RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03905
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20061105

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a National Guard E4, Light Wheel Vehicle Mechanic, medically separated for “chronic upper back pain” and “chronic myofascial pain affecting the right arm and shoulder,” rated 10% and 0%, respectively, with a combined disability rating of 10%.

CI CONTENTION:  “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 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 - 20061016	VARD – 20060225 and 20070124	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Upper Back Pain	5299-5237	10%	Residuals of Back Injury	5237	10%	20051229	
Myofascial Pain…Right Shoulder 	5099-5021	0%	No VA Placement	
Neck Stiffness	Not Unfitting	Residuals of Neck Injury	5237	10%	20051229	
Tension Headaches		No VA Placement	
Insomnia		No VA Placement	
Bilateral Upper Extremity Numbness/Tingling		Bilateral Upper Extremity Numbness Associated with…Neck Injury	8715	NSC	20051229	
Pustular Acne		Micrococcal Infection, Claimed as Acne	7820-7806	60%	20040729	
Hearing Loss Left Ear		Ringing in the Ears	6260	NSC	20040720	
Adjustment Disorder w/ Depressed Mood		No VA Placement	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  70%	

ANALYSIS SUMMARY:  

Chronic Upper Back Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s back condition began in November 2003 after the hood of a vehicle fell on her while she was performing mechanic duties.  X-rays in March 2004 were unremarkable.  Although she resumed her normal duties without a profile, completed her deployment and was released from active duty (REFRAD) in May 2004, she continued to have persistent upper back pain.  After REFRAD, she continued her duties with her National Guard unit and returned to her civilian job at a bakery she held prior to mobilization.  There was no surgical indication, and conservative treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “chronic upper back pain” for PEB adjudication.  

At the VA Compensation and Pension (C&P) examination in December 2005, performed 10 months before separation, the CI reported low back pain and the inability to sustain standing, walking or sitting for any extended period more than 15 minutes straight.  The CI reported she was working at Blockbuster in 4 hour shifts.  Physical exam showed normal posture and gait.  There was extreme wincing to even the lightest touch which the examiner stated was non-physiologic.  Strength, sensation and reflexes were all normal.  The findings of the straight leg raise test (for radicular symptoms) were discordant.  While sitting the findings were negative bilaterally; in the supine position, she reported severe low back pain at 20 degrees.  The examiner stated this was also non-physiologic.  With other testing, the CI reported pain with examination maneuvers not expected to elicit pain based on the known pathology.  Thoracolumbar range of motion (ROM) measurements showed flexion to 60 degrees (normal 90) and combined ROM of 205 degrees (normal 240).  The examiner stated “when moving up and about from the exam table in the chair, she did not have these limitations of motion.  

At the MEB examination dated April 2006, 6 months prior to separation, the CI reported chronic back pain.  Physical exam showed thoracolumbar ROM measurements of flexion to 70 degrees and combined ROM of 170 degrees after repetition, all limited by pain.  There were tenderness from C6-T8 with no muscle spasms.  

At the MEB NARSUM examination on 22 August 2006 (2 months prior to separation) the CI complained of upper back pain, rated 4/10.  The NARSUM physician referred to the physical ROM examination conducted and reported on the DD Forms 2807 and 2808.  Orthopedic consult in September 2006 documented normal heel and toe gait with negative provocative testing for radicular symptoms.  Lower extremity motor and sensory exams were normal.  X-rays showed thoracic scoliosis (abnormal lateral curve) and magnetic resonance imaging (MRI) was normal.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under an analogous 5299-5237 code (lumbosacral strain), citing tenderness and minimal limitation of motion by pain alone.  The VA initially assigned a 20% rating using the 5237 code (lumbosacral strain) based on a VA C&P examination 27 months before separation, citing forward flexion greater than 30 degrees but not greater than 60 degrees.  The VA reduced the 5237 rating to 10% based on the VA C&P examination 10 months before separation, citing limitation of motion and subjective complaints that were inconsistent with objective findings.  

