RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02843
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20020730

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Network Switching Systems Operator, Maintainer) medically separated “right myofascial pain syndrome of trapezius,” rated at 0%. 

CI CONTENTION:  The CI contends he was misled as to the severity of his injury and states that it continues to worsen.  The 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 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:  

IPEB - Dated 20020409	VA* - (~6 Mos. Pre-Separation)  -	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Myofascial Pain Syndrome of Trapezius…	5099-5021-5003	0%	Cervical Spine Strain with Headaches (also claimed as Spinal Stenosis and C7 Radiculitis)	5260	10%	20020208
	
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 5 	
RATING:  0%	RATING:  30%	
*Derived from VA Rating Decision (VARD) dated 20020828 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY:  

Right Myofascial Pain Syndrome of Trapezius Condition.  The service treatment record (STR) supplements and supports the two MEB narrative summaries (NARSUMs) dated 19 November 2001 and 13 March 2002, which reported the CI felt acute neck pain with radiation to his right arm on or about 11 July 1998 while doing jumping jacks (overhead claps) during AIT (advanced individual training).  Cervical spine X-rays in January 2000, performed for the CI’s “long history of neck pain,” revealed loss of the normal lordotic cervical curvature.  In September 2000, the CI reported worse upper back pain with push-ups and sit-ups, while in November 2000 the CI had “good ROM” (range-of-motion), pain and weakness, and a problem wearing his helmet for long periods of time.  The CI was seen by an orthopedic surgeon on 5 February 2001, who indicated the CI reported pain in his neck and arm and occasional numbness in his right hand.  On examination there was no weakness at the shoulder and ROMs were normal.  The impression was radicular pain of the right upper extremity.  A bone scan of the neck was normal in February 2001 and magnetic resonance imaging (MRI) of the cervical spine was essentially normal with the diameter of the spinal canal at C6-C7 at the lower limits of normal.  The CI was evaluated by a physical medicine and rehabilitation (PM&R) physician in September 2001 who noted the CI reported relatively severe pain of 7/10 (10 being the worst pain) with radiation, numbness and tingling primarily on the right from the arm to the middle and ring finger, but also on the left upper extremity; however, at the time of the evaluation, he did not have any specific neurological complaints of numbness, tingling or weakness.  Examination revealed tenderness over the C7 spinous process and mild tenderness over the right and left trapezius muscle with myofascial bands present.  There was a normal cervical ROM with positive Spurling (to assess nerve root pain) and Jackson compression (to assess nerve root pain) tests of the right and left describing radiation in a C7 type distribution.  Motor examination was unremarkable and there was a negative Tinel sign (nerve inflammation).  The PM&R physician’s assessment was bilateral C7 radiculitis, primarily on the right probably secondary to mild posterior disc bulge between C6-C7, bursitis over the C7 spinous process, and mild bilateral upper trapezius myofascial pain syndrome.  Conservative treatment with physical therapy and traction were not beneficial previously; therefore, further conservative measures were not pursued.  Orthopedic examination on 25 September 2001 noted full ROM of the cervical spine and normal motor and sensory examinations.  The CI indicated he did not want to have surgery for the cervical radiculitis.  Electrodiagnostic studies in March 2002 of the right arm were normal.  

The MEB narrative summary (NARSUM) dated 13 March 2002 indicated the examiner noted cervical forward flexion of 45 degrees and a combined ROM of 290 degrees with diffuse tenderness over C6-C7 and mild tenderness of the triceps on deep palpation at the mid humerus.  Extended hand strength was mildly diminished for lateral compression of the third and fourth digits, right compared to left.  Grip strength, extended arm strength, wrist flexion and forearm strength were equal bilaterally.  Shoulder ROM was intact with no clicking, popping or pain at the AC (acromioclavicular) joint.  The examiner’s diagnosis was right C7 radiculitis and right upper trapezius myofascial pain syndrome.  In spite of extensive therapy, nonsteroidal anti-inflammatory medication (naproxen) and muscle relaxant medication (methocarbamol), the CI’s condition worsened and the pain interfered with sleep and caused him to be unable to do overhead type activities or any impact activities.

At the MEB examination, the CI reported on DD Form 2807-1 dated 19 December 2001 that he had right and left C7 radiculitis and underwent physical therapy with traction and back manipulation.  The MEB physical examiner noted on DD Form 2808 dated 19 December 2001 that neck flexion and extension were intact at 45 degrees, rotation was 45 degrees bilaterally, and tilt was 30 degrees bilaterally.  There was tenderness at C6-C7 and of the triceps; right hand extension was weaker than the left; and paresthesia of the last two [right] digits was reported.  Sharp and dull sensation was intact and reflexes were normal in the antecubital area (where the inner forearm meets the arm).  The commander’s statement dated 3 January 2002 indicated the CI was incapable of wearing a Kevlar, which made him unable to deploy.  He was also unable to fire at the range, do PT with the company, lift, carry, sit or stand for extended periods of time without irritation his neck/back injury.  A permanent U3 profile was issued for right C7 radiculitis in February 2002 with limitations of no PT test, no sit-ups or push-ups, no wearing a backpack or helmet, no marching more than one mile, and no lifting greater than 25 pounds.  X-rays of the cervical spine and electrodiagnostic studies of the cervical spine and upper extremities to rule out radiculopathy were normal.  
At the VA Compensation and Pension (C&P) examination of the CI’s joints dated 8 February 2002, performed approximately 6 months before separation, the CI reported his neck hurt daily but varied in intensity and right upper extremity symptoms occurred about every other day.  He related weakness and fatigability to pain.  There was slight tenderness somewhat more on the right than the left in the trapezius/supraspinatus area and no tenderness in the right or left paracervical areas.  Grip strength was normal and reflexes were 1+ bilaterally.  The cervical spine ROMs were flexion 60-65 degrees, extension 65 degrees, right and left lateral rotation 80 and 70 degrees respectively, and right and left lateral flexion 45 and 35 degrees respectively with some complaint of pain on extension and left lateral flexion.  The CI also underwent a General Medical VA C&P examination on 11 February 2002 that indicated he was working full time, was in constant pain, and had neck pain flares three times every six months.  Examination revealed forward flexion and extension 45 degrees each, tilt laterally 30 degrees bilaterally and rotation 70 degrees bilaterally.  The CI was diffusely tender over C6 and C7 and had mild tenderness of the triceps on deep palpation at the mid humerus.  Extended hand strength was mildly diminished for lateral compression of the third and fourth digits of the right hand compared to the left. The results of the remainder of the upper extremities examination were equal bilaterally and the CI was able to lift his head and move his hands to meet at his lumbar spine.

