RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00466
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20040108

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Military Police, medically separated for “myofascial pain left upper back” with a disability rating of 0%.

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 – 20031027	VA	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Myofascial Pain Left Upper Back	5099-5021	0%	No VA Claim Filed	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  Not Applicable	

ANALYSIS SUMMARY:  

Myofascial Pain Condition.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI sustained an injury when a M249 Squad Automatic Weapon (SAW) dropped on her left shoulder and back approximately 2 years prior to referral for MEB.  A 6 December 2001 emergency department examination revealed a 3 cm area of abrasion and tenderness of the left paraspinal area at the scapular level.  There was pain with rotation and movement of the left shoulder.  A 17 January 2002, left scapula X-ray was normal.  An 18 February 2003, left shoulder magnetic resonance imaging (MRI) study was unremarkable and showed no suggestion of a rotator cuff tear.  At a 26 March 2003 orthopedic surgery encounter, the CI complained of 8/10 left shoulder pain for 1-½ years.  
She reported constant pressure and radiation and that symptoms were made “worse with everything.”  The physical examination revealed levator scapulae muscle tenderness with no deformity or winging.  Left shoulder range of motion (ROM) was full.  Strength, sensation, and deep tendon reflexes (DTRs) were normal.  The examiner recounted the findings of the X-rays and MRI and documented no orthopedic intervention or follow-up was indicated.  The 15 September 2003 goniometer-measured left shoulder ROM was flexion of 180 (180 normal) and abduction of 180 (normal) degrees with pain.  The 24 September 2003 NARSUM, 4 months before separation, recounted the history and interventions.  The CI complained of chronic left upper shoulder pain.  She did not experience significant improvement with conservative management.  The physical examination revealed tenderness on the left upper back between the scapula and the spine.  There was no upper extremity muscle atrophy.  Strength and sensation was normal.  Left shoulder ROM was flexion of 180 (normal) and abduction of 180 (normal) degrees with pain.  The diagnosis listed myofascial pain in the left upper back region.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 0% rating under an analogous 5021 code (myositis) citing myofascial pain left upper back, without limitation of motion.  There was no evidence of scapulohumeral ankylosis (5200), recurrent dislocation, loss of humeral head, nonunion, fibrous union, or malunion of humerus (5202), or nonunion or malunion of clavicle or scapula (5203) for consideration under the respective codes.  There was no compensable limitation of motion for consideration under 5201.  The Board agreed a 10% rating was supported based on VASRD §4.40 (functional loss) or §4.59 (painful motion).  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 condition, coded 5021.  

BOARD FINDINGS:  In the matter of the myofascial pain 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 the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Myofascial Pain Left Upper Back	5099-5021	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150530, with attachments
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

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for 
XXXXXXXXXXXXXXXXXX, AR20170000122 (PD201500466)

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
(  ) DVA