The VA examination’s probative value was judged to be compromised by its remoteness (10 months prior) from the date of separation, the subjective pain responses and discordant exam findings as recorded by the VA examiner were also not consistent with the objective findings.  The Board relied more heavily on the MEB examination; therefore, the Board agreed a 10% rating, but no higher, was justified for limitation of flexion (greater than 60 degrees but not greater than 85 degrees) and combined ROM (greater than 120 degrees but not greater than 235 degrees) reported on the MEB examination proximate to separation.  There was no muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour, thus the next higher 20% rating was not justified on this basis.  There was no evidence of intervertebral disc syndrome (IVDS) which resulted in incapacitating episodes requiring physician-prescribed bed rest to warrant consideration of rating under the alternate VASRD formula (for IVDS).  There was no evidence of an associated unfitting radiculopathy for consideration of a separate peripheral nerve 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 back condition.  

Chronic Myofascial Pain Affecting the Right Arm and Shoulder Girdle.  According to the STR and MEB NARSUM, the CI’s right arm (dominant) and shoulder pain began in November 2003 after the same injury that caused her upper back pain discussed above.  There was no surgical indication, and conservative treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “right scapular winging likely due to long thoracic nerve injury secondary to upper back trauma” for PEB adjudication.  

At the MEB examination dated April 2006 and the MEB NARSUM dated 22 August 2006 (6 and 2 months prior to separation respectively), the CI reported constant increasing pain in her shoulders, upper back and neck with stiffness, numbness and tingling in all limbs with inability to lift.  She had right scapular winging.  She reported most activities involving her upper torso and arms caused increased pain, especially lifting over 5-10 pounds or any overhead work.  She had occasional bilateral arm and hand numbness which was mostly positional, and noted subjective loss of strength in both upper extremities, mostly related to the weakness in her right shoulder.  MRI of the neck and of the right shoulder were reported as normal.  Cervical spine X-rays on 18 August 2006 showed minimal degenerative changes and on 11 September 2006 was reported as normal.  Physical examination showed tenderness in the paraspinous muscles in the right upper scapular area.  Right shoulder forward flexion was 120 degrees (normal 180) with abduction to 110 degrees (normal 180) with shoulder ROMs limited by pain in the muscles of the right upper back and neck.  

At the time of an orthopedic MEB orthopedic specialist consultation on 11 September 2006, the CI reported right shoulder pain and “popping out” with a grinding sensation.  Physical examination showed full neck ROM with tenderness on the right scalenus (shoulder blade area) muscle.  Shoulder ROM was full without a painful arc.  There was no motor weakness and no sensory or reflex deficit.  There was no winging of the scapula on repetitive testing.  

At the time of a neurology appointment on 13 September 2006, 1 months prior to separation, the CI reported right scapular winging and bilateral upper extremity weakness and numbness.  The examiner recorded normal strength and reflexes, with decreased sensation over the right scapular region.  There was winging of the right scapula reproducible with hand pushing forward.  EMG/NCV testing on 14 September 2006 was normal, but the neurologist stated “this does not rule out long thoracic nerve palsy as it is a clinical diagnosis.”  

The CI was seen by an orthopedic surgeon on 30 October 2006, within 1 month after separation, the CI complained of refractory right shoulder pain.  On examination she had tenderness about the right shoulder girdle, painful shoulder forward elevation, and “very dramatic winging of the scapula on the right.”  The assessment was long thoracic nerve injury, right shoulder, with severe scapular winging.  The CI subsequently underwent right shoulder girdle surgery (tendon transfer) on 8 December 2006 (within 2 months after separation) for right scapular serratus anterior muscle palsy.  

