RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02206
BRANCH OF SERVICE:  Navy 	SEPARATION DATE:  20070630

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E5, Storekeeper, medically separated for “pain disorder related to psychological factors” and “pain syndrome of soft tissue origin,” with a disability rating of 0%.

CI CONTENTION:  “Please consider all conditions”.  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 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 - 20070116	VARD - 20080229	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Pain Disorder…	---	0%	No VA Placement	
Pain Syndrome…				
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Pain Syndrome of Soft Tissue Origin.  The CI was seen for evaluation by a physical therapist with the complaint of constant bilateral knee pain diagnosed as patellofemoral syndrome in July 2005.  Examination revealed bilateral mild genu valgus and a normal range of motion (ROM) measurements of 0-145 degrees.  Subsequently, the right knee pain described as sharp/dull shot up and down her leg and she stated her lower back was painful post physical therapy.  Magnetic resonance imaging (MRI) of the right knee demonstrated mild chondromalacia patella.  Low back pain was treated with Motrin (ibuprofen, a nonsteroidal anti-inflammatory drug (NSAID)) along with home exercises in October 2005.  An MRI of the lumbar spine in October 2005, ordered for chronic low back pain with left leg pain and radiculopathy extending to the foot, was negative except for minimal degenerative disc changes.  There was no neural compromise, nerve root impingement or significant degenerative changes.  X-rays of the knees bilaterally were normal and X-rays of the lumbosacral spine showed very small osteophytes of vertebral bodies T12, L2, and L5.  Laboratory studies in February 2006 showed the ESR 30 (sedimentation rate normal < 20), ANA (antinuclear antibody) screen positive, rheumatoid factor negative and TSH (thyroid stimulating hormone) normal.  Orthopedic evaluation in February 2006 for bilateral knee, right hip and low back pain was carried out and revealed normal ROMs for all joints with no instability and mild medial joint line tenderness on the right knee.  An X-ray series of the knees was normal; and an X-ray series in March 2006 of the lumbar spine showed no acute findings and limited motion on flexion and extension.  Right foot numbness and weakness was evaluated and being followed in the spine clinic.  On examination there was decreased light touch on the lateral right foot and there was slight weakness (4+/5) of the right hamstring muscles.  An MRI of the thoracic spine in April 2006 demonstrated no significant thoracic spondyloarthropathy (inflammatory diseases that cause arthritis); however, there appeared to be a sclerotic (thickening in bone) lesion in the T5 vertebral body, which was not present on prior X-rays.   The question of whether the CI had fibromyalgia versus rheumatoid arthritis was raised because of the positive ESR and ANA laboratory tests.  The CI continued treatment with baclofen (β-(4-chlorophenyl)-γ-aminobutyric acid, a muscle relaxer to treat muscle spasms) and Naprosyn (an NSAID) was introduced.  An MRI of the brain, which was performed for intermittent neurologic symptoms including an intermittent right foot drop, was normal.  Laboratory studies in June 2006 for thyroid function were within normal limits, although the TSH was 3.041 (the higher side of normal) and one test of free T4 (a measure of thyroid function) was low, which on repeat was normal as were cerebral spinal fluid studies and Lyme titers.  Trauma evaluation on 7 July 2006, after the CI had been in a motor vehicle accident a day earlier and had acute cervical muscle spasm, was followed by neurosurgical evaluation of right foot and leg weakness and numbness and right arm weakness and numbness and tingling of the 2nd 3rd, and 4th digits of the right hand.  The cervical muscle spasm was treated with an Aspen collar and muscle relaxants.  An MRI in July 2006 of the cervical spine demonstrated a central disc herniation at C5-6 causing mild compression of the thecal sac with no cord compression.  A note in September 2006 indicated the CI had numbness in both feet and weakness of her legs and feet and aching of her arms when she elevated them.  An EMG (electromyogram) revealed peripheral sensory/motor neuropathy.  Laboratory studies revealed vitamin B12 was 299 (normal 211-911) and myelin glycoprotein IgM was high at 1:1600 (moderately high).  Examination revealed weakness in the proximal arm, proximal leg, distal leg, hip flexors and dorsiflexor musculature on the right side.  Tenderness was noted to palpation in the paraspinal cervical and paraspinal sacral region on both sides, but the ROMs were normal throughout.  Sensation was decreased to light touch, temperature and pin prick in the distal arm, dorsal hand and distal leg on both sides.  Diagnoses raised included B12 deficiency, brachial plexus traction injury, cervical radiculopathy, CIDP (chronic inflammatory demyelinating polyneuropathy), fibromyalgia, and spasmodic torticollis (wry neck). However, later in September 2006 the diagnoses of idiopathic relapsing polyneuropathy, vitamin B12 deficiency, and chronic major depression were made.  Treatment consisted of cyanocobalamin (vitamin B12) and Paxil (paroxetine, an anti-depressant) was changed to citalopram (an antidepressant) (see below).   A laboratory study revealed macrohepatic isoenzyme (a measure of liver or bone status) was elevated, which caused concern to the CI.  Neurologic evaluation in November 2006 assessed the CI’s condition as primarily a pain syndrome, though a mild sensorimotor neuropathy was possible with a supratentorial (psychosomatic) overlay (see below).  The neurologist could not totally rule out a right L5 or peroneal [nerve involvement].  Neurontin and a little Synthroid (levothyroxine) to cover possible thyroid issues was prescribed along with a strong aerobic exercise program.  An electrodiagnostic study of the sural, peroneal, and tibial nerves was normal; right lumbosacral paraspinal muscles and of selective muscles of the right leg were also normal. 

