RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02494
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070608

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Pharmacy Specialist, medically separated for “right shoulder pain,” “chronic cervical and mid back pain” and “tension headaches;” rated 10%, 0% and 0%, respectively, with a combined disability rating of 10%.  

CI CONTENTION:  Conditions adjudicated did not reflect the appropriate severity and not all of the applicant’s conditions were considered.  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 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 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 determinations 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 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 - 20070517	VARD - 20080414	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Shoulder Pain	5099-5003	10%	Impingement Syndrome, Right Shoulder 	5299-5201	10%	20070823	
Chronic Cervical & Mid Back Pain	5299-5237	0%	Myofascial Syndrome, Muscle Group I 	5301	10%	20070823	
			Herniated Nucleus Pulposus 
C5-6	5243	0%	20070823	
Tension Headaches	5399-5323	0%	Headaches, Tension & Migraine	8100	10%	20070823	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%		

ANALYSIS SUMMARY:  

Right Shoulder Pain.  According to service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the right-hand dominant CI’s shoulder pain condition began approximately 4 years prior to referral for MEB.  Right shoulder X-rays were unremarkable.  A right shoulder magnetic resonance imaging (MRI) study on 27 February 2006 showed a very subtle and small partial supraspinatus tendon tear and tendinosis (chronic tendon degeneration without inflammation).  

Serial physical therapy (PT) examinations between November 2006 and January 2007 documented right shoulder range of motion (ROM) was within normal limits (WNL).  On 13 March 2007, PT measured repetitive ROM for the MEB with a goniometer.  Pain-limited right shoulder ROM was flexion of 110 degrees (180 normal) and abduction of 130 degrees (180 normal).  The 21 March 2007 MEB NARSUM examination, 3 months prior to separation, noted complaints of right shoulder pain, rated 2-7/10 pain, exacerbated by load bearing and overhead work and generally controlled with the non-steroidal anti-inflammatory drugs (Celebrex).  The CI did not experience significant improvement with activity modification, PT and subacromial injections and was not deemed a surgical candidate.  He had not required narcotic medications.  Physical examination showed no evidence of rotator cuff impingement or tears or shoulder instability.

In the 23 August 2007 VA compensation and pension (C&P) evaluation, 3 months after separation, the CI reported right shoulder pain exacerbated by overhead activity and was associated with right arm numbness with prolonged activity.  Examination revealed tenderness without atrophy, heat, redness or swelling.  Right shoulder ROM was recorded as flexion of 160 degrees and abduction of 160 degrees, each with mild discomfort.  There was no additional limitation of ROM with three repetitions related to pain, fatigue, incoordination, weakness or lack of endurance.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under an analogous 5003 code (degenerative arthritis) citing the US Army Physical Disability Agency pain policy memorandum.  The VA assigned a 10% rating under an analogous 5201 code (arm, limitation of motion) based on the VA C&P examination 3 months after separation, citing right (dominant) shoulder pain with reduced painful ROM.  There was no evidence of disability 5200 (scapulohumeral ankylosis), 5202 (recurrent dislocation, loss of humeral head, nonunion, fibrous union, or malunion of humerus), or 5203 (nonunion or malunion of clavicle or scapula) for consideration under the respective codes.  There was no compensable limitation of motion for consideration under 5201.  The panel 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 panel concluded that there was insufficient cause to recommend a change in the PEB adjudication for the right shoulder condition.  

Cervical and Mid Back Condition.  The PEB combined the upper (cervical) and mid (thoracic) conditions as a single unfitting condition under an analogous 5237 code (lumbosacral or cervical strain) and rated 0%.  The approach by the PEB not uncommonly reflected its judgment that the constellation of conditions was unfitting, and there was no need for separate fitness adjudications or implied adjudication that each condition was separately unfitting.  The panel’s initial charge in this case was therefore directed at determining if the PEB’s approach of combining conditions under a single rating was justified in lieu of separate ratings.  When considering a separate rating for each condition, the panel considers each bundled condition to be reasonably justified as separately unfitting unless a preponderance of evidence indicates the condition would not cause the member to be referred into the DES or be found unfit because of physical disability.  When the panel recommends separate fitness recommendations in this circumstance, its recommendations may not produce a lower combined rating than that of the PEB.  The evidence for the upper (cervical) and mid (thoracic) conditions are presented together, with attendant recommendations regarding separate unfitness and rating in the rating discussion.

