RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01864
BRANCH OF SERVICE:  navy 	SEPARATION DATE:  20030410

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Ocular/Surgical Technician, medically separated for “fibromyalgia, bilateral biceps tendinitis, with depressed mood” with a disability rating of 20%.  

CI CONTENTION:  The CI asked that all conditions be reviewed.  He believes that the conditions that were grouped together under fibromyalgia should have been rated separately so he could have retired.  He has been severely depressed since his active duty years and has multiple conditions that were diagnosed on active duty, including spinal surgery he had at Walter Reed, which cause him to be totally disabled.  The 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 - 20021206	VARD - 20040408	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Fibromyalgia, Bilateral Biceps Tendinitis, with Depressed Mood	5025	20%	Fibromyalgia with Chronic Fatigue and Polyarthralgia and Constipation	5025	40%	20030618	
			Depression	9434	70%	20030708	
			Right Upper Extremity Radiculopathy Associated with…	8699-8610	40%	20030618	
			Left Upper Extremity Radiculopathy Associated with…	8699-8610	30%	20030618	
Chronic Daily Headaches	Cat II	Post Traumatic Headaches with Photophobia and Occipital Neuralgia	8199-8100	30%	20030610	
Migraine without Aura	Cat II					
Chronic Neck Pain, Musculoskeletal in Nature	Cat II	Cervical Myelopathy with Arthritis	5290	20%	20030618	
Chronic Low Back Pain, Musculoskeletal in Origin	Cat II	Degenerative Disc Disease Lumbar Spine	5292	10%	20030618	
Severe Left Temporomandibular Joint Syndrome	Cat II	Temporomandibular Joint Syndrome	9905	30%	20030618	
Bilateral Ischial Bursitis and Hamstring Tendinitis	Cat II	no VA placement	
Polyarthralgia	Cat II		
Primary Hypothyroidism	Not Unfitting	Hypothyroidism	7903	10%	20030618	
Status Post Arthroplasty Bilateral Fifth Toes	Not Unfitting	Left Foot, Fifth Toe Arthroplasty	5283	10%	20030618	
		Right Foot, Fifth Toe Arthroplasty	5283	10%	20030618	
Possible Mild Cochlear Hydrops	Not Unfitting	Bilateral Tinnitus with Otalgia due to Head Trauma	6260	10%	20030627	
Mild Eustachian Tube Dysfunction	Not Unfitting					
Intrameniscal Degeneration	 Not Unfitting	Patellofemoral Syndrome, Right Knee with Degenerative Changes	5010	10%	20030618	
		Degenerative Joint Disease, Left Knee	5010	10%	20030618	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  100%	

ANALYSIS SUMMARY:  

Fibromyalgia, Bilateral Biceps Tendinitis, with Depressed Mood.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s fibromyalgia condition began in June 2000 after a motor vehicle accident in 1999.  The CI originally presented with neck pain that was evaluated by a neurologist.  He then complained of diffuse pain of the left neck, shoulders, head and knees with pain all over at a 10/10 (10 being the worst pain) level, which varied in intensity and location.  Fibromyalgia treatment consisted of Depakote (divalproex), Flexeril (cyclobenzaprine, a muscle relaxer), and Relafen (nabumetone, a nonsteroidal anti-inflammatory drug (NSAID)).  He had headaches (see below), a history of hypothyroidism (see below) treated with Synthroid (levothyroxine), and a positive FTA (test for syphilis infection) necessitating treatment for presumptive neurosyphilis with 10 days of intravenous penicillin.  At a physical medicine evaluation in February 2002 gabapentin (for nerve pain) dosing was to be increased.  Rheumatology evaluation on 19 February 2002 found tender points bilaterally above and below the waist.  All joints had a full range of motion (ROM).  Amitriptyline (for nerve pain) was added to the treatment protocol.  The CI had a severe flare of fibromyalgia on 25 April 2002 with bilateral biceps tendonitis and pain all over with tender points bilaterally above and below the waist.  Imipramine (an antidepressant and for pain) was prescribed and the severe flare symptoms decreased within a month.  In December 2002 the CI was noted to have a depressed mood, which psychological evaluation noted was from physiological pain.  A muscle biopsy of the quadriceps muscle was negative for myopathy.  