At the VA Compensation and Pension (C&P) examination in July 2008, performed 20 months after separation, the CI reported constant stabbing right shoulder pain aggravated by motion and not relieved by surgery.  History indicated a normal deltoid (shoulder muscle) biopsy performed in September 2007.  Physical exam showed right shoulder forward flexion to 100 degrees and abduction to 120 degrees (normal 180) with pain.  There was scapular winging noted with the examiner indicating that it was paradoxical to the CI’s normal movements.  Strength and sensation were essentially normal.  The diagnosis was right shoulder strain and the examiner indicated that as he did not have records of the CI’s surgery, that the CI’s shoulder condition was “not at least as likely as not related to injury in service.”  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 0% rating under an analogous 5099-5021 code (myositis), citing no mechanical loss of motion.  This was likely application of AR 635-40, in effect at the time.  The VA did not service connect a right shoulder condition citing STRs were negative for complaints and a diagnosis of a right shoulder condition was not made while on active duty, as well as absence of surgical records noted at later exams and VARDs [of note, the operative report from 8 December 2006 was in evidence for the Board].  

The Board considered rating the myofascial pain affecting the right arm and shoulder girdle condition under both VASRD §4.71a (Schedule of ratings—musculoskeletal system) and/or §4.124a (Schedule of ratings–neurological conditions and convulsive disorders) as there were indications of limited shoulder ROM and pain with scapular winging that implicated the long thoracic nerve.  

The VASRD §4.71a threshold for rating for ROM impairment (code 5201, arm limitation of motion) is “at shoulder level” (approximately 90 degrees from the side), and the examinations in evidence demonstrated motion above this level.  The preponderance of examinations indicated painful shoulder motion with functional loss that would justify a 10% rating IAW VASRD §4.59 and §4.40.  There was no malunion or recurrent dislocation of the humerus and no dislocation or nonunion of the clavicle or scapula to justify a higher rating under the 5202 (humerus, other impairment of) or 5203 (clavicle or scapula, impairment of) codes.  

Given the scapular winging and possible nerve injury origin of the myofascial pain affecting the right arm and shoulder girdle the Board considered analogous or alternative rating under partial paralysis (scapular winging) or neuritis (pain and sensory) code of 8519 (Long thoracic nerve).  There was insufficient evidence that the CI’s disability more nearly approximated the incomplete severe paralysis criteria proximate to separation to warrant any rating higher than 10%.  In consideration of VASRD §4.14 (Avoidance of pyramiding) the Board recommended rating is 10% using analogous coding of 8519-5021.  

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 myofascial pain affecting the right arm and shoulder girdle condition, coded 8519-5021.  

Contended PEB Conditions:  Intermittent neck stiffness, recurrent tension headaches, chronic intermittent insomnia, intermittent bilateral distal upper extremity numbness/tingling with history of left carpal tunnel syndrome (clinically resolved), pustular acne, hearing loss on the left and history of adjustment disorder with depressed mood.  The Board’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  The adjustment disorder with depressed mood is a condition not constituting a physical disability, IAW DoDI 1332.38.  Therefore, the Board has no basis for recommending it as unfitting.  None of the conditions were profiled or implicated in the commander’s statement or judged to fail retention standards.  There was no performance-based evidence from the record that any of the conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for any of the contended conditions and so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the upper back pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the chronic myofascial pain affecting right arm and shoulder girdle condition, the Board unanimously recommends a disability rating of 10%, coded 8519-5021 IAW VASRD §4.71a.  In the matter of the contended Intermittent neck stiffness, recurrent tension headaches, chronic intermittent insomnia, intermittent bilateral distal upper extremity numbness/tingling with history of left carpal tunnel syndrome (clinically resolved), pustular acne, hearing loss on the left and history of adjustment disorder with depressed mood conditions, the Board unanimously recommends no change from the PEB determinations as not unfitting.  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 the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Upper Back Pain	5299-5237	10%	
Myofascial Pain…Right Shoulder	8519-5021	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140904, 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-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

02 DEC 2016

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for (PD201403905)

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 20% 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
(  ) DVA