RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXX	CASE:  PD-2015-02135
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20081120

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Air Defense System Operator/Maintainer, medically separated for “cervical myofascial pain” with a disability rating of 20%.

CI CONTENTION:  “Daily pain migraines and mental health issues related to unfitting condition that was not considered before.”  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 - 20080804	VARD - 20081229	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Cervical Myofascial Pain	5237	20%	Chronic Cervical Strain	5237	10%	20080925	
Depressive Disorder	Not Unfitting	Depressive Disorder	9434	30%	20080924	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  80%	

ANALYSIS SUMMARY:  

Cervical Myofascial Pain.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s neck pain began in June 2006 during basic training.  The 9 May 2007 cervical and thoracic spine magnetic resonance imaging (MRI) showed C5-6 and C6-7 disc protrusion/herniation, T2-3 and T6-7 minimal disc bulging, loss of lordosis, and no significant central canal or neural foraminal (nerve root opening) stenosis (narrowing).  The 4 February 2008 cervical and thoracic MRI showed C4-5, C5-6 and C6-7 small disc bulges; no significant central canal or neural foraminal stenosis; and mild cervical and thoracic degenerative changes.  A 12 February 2008 electrodiagnostic study revealed no evidence of thoracic outlet syndrome (disorders from compression, irritation, or injury of nerves and/or blood vessels in space between collarbone and first rib), radiculopathy (nerve root irritation or injury), plexopathy (complex nerve network irritation or injury), or median or ulnar nerve neuropathy (peripheral nerve irritation or injury).  There was no surgical indication and conservative treatment did not result in improvement sufficient to allow unrestricted duty.  

During the 8 February 2008 MEB examination, (DD Form 2808), 9 months prior to separation, examination revealed mild tenderness at the base of the cervical spine with paravertebral and trapezius muscle tightness.  Cervical spine active range of motion (ROM) was full.  The 28 March 2008 MEB NARSUM, 8 months prior to separation, noted complaints of constant throbbing neck pain rated 3/10 in severity, with flares to 10/10, lasting 1.5 to 6 hours.  The pain was made worse with prolonged standing or sitting, heavy lifting, repetitive upper extremity work or exercise.  The physical examination documented a normal gait.  The neck examination revealed posterior tenderness with no muscle spasm, step-off or decreased suppleness.  Neck ROM was “within normal limits.”  

At the 3 April 2008 orthopedic appointment, the CI reported “back pain” with abnormal sensation (paresthesia) of the left upper extremity, but he denied weakness.  On examination, gait was normal, and neck tenderness was reported, but spasm was absent.  Neurologic examination was normal, and cervical ROM was reported as “full” in all planes of motion.  Later that same month, on 21 April 2008, a second orthopedic examination reported the CI as moving “with no obvious problems” but posture as having the head thrust forward “about 2 inches” and marked spasm of the spinal muscles; but the spinal segment was not identified (i.e., cervical, thoracic, etc).  Cervical ROM was reported as “30% of normal secondary to tightness in the muscles.”  On 23 July 2008 physical therapy (PT) measured repetitive (X3) ROM for the MEB with a goniometer.  Pain-limited cervical spine active ROM was flexion of 30 (45 normal), extension of 20 (45 normal), right side bending of 30 (45 normal), left side bending of 30 (45 normal), right rotation of 45 (80 normal), left rotation of 50 (80 normal), and combined of 205 degrees (340 normal).  The CI complained of constant neck pain ranging from 3-9/10 in severity, with twice monthly flares lasting 4-6 hours, which were caused by prolonged sitting or standing as well as heavy lifting.  He also complained of fatigue, weakness, lack of endurance, and loss of hand coordination.  

At the 25 September 2008 VA Compensation and Pension (C&P) examination, 2 months before separation, the CI reported neck and upper back pain that occurred spontaneously 4 times per week and was rated at 8/10 in severity.  The physical examination documented a normal gait and posture.  The neck examination revealed no tenderness, muscle spasm, ankylosis, decreased suppleness, or radiating pain on movement.  Cervical spine active ROM was flexion of 40 (45 normal), extension of 30 (45 normal), right lateral flexion of 30 (45 normal), left right lateral flexion of 30 (45 normal), right rotation 20 (80 normal), left rotation 45 (80 normal), and combined of 195 degrees (340 normal).  The joint function of the spine was not additionally limited by pain, fatigue, weakness, lack of endurance, or incoordination after repetitive use.  Strength, sensation, pulses and DTRs were normal and pathologic reflexes were absent.  The cervical spine X-ray revealed no acute cervical spine abnormality.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the neck condition 20% under the 5237 code (cervical spine strain), citing limitation of motion.  The VA used the same code (5237), but assigned a 10% rating for limitation of motion.  The panel agreed that a 20% rating, but no higher, was justified for limitation of flexion (greater than 15 degrees but not greater than 30 degrees) as reported on the PT for MEB examination.  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).  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 neck condition.  

Contended PEB Condition:  Depressive Disorder.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended condition was not unfitting.  The contended condition was not profiled, implicated in the commander’s statement, or judged to fail retention standards.  There was no performance-based evidence from the record that the condition 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 the contended condition and so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the neck condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the contended depressive disorder condition, the panel unanimously recommends no change from the PEB determination as not unfitting.  There are no other conditions within the panel’s scope of review for consideration.  The panel, therefore, recommends that there be no modification or re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150805, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

	

AR20170010114, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found your separation disability rating and your separation from the Army for disability with severance pay to be accurate.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed), and I accept its recommendation.  I regret to inform you that your application to the DoD PDBR is denied.  

	This decision is final.  Recourse within the Department of Defense or the Department of the Army is exhausted; however, you have the option to seek relief by filing suit in a court of appropriate jurisdiction.

Sincerely,