According to STRs and the MEB NARSUM, the cervical and mid back conditions began approximately 4 years prior to referral for MEB.  The thoracic spine MRI on 17 August 2006 was unremarkable.  At the 6 September 2006 PT appointment, pain-limited thoracolumbar ROM (X3) was flexion of 85 degrees (90 normal) and combined of 235 (240 normal) degrees.  Serial PT examinations between November 2006 and January 2007 documented cervical and lumbar spine active ROM were within normal limits.  The cervical spine MRI on 21 November 2006 revealed a small right posterolateral C5-6 disc protrusion causing slight cord compression.  

On 7 March 2007, PT measured ROM (X3) for the MEB with a goniometer and inclinometer.  The physical examination documented no abnormal spinal contour, localized tenderness, muscle spasm, guarding, or abnormal gait due to muscle spasm or guarding.  Pain-limited thoracolumbar ROM was flexion of 68 degrees (90 normal), and combined of 205 (240 normal) degrees.

The 21 March 2007 MEB NARSUM examination, 3 months prior to separation, noted complaints of mid-thoracic and suboccipital aching pain started mid 2003 with no specific inciting event.  The 2-4/10 mid-back pain and 2-6/10 neck pain were exacerbated by body armor, standing, marching, impact activities, lifting, turning and bending.  He denied incontinence, hesitancy, perineal numbness, numbness, weakness or sensory complaints, “except episode of tingling after long drive.”  The CI did not improve with conservative management, was not deemed a surgical candidate and had not required narcotics.  Physical examination documented a normal gait and posture.  The spine examination revealed no abnormal curvature, deformity, step-off, tenderness, muscle spasm or guarding.  Strength, sensation and DTRs were normal and pathologic reflexes were absent.  The MEB addendum documented the cervicalgia was likely related to the bulging C4-5 disc with no radicular element, focal weakness, or sensory deficits.  On 16 May 2007, PT measured pain-limited cervical ROM with flexion of 45 degrees (45 normal), and combined of 310 degrees (340 normal).

The 23 August 2007 VA C&P evaluation, 2 months after separation, noted complaints of the back pain began gradually in 2003, without a specific history of trauma.  The neck pain began in 2005 with gradual onset upon awakening one morning.  The 3/10 sharp, interscapular, back pain occurred daily; and the 4-5/10 sharp, aching neck pain occurred every 2 or 3 months.  The CI was able to perform his usual activities of daily living without impediment from his neck or back pain.  Physical examination showed a normal gait and posture.  Cervical spine examination revealed normal head position, curvature, symmetry--without painful motion, spasm, weakness or tenderness.  Cervical ROM was flexion of 45 degrees (45 normal), and combined ROM of 340 degrees (340 normal).  The thoracolumbar spine exam revealed no spasm, weakness or tenderness.  Pain-limited thoracolumbar ROM was flexion of 85 degrees (90 normal) and combined ROM of 235 degrees (240 normal).  There was no additional limitation of ROM with three repetitions related to pain, fatigue, incoordination, weakness or lack of endurance.  Strength and sensation were normal.  

The panel directed attention to its rating recommendation based on the above evidence.  As previously elaborated, the panel must first consider whether upper (cervical) and mid (thoracic) conditions remain separately unfitting, having been de-coupled from a combined PEB adjudication.  The panel found there was no performance-based evidence from the record that the upper (cervical) condition significantly interfered with satisfactory duty performance and was not separately unfitting.  The panel found that the mid (thoracic) condition significantly interfered with satisfactory duty performance and was separately unfitting.  The PEB assigned a 0% rating under an analogous 5237 code (lumbosacral or cervical strain) citing chronic cervical and mid back pain, without neurologic abnormality, ROM limited by pain, and without tenderness or spasm.  The VA assigned a 10% back rating under the 5301 code (muscle Group I) based on the VA C&P examination citing myofascial syndrome, mid-back pain, reduced flexion, no additional functional loss due to pain, weakened movement, excessive fatigability, incoordination, or flare-ups with repetitive motion, no sensory or motor deficits, and rated for painful reduced ROM.  The panel recognized the constellation of symptoms involved the mid (thoracic) spine and were not explicitly related to the thoracolumbar spine.  The thoracolumbar ROM values in the C&P examination and PT for MEB (X 2) examinations, were consistent with the 10% rating (flexion of greater than 60 degrees but not greater than 85 degrees; or a combined ROM of greater than 120 degrees but not greater than 235 degrees of the thoracolumbar spine).  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).  The panel 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 panel recommends a disability rating of 10% for the mid (thoracic) condition, coded 5299-5237.

Headache Condition.  According to STRs and the MEB NARSUM, the headache (HA) condition began approximately 4 years prior to referral for MEB.  MRI on 19 July 2005 revealed no significant intracranial abnormality.  