The 1 March 2002 Rheumatology Addendum, 13 months prior to separation, noted complaints of fibromyalgia.  Physical examination showed tender points bilaterally above and below the waist.  The 22 April 2002 Psychiatric Addendum, 12 months prior to separation, noted complaints of chronic pain.  Other problems exacerbating his pain symptoms included bowel problems, a lack of sleep, sexual problems, fatigue, palpitations, and tremors.  The CI was referred for evaluation of how psychological factors contributed to his pain and whether he could benefit from behavior pain management.  On a mental status and behavioral evaluation the CI was well-dressed and well-groomed.  He had a sad and controlled demeanor, and maintained intermittent eye contact.  He was pleasant, courteous, and helpful, but appeared to be in pain.  His speech was fluent, and his interactions were appropriate.  He appeared to have adequate formal thought functioning and his narrative was logical, linear and goal directed.  There was no evidence of hallucinations or other thought disorders and no suicidal thoughts were reported.  He seemed preoccupied about his pain throughout the interview.  His affect was congruent with his concerned mood, but it was stable and maintained within an appropriate and full range.  He was fully alert and oriented to his social environment.  His intellectual abilities appeared to be within the above average range of intelligence.  Memory, concentration and other cognitive processes appeared to be intact.  Impulse control was good and his judgment and insight appeared to be intact.  A Beck Depression Inventory revealed mild depression.  The psychologist’s impression was no diagnosis for Axis I and the CI’s Global Assessment of Functioning (GAF) score was 67-70 (some mild symptoms or some difficulty in social, occupational, or school functioning, but generally functioning pretty well, has some meaningful interpersonal relationships).  The psychologist indicated the CI was fit for full duty from a psychological perspective and there did not appear to be a psychological disorder that exacerbated his pain condition.  The CI was felt to be a good candidate for a comprehensive, interdisciplinary pain program that focused on using cognitive and behavioral techniques to prevent and reduce his perception of pain.  

The 31 May 2002 ENT (Ear, Nose and Throat) Addendum indicated the CI had a bubble feeling in his left ear with pain and good hearing (see below).  Examination in October 2001 showed both eardrums were normal and he had very tender temporomandibular joints.  The rest of the examination including a fiberoptic examination of his nasopharynx was normal.  Magnetic resonance imaging of the internal auditory canal was normal except for some effusion in the mastoids.  The CI was diagnosed with TMJ (temporomandibular joint) pain, which also caused ear pain.  Treatment consisted of a night guard and an NSAID.  Hot compresses were added to treat the condition along with Flonase (fluticasone, a nasal steroid) and Valsalva maneuver exercises (forceful exhalation against a closed airway).  

During the 27 September 2002 MEB examination (recorded on DD Forms 2807-1 and 2808), 7 months prior to separation, the CI reported severe, unbearable pain in the shoulders, elbows, knees, ankles, wrists, fingers and feet.  Physical examination showed tenderness with palpation to the posterior cervical area, left upper quadrant, right upper quadrant, left lower quadrant, right lower quadrant, scapula, deltoids, mid thoracic, and lumbar areas.

The 18 October 2002 Physical Medicine and Rehabilitation Addendum, 6 months prior to separation, noted complaints of pain for 3 years.  Physical examination showed bilateral paracervical tenderness to palpation.  Spurling’s sign (to determine nerve root irritation) revealed axial neck pain.  Strength was 5-/5 in the upper and lower extremities bilaterally, which was limited by pain.  Sensation was intact; reflexes were 2+ and equal bilaterally; muscle tone and bulk were normal; and the CI’s gait was slightly wide-based, but steady and reciprocal.  On 28 May 2003, 6 weeks after separation, the CI underwent a C3-C4 anterior cervical discectomy and fusion for cervical myelopathy (see below).   

