beneficial for the back pain.  Trigger point injections had also been partially beneficial.  On examination the back was tender to palpation including the lumbar and sacroiliac joint areas.  He could flex to the mid-calf, but with pain.  The neurology addendum showed a normal neurological examination.  

At the VA C&P evaluation, the CI reported that his symptoms had improved since their onset.  On examination the posture and gait were normal.  The ROM was reduced with flexion of 75 degrees (VA normal 90) and the combined ROM was 200 (240 is normal).  The neurological examination was normal.  X-rays of the lumbar spine and pelvis (with the sacro-iliac joints) were normal.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the lumbar spondylosis condition at 10%, coded 5237 (lumbosacral strain).  The PEB determined that the pain disorder, right sacroiliac joint dysfunction, and intervertebral disc disease conditions were Category 2.  The MEB mental health evaluator determined that the CI was fit from a mental health standpoint.  The CI was noted to have tenderness of the sacro-iliac joint, but X-rays on the VA examination were normal.  IAW VASRD §4.66 (sacroiliac joint), the lumbar spine and sacroiliac joint are considered as one anatomical segment for rating purposes.  Accordingly, a separate rating is not supported.  The intervertebral disc syndrome is also subsumed under the low back pain condition.  The VA also rated the chronic strain of the lumbar spine condition at 10%, coded 5237, based on the VA C&P examination 2 months after separation.  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 lumbar spondylosis condition.  

BOARD FINDINGS:  In the matter of the myofascial pain syndrome condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the lumbar spondylosis condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the chronic neck/back pain, cervical spondylosis, pain disorder, right sacroiliac joint dysfunction, and intervertebral disc disease conditions, the Board unanimously  recommends no change from the PEB determinations as Category II conditions and not separately unfitting.  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 20140512, 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 21 Sep 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, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN

						  
XXXXXXXXXXXXXXXXXXXX
Assistant General Counsel
	(Manpower & Reserve Affairs)