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

Cervical ROM
(Degrees)	Ortho ~10 Mo. Pre-Sep
	NARSUM ~9 Mo. Pre-Sep
	VA C&P  Joint~6 Mo. Pre-Sep
	VA C&P GEN MED ~6 Mo. Pre-Sep
	MEB ~5 Mo. Pre-Sep
	
Flex (45 Normal)	FROM	NORMAL	(45)60-65	45	45	
Extension (45)			(45)65	45	45	
R Lat Flexion (45)			45	30	30	
L Lat Flexion (45)			35	30	30	
R Rotation (80)			70	70	70	
L Rotation (80)			80	70	70	
Combined (340)	-	-	320	290	290	
Comment	Weakness in his  triceps; MRI-stenosis at C6/C7; motor and sensory intact	Extensive tenderness right upper trapezius with palpable myofascial bands present; negative Spurling and Jackson compression tests; pain in C7 distribution of the RUE	Tenderness more on the right than the left in the trapezius/supraspinatus areas; grip strength normal; some pain on extension and left lateral flexion	Diffusely tender over C6 and C7; mild tenderness of triceps on deep palpation	Diffusely tender over C6-C7; mild tenderness of triceps on deep palpation	
§4.71a Rating	-	-	VA 10%	VA 10%	PEB 0%	

Right Shoulder ROM
(Degrees)	VA C&P ~6 Mo. Pre-Sep
	NARSUM~5 Mo. Post-Sep
	
Flexion (180 Normal)	Intact	Intact	
Abduction (180)			
Comments	Tenderness more on the right than the left in the trapezius/supraspinatus areas	No clicking or popping; no pain at AC joint	
§4.71a Rating	0%	0%	

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB assigned a 0% rating using analogous code 5099-5021-5003 (myositis/degenerative arthritis) for right myofascial pain syndrome of the right trapezius radiating into the right shoulder and arm and when severe producing a right C7 radiculopathy.  The VA assigned a 10% rating using code 5290 (cervical spine limitation of motion) for cervical strain with headaches (also claimed as spinal stenosis and C7 radiculitis).  The Board noted the PEB integrated code 5021 into code 5099-5003 presumably to define the location of the pain rather than bundling the conditions.  Code 5003 permits a 10% rating for a noncompensable ROM if confirmed by findings such as swelling, muscle spasm or satisfactory evidence of painful motion.  While the VA examination and the MEB examinations proximate to separation had essentially the same clinical examination findings and both were silent on objective findings of limitation of motion, the VA examination of the joints 3 days earlier noted pain on extension and left lateral flexion of the cervical spine.  In the absence of ankylosis, any additional limitation of motion, or incapacitation, the Board was unable to find an applicable rating greater than 10%, although an argument can be made for use of code 5290 (slight limitation of motion of the cervical spine) at 10%; however, it affords no additional benefit to the CI.  The Board also discussed whether muscle code 5301 (Group I) for the right mild trapezius myofascial pain would offer any additional benefit with slight impairment affording a 0% rating and moderate warranting 10% rating, but neither offers any additional benefit especially since pyramiding IAW VASRD §4.14 is to be avoided.  The Board then considered whether an additional rating could be recommended under a peripheral nerve code for the right C7 radiculopathy.  Although the pain was present, there was no sensory component with any significant functional implications, no motor weakness was in evidence, and electrodiagnostic studies were normal.  Therefore, the radiculopathy could not be recommended for additional disability rating.  Alternatively, although the radiculitis was intermittent, nevertheless the CI could not perform overhead activities; however, he had normal grip strength and no documented triceps or brachioradialis weakness, but did have tenderness of the triceps and decreased reflexes at the antecubital fossa at least in one examination.  Therefore, the Board considered application of a nerve code 8510 (partial paralysis upper radicular group) or 8710 (neuralgia upper radicular group), but the Board discussion reiterated and concluded there were no significant functional limitations sufficient to warrant an additional rating.  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 right myofascial pain syndrome 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.  As discussed above, PEB reliance on the USAPDA pain policy for rating right myofascial pain syndrome was operant in this case and the condition was adjudicated independently of that policy by this Board.  In the matter of the myofascial pain syndrome condition, the Board unanimously recommends a disability rating of 10%, coded 5099-5021 IAW VASRD §4.71a.  There were no other conditions within the Board’s scope of review for consideration.  

\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	
Right Myofascial Pain Syndrome	5099-5021 	10%	
RATING	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140612, 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-00), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation
for AR20160005122 (PD201402843)

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 10%
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
( ) OVA