At the 18 June 2003 VA Compensation and Pension (C&P) evaluation, 2 months after separation, the CI reported fibromyalgia characterized by generalized fatigue and polyarthralgias involving the shoulders, thighs, elbows, wrists, and fingers.  Physical examination showed a slow and stiff gait without any assistive devices.  The abdomen was soft and nontender.  There was no spasm of the paravertebral muscles in the lumbar region, although there was tenderness to percussion over the lumbar spine.  Flexion was 70 degrees (normal 90) and movements were performed slowly and in a stiff manner with pain on flexion and extension. There was tenderness to palpation over the trapezius muscles bilaterally.  His shoulders, elbows, wrists, hips, and knees were nontender, while his ankles were tender.  At 8 July 2003, 3 months post-separation, the C&P evaluation for Mental Disorders the CI reported increasing depression since November 2001 with daily dysphoria, inertia, irritability and low frustration tolerance, decreased sleep and appetite with resulting loss of weight and muscle tone, feelings of worthlessness/ hopelessness/helplessness, increased somatic aches and pains, anhedonia, social isolation, obsessive rumination, passive death wishes, paranoid and referential thinking and attendant auditory hallucinations, which were derogatory in nature.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the fibromyalgia, bilateral biceps tendinitis, with depressed mood condition 20%, coded 5025 (fibromyalgia), citing that the CI was restricted to working 4½ hours a day in split shifts due to the exacerbation of his symptoms.   The chronic headaches, neck, back, shoulder, hip and leg pain that produced impairment was considered closer to the 20% rating criteria.   The Navy PEB also listed chronic low back pain, musculoskeletal in origin, severe left temporomandibular joint syndrome, bilateral ischial bursitis and hamstring tendinitis, and polyarthralgia as related Category II conditions that contributed to or were related to the primary unfitting condition but were not separately ratable.  The impairment from the chronic low back pain, musculoskeletal in origin, severe left temporomandibular joint syndrome, bilateral ischial bursitis and hamstring tendinitis, and polyarthralgia were properly subsumed under the overall rating for the fibromyalgia IAW §4.14 (avoidance of pyramiding; more than one rating based on the same impairment is prohibited).  The PEB also listed chronic daily headaches, migraine without aura, and chronic neck pain, musculoskeletal in origin as Category II conditions, which warrant further discussion (see below) because of the severity of each of the conditions.  The VA rated the fibromyalgia condition 40%, coded 5025, (fibromyalgia), based on the C&P examination 2 months after separation, citing polyarthralgia reported as constant on the VA examination.  The VA also rated the depression at 70%, coded 9434 (major depressive disorder), citing depressed mood with psychotic features, obsessive ruminations, auditory hallucinations, and paranoid thinking.  The CI stated he was being treated with Zoloft for depression, which he took erratically, but there was no record in his file.  The mental status examination noted the CI was adequately groomed and frequently squirmed in pain.  His speech was normal, mood depressed, affect irritable, thought process goal directed with some thought blocking, thought content with ideas of reference and paranoid and appeared to be attending to internal stimuli.  There was no active suicidal or homicidal intent or plan.  The Axis I diagnosis was major depression with psychotic features with a GAF score of 45 (serious symptoms or any serious impairment in social, occupational, or school functioning.

Panel members noted the disparity between the PEB rating and the VA rating.  VASRD code 5025 addresses fibromyalgia as “with widespread musculoskeletal pain and tender points, with or without associated fatigue, sleep disturbance, stiffness, paresthesias, headache, irritable bowel symptoms, depression, anxiety, or Raynaud's-like symptoms.”  The VASRD notes that “widespread pain means pain in both the left and right sides of the body, that is both above and below the waist, and that affects both the axial skeleton (i.e., cervical spine, anterior chest, thoracic spine, or low back) and the extremities.”  A 40% rating requires the fibromyalgia symptoms to be “constant, or nearly so, and refractory to therapy,” while a 20% rating requires the symptoms to be “episodic, with exacerbations often precipitated by environmental or emotional stress or by overexertion, but that are present more than one-third of the time.”  The CI symptoms were constant, or nearly so, and were refractory to therapy, albeit reports of his being able to work 4½ hours a day in split shifts.  It was the exacerbations that limited his full work capacity; and it is those exacerbations as well as the widespread, recalcitrant symptoms, which were present on multiple examinations, which justify a 40% rating.  Members noted that during service, the CI’s depressive mood did not include symptoms on which the VA based its separate 40% rating for a major depressive disorder.  Therefore, panel members agreed that the depressive mood noted by the PEB was a component of fibromyalgia and not a separate or independent condition warranting an unfitting condition or rating based on findings during service.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 40% for the fibromyalgia, bilateral biceps tendinitis, with depressed mood condition, coded 5025.  