The non-medical assessment dated 6 November 2006 indicated the CI’s duties and responsibilities had been reduced to clerical work only.  She had waivers for lifting, standing, running, and body fat with no signs of successful treatment.  Her clerical work was excellent. but the burden of her storekeeper’s duties fell on her shipmates.  She was not worldwide assignable and did not have good potential for continue service.  At the MEB examination dated 2 December 2006 the CI reported on DD Form 2807-1, Report of Medical History, “neck, shoulder arm (right) painful, weakness, down into the joint and hand,” “numbness and tingling in leg and foot,”  “painful to walk upstairs or stand for long periods of time and running is very difficult if not impossible,” and “anxiety and depression.”  The MEB physical examination noted on DD Form 2808, Report of Medical Examination, checked off on clinical evaluation abnormal on lower extremities, spine, neurologic, and psychiatric and referred to prior exams and specialty notes in the health record;  biceps and patellar deep tendon reflexes were recorded as normal.    

The MEB narrative summary (NARSUM) dated 15 December 2006 noted the CI had a 4-year history of pain in her entire body, which seemed to start after doing a lot of running at one time.  The CI had trouble walking up stairs and lifting.  Rheumatology workup yielded no diagnosis.  Neurology evaluation including imaging and spinal fluid analysis studies was normal.  A recent EMG was felt to show a neuropathy.  The CI complained of pain over the entire right side of the body as well as her right neck with some left-side pain as well, but less.  Her feet had the worst pain, which felt numb. A repeat EMG for myopathy and neuropathy, as well as for the possibility of radicular problems with the right foot, was completely normal.  On examination the CI had a full ROM and she was able to walk normally on the toes and heels.  Neurologic examination of the cranial nerves and reflexes was normal.  Motor strength was normal, but there was some giveaway weakness of the right greater than the left toe dorsiflexors, but when the CI was encouraged it became normal.  There was spotty diminution of subjective pinprick in the right leg and left arm with no anatomical pattern.  The NARSUM author’s assessment was that there was no neuropathy and no perineal or L5 radiculopathy or myopathy and opined the CI suffered from a pain syndrome of soft tissue origin and there was much supratentorial overlay to the examination; however, with encouragement, it was a normal examination.  A strong aerobic exercise program was recommended with increased doses of Neurontin (gabapentin for nerve pain) and Elavil (amitriptyline, an antidepressant and for nerve pain).  The NARSUM author concluded that he considered her to suffer from intractable soft tissue pain syndrome of the feet.  Multiple follow-up laboratory tests and imaging studies were ordered, the results of which were not part of the service treatment record.  

