RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02513
BRANCH OF SERVICE:  NAVY 	SEPARATION DATE:  20090810

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Information Systems Administrator, medically separated for “myofascial pain syndrome” and “cervicalgia,” each rated at 10%, with a combined disability rating of 20%.

CI CONTENTION:  The VA provided higher disability ratings for his conditions and rated conditions not identified by the service.   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 - 20090501	VARD - 20091123	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Myofascial Pain Syndrome	5237	10%	Myofascial Pain Syndrome	5099-5025	20%	20091006	
Leg Length Discrepancy 	Cat II	No VA Placement	
Bulging Intervertebral Disk Lumbar	Cat II
	Herniated Disc, Lumbar spine with Compression Fracture	5299-5235	10%	20091006	
Sacroiliac Joint Dysfunction	Cat II	No VA Placement	
Cervicalgia	5237	10%	Herniated Disc, Cervical Spine w/ Degenerative Disc Disease	5235-5242	0%	20091006	
Cervical Disk Herniation	Cat II					
Cervical Spondylosis	Cat II					
Cervical Degenerative Disc Disease	Cat II					
Cervical Degenerative Disk	Cat II					
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

Myofascial Pain Syndrome.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI began experiencing chronic neck and back pain following a fall while on a ship in 2006.  The back pain was associated with bilateral lower extremity (BLE), but mostly right lower extremity (RLE), radiation and subjective sensory complaints.  Magnetic resonance imaging (MRI) showed a bulging disc at L5/S1 without nerve root compromise (non-surgical).  Repeated BLE neurological examination findings and an electromyelogram (EMG) were normal.  A diagnosis of “myalgia and myositis” appeared in chiropractic notes in September 2008, although clinical details were sparse.  While paracervical and thoracolumbar muscle complaints were cited in the STR, no documented diagnosis (or listed differential diagnosis) of fibromyalgia was found.  Additionally, there were no STR clinical entries recording significant range of motion (ROM) limitation, abnormal spinal contour, persistent gait disturbance, ratable neurological findings, or of any incapacitating episodes.  

At the 19 February 2009 MEB NARSUM examination, 6 months prior to separation, the CI reported “lower back” pain rated at 5-6/10 with RLE radiation and subjective sensory complaints.  The physical examination documented paraspinal and left sacroiliac tenderness (only indication for NARSUM diagnosis of sacroiliac joint dysfunction) without comment on spasm, abnormal contour, or gait disturbance.  The examiner noted a measured leg length discrepancy of “less than 2 centimeters,” and recorded normal BLE neurological findings (5/5 strength).  With regard to ROM, the examiner cited flexion “to the mid-calf” (~70-80 degrees) with pain.  The NARSUM diagnosis for the lumbar condition was “myofascial pain syndrome,” without elaboration and with no documentation of myalgia other than the back complaints.  On 27 February 2009, physical therapy (PT) recorded ROM (goniometric) with flexion to 50 degrees (normal 90) and a combined ROM of 165 degrees (normal 240).  A 20 April 2009 PT follow-up noted flexion to 50 degrees with painful extension.

At the 26 August 2009 VA Compensation and Pension (C&P) evaluation, 16 days after separation, the CI reported he had been “diagnosed with fibromyalgia” which had existed for 4 years.  This was addressed as a separate condition from the back pain indicated in the PEB “myofascial pain syndrome” diagnosis.  The examiner noted associated headache and sleep disturbance, but negated fatigue and all other ratable elements of fibromyalgia except for CI reports of “muscular pain located on both the right and left sides of the body and above and below the waist.”  The physical examination documented six non-paired tender points (failing diagnostic standard for fibromyalgia).  With specific regard to the “lower back pain” condition, the examiner noted constant “mild” pain that limited walking and was exacerbated by driving.  The physical examination recorded a normal gait and spinal contour, no tenderness or spasm, and normal BLE neurological findings (motor, reflexes, and sensory).  Measured ROM was normal in all planes without painful motion or degradation with repetition. 

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the myofascial pain syndrome condition 10%, coded 5237 (lumbosacral strain), without citing a rationale.  The PEB listed leg length discrepancy, bulging intervertebral disk, and lumbar and sacroiliac joint dysfunction conditions as related diagnoses (Category II) contributing to the disability in this case.  The panel’s first charge for this 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 and remains adherent to the DoDI 6040.44 “fair and equitable” standard.  The panel concluded the Category II diagnoses could not be reasonably justified as separately unfitting; nor would separate ratings be achievable without violation of VASRD §4.14 (avoidance of pyramiding).  

The VA conferred a separate rating of 20% for myofascial pain syndrome under code 5099-5025 (analogous to fibromyalgia), as addressed above; as well as a 10% rating for the lumbar disc condition, coded analogously to 5235, citing tenderness and spasm noted at the C&P examination.  There was a significant disparity between the service PT and C&P ROM evidence; but, members concluded that the C&P evaluation carried the determinant probative value because it was more proximate to the date of separation and there was no corroborating STR evidence for the degree of ROM limitation reflected by the PT measurements.   The C&P ROM evidence, therefore, did not support a rating higher than 10%.  Additionally, there was no evidence of abnormal gait or spinal contour to support a 20% rating, no evidence for ratable peripheral nerve impairment that would provide for additional rating, and no documentation of incapacitating episodes that 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 concluded there was insufficient cause to recommend a change in the PEB adjudication for the myofascial pain syndrome (lumbar condition). 