The PEB listed the chronic daily headaches, migraine without aura condition and chronic neck pain, musculoskeletal in origin condition as Category II conditions (conditions that are related to the primary unfitting condition and contribute to the primary unfitting conditions).  The panel’s first charge for these Navy PEB Category II conditions is to assess whether any of them can be reasonably justified as separately unfitting for rating consideration.  The panel’s threshold for such determinations is reasonably unfitting.  

Chronic Daily Headaches and Migraine without Aura.  In April 2001 the CI complained of migraine headaches since 1999 as a result of a motor vehicle accident that occurred every day and were lasting longer and were accompanied by nausea and vomiting.  Throbbing pain was felt in the right periorbital, frontal, and temporal areas along with photophobia (light sensitivity).  The CI was admitted to the hospital in September 2001 for a headache claimed to last 22 days without interruption.  Treatment consisted of DHE (dihydroergotamine mesylate).  At the time of discharge his headache was minimal.  The CI presented to the Emergency Room (ER) with a migraine headache on 20 September 2001 where computerized tomography demonstrated fluid in the left mastoid.  The CI had additional visits to the ER on 4 October 2001 and 25 October 2001 where DHE and Reglan (metoclopramide for nausea) were given.  The CI underwent a spinal tap based on a positive FTA laboratory result with subsequent treatment for presumptive neurosyphilis; however, the headaches persisted.    

The 15 February 2002 Neurology MEB NARSUM noted complaints of daily headaches for several years, which were typically on the left side of the face, but with no associated aura, weakness, or numbness.  They were severe and throbbing with associated photophobia and phonophobia (noise sensitivity), as well as nausea, and the CI had to lie down.  He typically lost approximately 2 to 4 days of work monthly.  Magnetic Resonance Imaging (MRI) of the brain with contrast was normal.  His headaches were refractory to inderal (a beta blocker), Pamelor (nortriptyline, an antidepressant and for nerve pain), desipramine (an antidepressant), Neurontin (gabapentin), Amerge (naratriptan for migraine treatment), Imitrex (sumatriptan for migraine treatment), steroids, Indocin (indomethacin, an NSAID), Vioxx (rofecoxib, an NSAID), Depakote (divalproex), and Maxide (dyazide, a diuretic).  Maxalt (rizatriptan for migraine treatment) did help to some extent, while Motrin (ibuprofen, an NSAID) and Tylenol (acetaminophen, a pain reliever) may have contributed to analgesic rebound headaches.  Neurologic examination was unremarkable except for equivocal plantar reflexes bilaterally.  The examiner noted no etiology for his headaches, which were likely to be migrainous in nature.  The CI was hospitalized for 4 days in April 2002 for chronic daily headaches, which caused difficulty sleeping and awakened him at night.  Treatment consisted of intravenous DHE with significant improvement in the headache; however, neck, back, and shoulder pain, which was present on admission, persisted.    

At the 10 June 2003 VA Compensation and Pension (C&P) evaluation, 2 months after separation, the CI reported headaches that were improving.  A few weeks earlier he had undergone a diskectomy and was still wearing a collar from that operation.  Nevertheless, he still had the a generalized headache with pain around his eye, mouth, face, neck, low back, and down his arm and shoulder.  Physical examination showed the CI acted as if he were in pain.  The examiner opined the CI did not have migraine, but had post traumatic headaches.