At the VA Compensation and Pension (C&P) examination dated 28 August 2007, performed 2 months after separation, the CI reported pain in the right hand at rest with a severity of 8/10 and a dull constant ache in the left hand at rest with a severity of 6/10.  She complained of morning stiffness in the joints in her entire body, but more predominantly in both her hand and had generalized aches and pains during the day.  The symptoms waxed and waned. On examination of both hands there was no evidence of deformities of the joints; hand grip was normal; and the ROMs in all the digits was normal.  There was no loss of motion with repetition.  There was no evidence of muscle atrophy and no specific tender points in the muscles.  She worked as a clerk and missed work twice a month.  The diagnosis of polyarthralgias and polymyalgias of undetermined etiology was made.  A VA examination for possible multiple sclerosis noted the CI did not have multiple sclerosis.  A VA examination of the spine on 22 August 2007 noted that CI claimed to have had constant moderate burning pain with tingling and numbness radiating of her right upper arm accompanied with weakness and fatigue.  She described moderate burning pain with tingling numbness in the right upper extremity with right upper extremity weakness, fatigue, but no functional loss.  Neurological examination of the right upper extremity as well as the left upper extremity revealed normal sensory function.  Motor functions of the upper extremities was normal and the CI had a normal gait.  ROM measurements of the cervical spine were normal with mild to moderate pain on motion.  The diagnosis of cervical strain with a history of cervical disk herniation at C5/C6 was made.  Lumbar ROM measurements were flexion 90 degrees, extension 20 degrees, lateral flexion right and left 0 to 20 degrees, and rotation right and left 0 to 30 degrees with mild to moderate pain with moderate muscle spasm and moderate tenderness but no weakness.  The diagnosis of lumbar strain, mildly to moderately active at time of examination was made. There were no incapacitating episodes in the prior year related to either the cervical or lumbar spine.  Examination of the right knee was normal.  

Pain Disorder Related to Psychological Factors.  Limited references to mental health issues were available in the service treatment record.  Apparently, the CI was prescribed Paxil (paroxetine, an antidepressant), which was first mentioned in an orthopedic note in November 2004 that indicated the CI had a past history of mood alteration.  She was switched to citalopram (an antidepressant) for treatment of chronic major depression marked by having issues dealing with her diagnosis and weight gain, limited physical activity, fluctuant appetite, anhedonia, crying spells, without suicidal or homicidal ideation on 15 September 2006 by the CI’s primary care physician, who noted she had no therapy in the past.

A VA psychological disability evaluation was performed on 22 August 2007.  The CI pointed out her depression began on active duty when there was a lot of stress at her particular unit and she broke down and started crying.  She was given Paxil, but received no counseling.  She noted her depressive symptoms seemed to interfere with her ability to do her job and she was switched to Celexa (citalopram, an antidepressant).  Since separation she wanted to sleep all the time and took naps up to 6-9 hours at a time.  She felt confused and worthless at times and her concentration was poor; and, she felt she had a significant loss of short-term memory.  She reported being withdrawn for days at a time and kept to herself; however, she denied suicidal ideation, but felt a lack of energy and stopped doing pleasurable things.  The CI did not appear to have any significant impairment of thought process or communication or to show any significant bizarre or idiosyncratic behavior.  Mental status evaluation revealed she had good reality contact and was oriented in all three spheres (person, place, time [including date]).  There was no evidence of any delusions or hallucinations in her thought content, and no suicidal or homicidal ideation.  General reasoning and judgment seemed adequately intact and memory for both recent and remote events seemed fair.  Her affect was clearly quite tearful and depressed throughout the interview.  The examiner opined the CI was suffering from a major depressive disorder and her Global Assessment of Functioning (GAF) was 52, which he indicated was of moderately severe symptomatology.