Cervicalgia.  As mentioned above, the CI’s chronic neck pain began in 2006.  A 14 April 2008 MRI revealed mild degenerative disc disease at C5-C6 with a posterior annular bulge causing mild central canal stenosis.  At a 9 May 2008 orthopedic examination, the CI reported midline neck pain that started after the fall with associated tingling and numbness of the right upper extremity to the second through fifth digits.  On the same day, the CI underwent a cervical epidural steroid injection at C7-T1 which only provided temporary improvement.  He then received a local anesthetic block of the right side C4-C6 medial branches and reported an 80% reduction in pain; a 20 June 2008 EMG was normal.  On 18 August 2008, the CI underwent a radiofrequency ablation on the same nerves with minimal relief.  In September 2008, he was involved in a motor vehicle accident (MVA) in which he sustained another injury to his neck.  A follow-up MRI showed bulging of the C5-C6 disks.  On 15 January 2009 the CI was involved in a second MVA and diagnosed with neck strain.  There was no STR documentation of significant ROM limitation, spasm inducing abnormal spinal contour, ratable neurological findings, or of any incapacitating episodes.  

During the 5 March 2009 MEB examination (recorded on DD Forms 2807-1 and 2808), 6 months prior to separation, the CI reported neck pain and subjective sensory complaints of the right arm.  There were no positive findings recorded on the physical examination.  The 20 February 2009 MEB NARSUM, 6 months prior to separation, noted complaints of baseline neck pain rated at 5-6/10 with monthly exacerbations rated at 8/10.  The CI reported bilateral upper extremity (BUE) radiation with subjective sensory complaints but no weakness.  He was prescribed multiple analgesics and an orthopedist opined that there were no additional procedures or medications likely to fully relieve the pain.  The physical examination showed paraspinal tenderness without note of spasm or abnormal contour, normal BUE neurological findings (5/5 strength), and non-specific ROM limitation.  Formal PT goniometric ROM measurements on 27 February 2009 were   flexion to 25 degrees (normal 45) with a combined ROM of 175 degrees (normal 340).  A follow-up PT note on 20 April 2009 documented flexion as “within normal limits,” but bilateral rotation “decreased by 50%.”

At the 26 August 2009 VA C&P evaluation, 16 days after separation, the CI reported constant “moderate” lower neck pain exacerbated by “physical activity” (driving over 30 minutes was the only cited example) and associated with unelaborated sensory complaints.  The physical examination recorded the absence of radiating pain on movement, muscle spasm, tenderness, guarding, or abnormal spinal contour.  All BUE neurological findings were normal (motor, reflexes, and sensory).  Measured ROM was normal in all planes without painful motion or degradation with repetition. 

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the cervicalgia condition 10%, coded 5237 (lumbosacral or cervical strain), without citing a rationale.  Members agreed that the PEB’s Category II diagnoses (in rating comparison chart above) were intrinsic to the rated condition and that a separate rating could not be supported without pyramiding (VASRD §4.14); thus, they are appropriately subsumed in the same rating.  The VA rated the cervicalgia condition 0%, coded 5235-5242 (vertebral fracture or dislocation- degenerative arthritis of the spine), based on the C&P examination and citing the absence of ROM limitation or painful motion.  As previously discussed, the panel noted a significant disparity between the service PT and C&P ROM evidence, but after reviewing the overall evidence for corroboration, determined the C&P evidence carried the most probative value because it was more proximate to the date of separation and there was no STR evidence explaining the degree of ROM limitation reflected by the PT measurements.   The C&P ROM evidence, therefore, did not support a rating higher than 10%.  There was no evidence for abnormal spinal contour to support a 20% rating, no evidence for ratable peripheral nerve impairment that would provide for additional rating, and no documentation of incapacitating episodes that 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 concluded that there was insufficient cause to recommend a change in the PEB adjudication for the cervicalgia condition. 

BOARD FINDINGS:  In the matter of the myofascial pain condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the cervicalgia 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 there be no modification or re-characterization of the CI’s disability and separation. 

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20151021, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

MEMORANDUM FOR DIRECTOR, SECRETARY OF THE NAVY COUNCIL OF REVIEW
               BOARDS 

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS
 
Ref:   (a) DoDI 6040.44

      In accordance with reference (a), I have reviewed the cases listed below and approve the recommendations of the PDBR that the following individual’s records not be corrected to reflect a change in either characterization of separation or in the disability rating previously assigned by the Department of the Navy’s Physical Evaluation Board:

		- XXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXX, former USMC

		
							XXXXXXXXXXXXXXXXXXX
	     				Principal Deputy, Assistant 
						Secretary of the Navy
						(Manpower and Reserve Affairs)
						Performing the Duties of the 
						Assistant Secretary of the Navy
						              (Manpower and Reserve Affairs)