Chronic Neck Pain, Musculoskeletal in Origin.  In December 2001 the CI reported a history of chronic cervical pain with a background of migraine headaches.  Chiropractic evaluation indicated the CI’s neck pain was characterized as dull and he had sharp lower back pain.  Treatment did not afford significant improvement.  Gabapentin (for nerve pain) dosage was increased over several visits.  Cervical spine X-rays in March 2002 showed a mild curvature suggestive of muscle spasm.  The CI received trigger point injection at a physical medicine treatment visit on 14 May 2002.  An ENT note dated 16 October 2002 indicated the CI complained of persistent left ear and neck pain.  Examination and tests were suggestive of a left typanomandibular joint (TMJ) syndrome and left greater occipital neuralgia.  An MRI dated 31 October 2002 demonstrated multilevel cervical spondyloarthropathy, the effects of which were amplified by the presence of a developmentally narrowed central bony canal.  There were no concerning pathologic enhancement although the CI may have had scar/fibrosis in the superficial soft tissues of the dorsal midline neck overlying C6.  On 19 March 2003 the CI reported constant pain in the cervical area with tingling the upper trapezius over the right deltoid.  On 8 April 2003 an orthopedic surgeon noted the CI had severe degenerative disk disease with myelopathy (compression of the spinal cord), which would require conservative management and a possible surgical fusion decompression of his cervical spine.  On 28 May 2003, 6 weeks after separation, the CI underwent a C3-C4 anterior cervical discectomy and fusion with a plate and allograft bone for cervical myelopathy marked by hyperreflexia, an ataxic gait as well as Hoffmann reflexes (indicate presence of an upper motor neuron lesion from spinal cord compression), and a positive Lhermitte sign (a shock-like sensation that passes down the neck when the head is flexed forward).  Postoperatively, the CI reported severe neck pain and was seen in the ER on 30 June 2003.  Treatment consisted of Percocet (oxycodone, a narcotic, and acetaminophen, a pain reliever) and a referral to orthopedics where he was seen on 2 July 2003 and reported “difficulty swallowing.”  ROM of the neck was decreased due to pain.  Sensation to light touch of the upper extremities was intact and muscle strength was 4/5 bilaterally in the upper extremities and 4-4+/5 bilaterally of the lower extremities, but sensation was decreased in the left leg.  He had a poor tandem gain and decreased ability to walk on the toes and had anesthesia of the buttocks and inner thighs. 

The VA rated the post traumatic headaches with photophobia and occipital neuralgia condition 30%, coded 8199-8100, (migraine) on the C&P examination 2 months after separation, citing photophobia and pain involving the face.  The VA also rated the upper extremity and cervical myelopathy conditions, which are not in the scope of review. 

Members agreed that the subsumed Category II chronic daily headaches and migraine without aura and chronic neck pain, musculoskeletal in origin conditions were reasonably justified as separately unfitting and independent of the fibromyalgia, the cause of which is unknown.  Furthermore, given the fact that the headaches were recalcitrant to therapy and the CI lost 2 to 4 days of work each month and the chronic neck pain that was originally deemed to be musculoskeletal in origin was a result of the spondyloarthropathy that eventuated into a myelopathy, which required neurosurgical intervention proximate to separation support each as an unfitting condition.  Panel members noted that myelopathy was not in the scope of review and cervical quantitative ROMs on which a rating is determined were not in the STR; therefore, members considered a rating using code 5099-5003 since there was painful motion both pre- and post-separation.  There was no documentation of intervertebral disc syndrome with incapacitating episodes which would provide for a higher rating under that formula.    

After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 30% for the chronic daily headaches and migraine without aura, coded 8100, based on “characteristic prostrating attacks occurring on an average once a month over last several months” and a history of missing work 2 to 4 days each month.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the chronic neck pain, musculoskeletal in origin, coded 5099-5003.

Contended PEB Conditions:  Primary Hypothyroidism; Status Post Arthroscopy Bilateral Fifth Toes; Possible Mild Cochlear Hydrops, Mild Eustachian Tube Dysfunction, Intrameniscal Degeneration.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  There were no Limited Duty documents available for review and none of the conditions were explicitly implicated in the commander’s statement. 

Primary Hypothyroidism.  The CI was diagnosed with hypothyroidism and was treated with Synthroid (levothyroxine).  Follow-up physical examination and laboratory studies were normal.