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB assigned a 0% rating for the overall effect of the following Category I diagnoses: pain syndrome of soft tissue origin and pain disorder related to psychological factors.  The VA assigned a 30% rating using code 9434 for major depressive disorder, a 10% rating using code 5242 for multi-level degenerative changes, lumbosacral spine, a 10% rating for C5-6 disc herniation with right upper extremity radiculopathy, a 0% rating using code 5099-5014 for patellofemoral syndrome, right knee, and a 0% rating using code 7805 for right wrist ganglion cyst, status post excision.  The Board sought a route to a higher rating and noted the PEB combined the pain syndrome of soft tissue origin and pain disorder related to psychological factors conditions under a single disability rating for “overall effect.”  Board members discussed the CI’s many complaints and non-specific or non-reproducible clinical findings despite multiple examinations, imaging, and laboratory studies.  However, on many occasions she had either complaints of pain, numbness or weakness in the right arm with a known disc herniation of C5-6, more so than other issues that were not clinically confirmed by imaging or laboratory testing.  

The majority of Board members concluded that there was not a preponderance of evidence showing that the pain syndrome of soft tissue origin condition standing alone would have caused the CI to be referred into the DES or be found unfit due to the pain syndrome of soft tissue origin condition.  The Board members concluded that there was not a preponderance of evidence showing that the pain disorder related to psychological factors condition standing alone would have caused the CI to be referred into the DES or be found unfit due to the pain disorder related to psychological factors condition.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board majority concluded that there was insufficient cause to recommend a change in the PEB adjudication for the pain syndrome of soft tissue origin condition.  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 pain disorder related to psychological factors condition.  

BOARD FINDINGS:  In the matter of the pain syndrome of soft tissue origin condition and IAW VASRD §4.71a, the Board majority recommends no change in the PEB adjudication.   In the matter of the pain disorder related to psychological factors condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  The single voter for dissent submitted the appended minority opinion.  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 20140501, 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 24 Jun 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 USMC
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXXX, former USMC 

						XXXXXXXXXXXXXXXXXXXX
	     				             Assistant General Counsel
						(Manpower & Reserve Affairs)

Minority Opinion

The CI’s many complaints stumped many physicians as to what her diagnosis actually was.  While she was found unfit as a result of the overall effect, there was no precise condition on which the PEB was able to confirm, let alone find her condition independently unfitting.  However, at the VA examination, which was within the 12-month window permitted by DoDI 6040.44, it became evident that the neuropathy of C5 and C6 stood out from the rest of the diagnoses and had imaging documentation of a herniated disc to confirm the CI’s symptoms of weakness of the right hand and arm.  As a result, her profile precluded her from lifting and although she was an excellent worker when it came to administrative work, a job in the 21st century involves working with a computer, rather than lifting, moving, or performing military duties and obligations.  Furthermore, the Board did not have the laboratory results to review that were ordered prior to separation.  While it is presumptive and beyond the boundaries of the PDBR to diagnose or second guess a CI’s condition, the lack of a baseline Vitamin D level to rule in or rule out a deficiency of Vitamin D, which when deficient includes several of the CI’s symptoms, both physical and mental.  Therefore, the CI was clearly unfit and the PEB determination was correct; however, based on clinical and imaging findings at least one of the conditions, the C5-C6 neuropathy was separately unfitting and impaired the CI’s capability and functionality to perform her duties as a Navy Storekeeper, which involves not only administrative work, but heavy physical work not infrequently and with the neuropathy, which the VA found credible and ratable, she could not do her military occupational specialty.   

Therefore, the preponderance of evidence showed that the pain syndrome of soft tissue origin standing alone was separately unfitting for continued military service and a rating using code 8710 (mild neuralgia of the upper radicular group (fifth and sixth cervicals)) at 20% is not unreasonable since the pain was intermittent and did not rise to a moderate level for a higher rating.

In the matter of the pain syndrome of soft tissue origin condition, the Board minority recommends a disability rating of 20%, coded 8710 IAW VASRD §4.124 and VASRD §4.124a.  

The Board minority recommends that the CI’s prior determination be modified as follows, effective as of the date of her prior medical separation:  

CONDITION	VASRD CODE	RATING	
Pain Origin of Soft Tissue Origin 	8710	20%	
COMBINED	20%