RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01223
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20031015

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Fuels Technician, medically separated for “cervical radiculopathy associated with headaches and myofascial pain syndrome,” rated 10% with a disability rating of 20%.

CI CONTENTION:  “Review all conditions”.  The CI’s complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The panel’s scope of review is defined in DoDI 6040.44.  It is limited to review of disability ratings assigned 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 or non-compensable.  Any conditions outside the panel’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 panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The panel’s assessment of the PEB rating determination is based on 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(s) at the time of separation.  The panel 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 panel 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 - 20030818	VARD - 20050629	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Cervical Radiculopathy associated with Headaches and Myofascial Pain Syndrome	5290	10%	Neck and Back Condition	5237	NSC	STR	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  --NSR	

ANALYSIS SUMMARY:  

Cervical Radiculopathy Associated with Headaches and Myofascial Pain Syndrome.  According to the service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s cervical radiculopathy condition began in October 2001 when she sustained a “whiplash” injury to her neck.  The CI was treated for neck and upper back pain with some radiation of pain to the upper extremities, without any weakness, sensory deficits or reflex changes.  Thoracic and cervical X-rays were normal.  On 9 April 2002, cervical magnetic resonance imaging (MRI) showed a “minimal” left disc bulge at C5-6, and was otherwise normal.  There was no evidence of soft tissue injury.  In June 2002 the CI was evaluated by a pain specialist and neck range of motion (ROM) was slightly limited in all directions and maneuvers to detect arthritis of the spine were minimally positive.  The cervical muscles were taut and tender, without obvious or discrete trigger points.  The upper trapezius muscles were involved bilaterally with radiation into the shoulder region (trapezius muscle extends from the top of the neck to bottom of the thoracic spine and inserts on the clavicle and the scapula bilaterally).  The CI was diagnosed with cervical disc disease with radiculopathy, headaches and myofascial pain syndrome (all related to the cervical spine condition).  In September 2002 a family practice examination noted full cervical spine ROM.  After neck injections, the CI reported significant improvement in neck pain and headaches, but pain between the shoulder blades continued.  In February, May and July 2003 pain medicine examinations showed neck range of motion “extremely limited” to the left, with “grossly” positive examination maneuvers for spine arthritis on the left 

The MEB NARSUM examination on 13 August 2003, 2 months prior to separation, noted a complaint of back pain.  Physical examination showed the neck was supple and gait was steady.  Strength, sensation, and reflexes of all extremities were normal.  

In November 2003 and June and October 2004 VA outpatient evaluations, 5 months after separation, showed cervical ROM was recorded as “full”.  There was tenderness of the cervical and upper thoracic muscles noted at two out of three of the examinations, and a small amount of thoracic muscle spasm noted at one examination (June 2004).  In March 2004 VA physical therapy evaluation,  noted cervical ROM of flexion within normal, extension and side bending minimal to moderate limitation, left rotation mild limitation, and right rotation minimal limitation.  In January 2004 cervical and thoracic MRIs were both read as normal.  Tenderness of the trapezius muscles bilaterally was noted, left greater than right.  

At the initial VA Compensation and Pension (C&P) evaluation, performed on 9 June 2005, 21 months after separation, the CI reported pain in her neck, upper back and chronic headaches.  She denied arm pain, low back pain or lower extremity pain.  The neck pain was aggravated by lifting or prolonged periods of sitting standing, or writing.  She reported flare-ups with activity that lasted for hours and denied any incapacitating episodes over the past year. Physical examination showed tenderness to palpation of the cervical and thoracic musculature.  Cervical ROM was full in all planes of motion and was without pain except for at the extremes of rotation.  There was no additional loss of motion with repetitive motion.  Strength, sensation, and reflexes of all extremities were normal.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the cervical radiculopathy condition 10%, coded 5290 (limitation of cervical motion), using a VASRD spine code in effect at the time of the PEB, but replaced by the current VASRD spine codes effective 26 September 2003.  The VA did not service-connect the neck/back condition citing unavailability of service medical records 

The panel must make its rating recommendation based on the current VASRD rules for rating the spine in effect on the date of separation.  The panel agreed that a 10% rating, but no higher, was justified for limitation of flexion combined ROM (greater than 170 degrees but not greater than 335 degrees) reported at multiple pain medicine examinations proximate to separation.  The pain medicine evaluations noted “extremely limited” neck ROM to the left.  Even if assuming no rotation to the left, combined ROM was 260 degrees.  All other examinations in the STR noted that cervical ROM in all other planes was “slightly” limited or normal.  At VA outpatient examinations within a year of separation full cervical ROM was noted at three of four evaluations and at one PT evaluation the limitation of cervical ROM, as described supported, a 10% rating.  At the initial VA examination, which was performed more than a year after separation, the cervical ROM was also normal, with pain noted at extremes of cervical rotation.  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 also 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).  The CI’s neck condition was characterized as cervical radiculopathy with headaches and myofascial pain.  Radiating pain from the neck condition is subsumed under the general spine rating criteria, which specifically states “with or without symptoms such as pain (whether or not it radiates).”  There was no objective evidence of additional functional impairments, such as muscle weakness and/or a sensory deficits, with a direct impact on fitness that were separately functionally impairing for duty.  

The panel therefore concluded that additional disability rating was not justified on this basis and, in this case, the panel also agreed that the CI’s cervical spine condition was not more appropriately coded and rated under VASRD 4.124a (neurological conditions).  Although the PEB utilized an earlier VASRD code that was not in effect on the CI’s date of separation, the panel arrived at the same rating under the current VASRD codes and there is no ratings benefit for the CI in recommending a change in the code. 

After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded that there was insufficient cause to recommend a change in the PEB adjudication for the “cervical radiculopathy condition associated with headaches and myofascial pain syndrome” condition.  

BOARD FINDINGS:  In the matter of the “cervical radiculopathy condition associated with headaches and myofascial pain syndrome” condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  There are no other conditions within the panel’s scope of review for consideration.  The panel, 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 20150612, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAF/MRB
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Dear XXXXXXXXXXXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2015-01223.

After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was appropriate.  Accordingly, the Board recommended no re-characterization or modification of your separation.

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding and their conclusion that re-characterization of your separation is not warranted.  Accordingly, I accept their recommendation that your application be denied.

Sincerely,

Attachment:
Record of Proceedings