Status Post Arthroscopy Bilateral Fifth Toes.  The CI had hammertoe deformities of the fifth toes bilaterally.  The CI underwent surgery in December 2000.  Postoperatively, the CI had a fungal wound infection that was treated.  The operative sites healed and X-rays demonstrated normal bone with no signs of infection in the fifth toes of either foot.  However, the CI complained of pain at both surgical sites.  

Mild Cochlear Hydrops and Mild Eustachian Tube Dysfunction.  Mild cochlear hydrops manifested by a bubble feeling in his left ear.  There was some effusion in the mastoids.  Treatment consisted of a diuretic.  Mild eustachian tube dysfunction was treated with Flonase (fluticasone) and valsalva maneuvers.  The examiner felt the ear conditions were related to the TMJ pain; however, an audiogram and tympanogram were normal.

Intrameniscal Degeneration, Left Knee Medial Meniscus.  The CI had a full ROM at the knee with a slight varus alignment.  The knee was stable with some medial joint line and bursa tenderness.  X-rays demonstrated minimal degenerative changes diffusely in the left knee.  An MRI revealed Intrameniscal degeneration of the medial meniscus.  The examiner felt the knee pain was largely due to the fibromyalgia.

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 panel 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 fibromyalgia, bilateral biceps tendinitis, with depressed mood condition, the panel unanimously recommends a disability rating of 40%, coded 5025 IAW VASRD §4.71a.  In the matter of the Category II chronic daily headaches and migraine without aura, the panel agrees that it was unfitting and unanimously recommends a disability rating of 30%, coded 8100 IAW VASRD §4.124a.  In the matter of the Category II chronic neck pain, musculoskeletal in origin, the panel agrees that it was unfitting and unanimously recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a.  In the matter of the contended primary hypothyroidism; status post arthroscopy bilateral fifth toes; possible mild cochlear hydrops, mild Eustachian tube dysfunction, and intrameniscal degeneration conditions, the panel unanimously recommends no change from the PEB determinations as not unfitting.  There are no other conditions within the panel’s scope of review for consideration.  

The panel recommends that the CI’s prior determination be modified as follows; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective as of the date of the prior medical separation:  

The panel 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	
Fibromyalgia, Bilateral Biceps Tendinitis, with Depressed Mood	5025	40%	
Chronic Daily Headaches and Migraine without Aura	8100	30%	
Chronic Neck Pain	5099-5003	10%	
COMBINED	60%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150708, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

MEMORANDUM FOR COMMANDER, NAVY PERSONNEL COMMAND	
	                          
Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS          

Ref:  (a) DoDI 6040.44
	(b) PDBR ltr dtd 12 Jul 17 ICO XXXXXXXXXXXXXXXXXX
	(c) PDBR ltr dtd 02 Aug 17 ICO XXXXXXXXXXXXXXXXXX
	(d) PDBR ltr dtd 07 Jul 17 ICO XXXXXXXXXXXXXXXXXX
	(e) PDBR ltr dtd 31 Jul 17 ICO XXXXXXXXXXXXXXXXXX
	(f) PDBR ltr dtd 31 Jul 17 ICO XXXXXXXXXXXXXXXXXX
	(g) PDBR ltr dtd 14 Jul 17 ICO XXXXXXXXXXXXXXXXXX

1.  Pursuant to reference (a), the recommendations of the Physical Disability Board of Review set forth in references (b) through (g) are approved.  The official records of the following individuals are to be corrected as follows:

     a. XXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge. 

     b. XXXXXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 30 percent rating (increased from 10 percent) effective date of discharge.      

     c. XXXXXXXXXXXXXXXXXX, former USN: Retroactive placement on the Temporary Disability Retired List for six months beginning date of discharge with a 60 percent combined disability rating and a final rating after six months of 20 percent.  

     d. XXXXXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 60 percent rating (increased from 20 percent) effective date of discharge.       

     e. XXXXXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 30 percent rating (increased from 10 percent) effective date of discharge.

     f. XXXXXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 40 percent rating (increased from 20 percent) effective date of discharge.
     
3.  Please take action to implement these decisions and provide notification to the above individuals once those actions are complete.

	XXXXXXXXXXXXXXXXXX
	Acting