The 10 October 2006 MEB neurology consultation, 8 months prior to separation documented a longstanding history of “two types of headaches.”  Migraines occurred once every two months and lasted for hours to days.  He had not sought acute medical attention in the last 6 months.  Migraines were associated with photophobia (light sensitivity) and phonophobia (sound sensitivity) but not nausea, vomiting or aura.  The CI took Propranolol for preventative therapy and Zomig for abortive therapy.  He also complained of chronic, dull, bi-frontal HAs 3-4 times per week.  This HA was characterized as “a general annoyance” and was provoked by wearing Kevlar.  He denied gait difficulties, weakness, numbness, incoordination, depression or anxiety.  The mental status, cranial nerves, motor, and sensory examinations were normal.  The neurologist stated the migraine HAs were moderately well controlled with medications and were medically acceptable.  With regard to the tension HAs, the physician stated, “If the soldier cannot wear a Kevlar because of headaches, I would agree that this is medically unacceptable.”  A head/brain computed tomography (CT) on 21 November 2006 was unremarkable.  

The 21 March 2007 MEB NARSUM examination, 3 months prior to separation, noted onset of severe headaches in 2003 without inciting trauma.  The CI developed severe, diffuse, throbbing, migrainous headaches with associated nausea and photophobia approximately once every two months.  He also reported bi-frontal “annoying” headaches approximately 3 times per week, but denied weakness, numbness, or sensory complaints, except an episode of tingling after long drive.  The examiner note the CI had been evaluated by Neurology and would meet retention, if he could tolerate battle gear/helmet.  He was taking Zomig for abortive therapy and Propranolol for control of his migraines with good results.  His tension headaches were generally a nuisance, but not significantly limiting, unless he is required to wear helmet.  The focused physical and neurological examination was unremarkable.  The 1 May 2007 MEB addendum documented “His intolerance for wear of the helmet will prevent him from successful duty.  If he did not complain of disabling headaches when wearing a helmet, his headaches would not require separation and in fact would be considered well controlled.”

The 23 August 2007 VA C&P evaluation, 2 months after separation, noted complaints of throbbing migraine headaches with photophobia since 2003, every 2 months, lasting for 1 hour, and aborted with Zomig.  He also reported tension headaches at neck base since 2005, once a month, which were not incapacitating.  The CI reported being placed in quarters on 3 occasions, and going to the emergency room for Toradol injections on 3 occasions, for migraines.  The physical examination documented “Neurological examination of the upper and lower extremities reveals motor, sensory, and deep tendon reflexes to be intact.”  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 0% rating under an analogous 5323 code (muscle group XXIII) citing tension HAs and rated as slight.  The VA assigned a 10% rating under the 8100 code (migraine headaches) based on the VA C&P examination citing HAs, tension and migraine, tension HA occurs about once a month, migraine HA occurs about every 2 month, migraine HA medication prescribed "as needed," and no report of episode of HA seen.  Regarding the tension HAs, the MEB addendum documented “His intolerance for wear of the helmet will prevent him from successful duty.  If he did not complain of disabling headaches when wearing a helmet, his headaches would not require separation and in fact would be considered well controlled.”  Rating guidance under diagnostic code 8100 is based on the frequency of “prostrating attacks” over the “last several months.”  The VASRD does not further define prostrating attacks, but commonly accepted definitions include “utter physical exhaustion or helplessness” (Webster's New World Dictionary of American English), “complete physical or mental exhaustion” or “extreme exhaustion or powerlessness” (Dorland's Illustrated Medical Dictionary).  The panel considered the totality of available evidence in the treatment records in order to most accurately assess the overall disability picture (§4.2) at the time of separation.  The NARSUM documented “He is currently taking Zomig for abortive therapy and Propanolol for prophylaxis … for control of his migraines with good results.”  While the CI reported migraines occurring every 2 months, usually lasting for 1 hour, the panel did not characterize these as “prostrating attacks.”  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 headache condition.  

BOARD FINDINGS:  In the matter of the right shoulder condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the chronic mid back condition, the panel unanimously recommends a disability rating of 10%, coded 5299-5237 IAW VASRD §4.71a.  In the matter of the headache 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 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	
Right Shoulder Pain	5099-5003	10%	
Chronic Mid Back Pain	5299-5237	10%	
Tension Headaches	5399-5323	0%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150810, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170013264, XXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found that your disability rating should be modified but not to the degree that would justify changing your separation for disability with severance pay to a permanent retirement with disability.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed) and I accept its recommendation.  This will not result in any change to your separation document or the amount of severance pay.  A copy of this decision will be filed with your Physical Evaluation Board records.  I regret that the facts of the case did not provide you with the outcome you may have desired.
  
	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. 

	A copy of this decision has also been provided to the Department of Veterans Affairs.

Sincerely,	
Enclosure