15RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02375
BRANCH OF SERVICE:  Navy 	SEPARATION DATE:  20071231

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an  E6, Automatic Combustion Control Console Operator, medically separated for “myofascial pain” with a disability rating of 10%.    

CI CONTENTION:  The CI made no specific contention.  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 - 20071119	VARD - 20080422	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Myofascial Pain	5099-5021	10%	No VA Placement	
Lumbago	Cat II	DDD, Thoracolumbar Spine	10%	20071024	
Cervicalgia		DDD, Cervical Spine	20%		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  70%	

ANALYSIS SUMMARY:  

Myofascial Pain.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s myofascial pain condition began in March 2004 after sustaining a motor vehicle accident leading to “chronic, non-radiating neck and lower back pain.”  At a physical therapy clinic evaluation on 6 April 2004 the CI presented with diagnoses of whiplash and mild back strain, which by the time of the visit, most of the neck pain and headaches had resolved; however, he had a little bit of stiffness in his cervical spine and mid back pain worked its way to the lower back.  There was tenderness to palpation in the mid thoracic spine paraspinals, right greater than left, and stiffness in the bilateral upper trapezoid muscles and cervical spine paraspinals.  X-rays of the cervical spine dated 26 March 2004 were normal, while magnetic resonance imaging (MRI) of the lumbar spine demonstrated posterior bulging present at L4-L5 level causing only mild spinal stenosis, greater on the left than the right.  X-rays of the thoracic spine dated 14 May 2004 showed mild dextroscoliosis (curvature to the right).  An MRI of the thoracic spine dated 28 May 2004 was normal.  At a primary care visit on 28 February 2005 the CI reported burning pain in the upper and lower back, which was exacerbated by exertion and relieved by rest, without radiation.  Examination revealed no swelling.  There was a full range of motion (ROM) with no pain and there was paraspinous muscle spasm from T12 downward.  Treatment consisted of Zanaflex (tizanidine, a muscle relaxer).  In March 2005 the CI reported increased pain, described as stabbing and burning, located in the lower back.  On examination the ROM was decreased and movements were painful with paraspinous muscle spasm and tenderness over thoracic vertebrae.  Relafen (nabumetone, a nonsteroidal anti-inflammatory medication (NSAID)) and Neurontin (gabapentin for nerve pain) were added and steroid and anesthetic trigger injections were given in the left thoracic area.  The CI reported pain radiated to the right thigh, upper back, and neck.  Elavil (amitriptyline for nerve pain) was added to the treatment regimen.  On 6 June 2005 X-rays of the thoracic spine were normal; the lumbosacral spine demonstrated a minimal bulge of L4-L5; and the cervical spine showed spinal stenosis of C5-6.  An MRI dated 6 June 2005 demonstrated spinal stenosis due to disc protrusion at C5-6, producing spinal stenosis and cord contouring, while a minimal disc bulge at L4-5, which did not appear to be clinically significant, was noted; and a MRI of the thoracic spine was normal.  At a neurosurgical visit on 13 June 2005 the ROMs of the neck and the thoracolumbar spine were normal and Spurling’s test (to determine nerve root irritation) was positive.  Treatment consisted of Lidoderm patches (lidocaine, an anesthetic), Lexapro (escitalopram, an antidepressant), tramadol (an opioid-like medication), and Robaxin (methocarbamol, a muscle relaxer).     Diagnostic/therapeutic injection treatments were discussed as well as terms of treatment with controlled substances.  At a visit on 2 August 2005 the CI was given prescriptions for trazodone (an antidepressant and sedative) and baclofen (β-(4-chlorophenyl)-γ-aminobutyric acid, a muscle relaxer to treat muscle spasms).  A neurology evaluation for recurrent episodes of back pain that were refractory to any resolution despite physical therapy and massage therapy was performed on 18 October 2005.  The cranial examination was normal and the ROMs of the neck and the back were normal.  The CI had good mechanics of movement of all limbs and of sitting, standing, walking, turning, and pivoting.  The remainder of the neurological examination was unremarkable.  The neurologist noted the images of the spine demonstrated mild disc bulging in the cervical and lumbar spine, which did not bear any significant relationship to the CI’s symptoms.  The neurologist talked about self-directed exercise and strategies of strengthening and stretching, but did have not have any other strategy the CI could implement nor did he think there were any other diagnostic modalities that would be useful at that time nor did he think any surgery was warranted.   A note dated 21 July 2006 indicated the CI was taking Ultracet (tramadol and acetaminophen, a pain reliever) and Mobic (meloxicam, an NSAID) for the lower back and neck pain.  Electrodiagnostic testing dated 15 March 2007, ordered for low back pain and upper and lower extremity paresthesia, revealed normal nerve conduction studies of the right arm and leg and normal EMG (electromyogram) of the right arm, right leg and left leg.  There was no denervation in the limbs including the left C6 arising from the C5-6 disk seen on MRI.

During the 25 September 2007 MEB examination (recorded on DD Forms 2807-1 and 2808), 3 months prior to separation, the CI reported he was advised to have surgery for a herniated disc of the neck.  The examiner recorded “hnp (herniated nucleus pulposus)-med board” as an abnormal finding for the clinical evaluation of the spine.   The 6 September 2007 MEB NARSUM examination, 3 months prior to separation, noted complaints of inability to sit for more than 40-45 minutes without his back pain becoming severe. He was unable to stand or walk for more than a few minutes without pain increasing.  The examiner noted the pain was severe enough to significantly limit his ability to perform his duties.  Physical examination showed a normal gait with paraspinal tenderness throughout the back and neck.  Neurologic evaluation was unremarkable. The Non-Medical Assessment dated 21 September 2007 indicated the CI last passed the physical fitness test in May 2003, was away from work for treatment, evaluation, and/recuperation 14 hours per week, and contributed to the mission as much as his physical limitations permitted.  

At the 24 October 2007 VA Compensation and Pension (C&P) evaluation, 2 months before separation, the CI reported pain of the neck and the right trapezius most of the time with occasional involvement of the left trapezius.  He also reported low back pain across the low back and buttock, right side more than the left.  Physical examination showed tenderness to the base of the neck with increase in muscle tone on the left trapezius more so than the right trapezius.  The ROM for flexion of the neck was 30 degrees (normal 45), extension 30 degrees (normal 45), rotation 55 degrees (normal 80) right and 55 degrees (normal) left.  Lateral flexion was 40 degrees (normal 45) to the right and 40 degrees (normal 45) to the left.  Vertical compression caused tenderness at the base of the neck and the trapezius, right greater than left.  Motor strength of the upper extremity was 5/5 and reflexes were not elicited bilaterally.  X-rays demonstrated vertebral body heights were preserved with no fracture or dislocation and the neural foramina were patent bilaterally.  Painful and limited motion were negative. Examination of the back revealed the pelvis was parallel to the floor to slight elevation on the right side.  There was no spasm, but there was triggering to the L5-S1 area.  Sacroiliac discomfort was positive bilaterally with no sciatic irritation.  Flexion was 95 degrees (normal 90), extension 30 degrees (normal 30), lateral flexion 40 degrees (normal 30) to the right and 40 degrees (normal 30) to the left, and rotation 35 degrees (normal 30) to the right and 35 degrees (normal 30) to the left.   Motor strength was 5/5.  Reflexes could not be elicited.  X-rays revealed minimal degenerative change in the lower lumbar spine.  There was painful motion and limited motion was negative.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the myofascial pain condition 10%, analogously coded 5099-5021 (myositis), citing Navy Category II (conditions which contribute to the unfitting condition) diagnoses of lumbago and cervicalgia (see below).  There was no VA placement for the myofascial pain condition.  However, the VA rated the lumbago condition 10%, coded 5242 (degenerative arthritis of the spine), based on the C&P examination 2 months before separation, citing a flexion of 0-85 degrees with pain and rated the cervicalgia condition 20%, coded 5242 (degenerative arthritis of the spine), citing 0-30 degrees of flexion with no pain.  

Members discussed the PEB’s choice of the diagnosis of myofascial pain for the CI’s unfitting condition noting that it was the cervicalgia and the lower back pain that occurred as a result of the motor vehicle accident in 2004 and multiple examinations were directed toward both the cervical and lumbar regions.  Myofascial pain affects skeletal muscles that “can cause local or referred pain.”  “Trigger points (TrPs), which cause referred pain in characteristic areas for specific muscles; restricted range of motion (ROM); and a visible or palpable LTR (local twitch response) are classic signs of myofascial pain.”  Several examinations demonstrated tenderness of the muscles of the neck and triggering of the back.  Code 5021 is rated on the limitation of motion of affected parts, as arthritis, degenerative (5099-5003).  At the VA examination flexion of the neck was 30 degrees and flexion of the lower back was 95 degrees.  Therefore, a 20% rating is warranted based on the limitation of motion of the neck, while the 95 degrees of flexion of the back would warrant a 0% rating, but for the fact of painful motion, use of code 5099-5003 would warrant a 10% rating.  However, to do get to a dual rating, further analysis of the Category I condition is necessary.

The PEB listed the lumbago and cervicalgia conditions as Navy Category II conditions (conditions that are related to the primary unfitting condition and contribute to the primary unfitting condition).  The panel’s first charge for this these Navy PEB Category II conditions  is to assess whether either of them can be reasonably justified as separately unfitting for rating consideration.  The panel’s threshold for such determinations is reasonably unfitting and remains adherent to the DoDI 6040.44 “fair and equitable” standard.  

Members agreed that the subsumed Category II lumbago and cervicalgia conditions were reasonably justified as separately unfitting, given the facts that each occurred as a result of the same motor vehicle accident; each was recalcitrant to treatment; and each independently impacted performance of his MOS and duties including physical training and testing.  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 myofascial pain lumbago condition, coded 5099-5003 and a disability rating of 20% for the myofascial pain cervicalgia, coded 5021-5237 (cervical strain).  There was no documentation of intervertebral disc syndrome (IVDS) with incapacitating episodes which would provide for a higher rating under that formula (for IVDS).  Alternatively, code 5099-5003 provides a 10% option with X-ray evidence of involvement of two or more major joints or two or more minor joint groups; however, that offers no benefit to the CI.

BOARD FINDINGS:  In the matter of the myofascial pain lumbago condition, the panel unanimously recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a.  In the matter of the myofascial pain cervicalgia condition, the panel unanimously recommends a disability rating of 20%, coded 5021-5237 IAW VASRD §4.71a.  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:  

CONDITION	VASRD CODE	PERMANENT RATING	
Myofascial Pain Lumbago	5099-5003	10%	
Myofascial Pain Cervicalgia	5021-5237	20%	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150922, 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