RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXXXXXX	CASE: PD-2016-00470 BRANCH OF SERVICE: COAST GUARD	SEPARATION DATE: 20061128

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Boatswain’s Mate, medically separated for “myofacial pain syndrome” with a disability rating of 20%.

CI CONTENTION: Given a higher rating by the VA for the disability. 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 Medical Evaluation Board (MEB), but determined by the PEB 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. The panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections when appropriate. The panel’s assessment of the PEB rating determination is based on review  of medical records and all available evidence relevant to application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards for 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, which operates 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 disability at the time of separation.

RATING COMPARISON:

SERVICE PEB - 20060823	VARD - 20070416	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Myofacial Pain Syndrome	5099-5021	20%	Myofascial Paracervicothoracic Strain, Mild Anterior Wedging and Spondylosis T6-T10	5299-5237	20%	20070212	
COMBINED RATING: 20%	COMBINED RATING OF ALL VA CONDITIONS: 40%	

ANALYSIS SUMMARY:

Myofacial Pain Syndrome. According to the service treatment record and MEB narrative summary (NARSUM), the CI’s neck condition began in January 2006 with gradual onset. In February, 2006, when he was involved in a motor vehicle accident which aggravated his condition. He was evaluated several days later with a diagnosis of whiplash syndrome. X-rays at that time showed lack of lordosis reflecting muscle spasm, and slight disc space narrowing at L4-
5.  An April 2006 MRI of the cervical spine demonstrated no canal stenosis, and no disc   bulging

or disc herniation was seen within the cervical spine. The cervical spine appeared normally aligned.  The radiologist’s impression was a “negative study”.

During the 19 May 2006 MEB NARSUM examination, 6 months prior to separation, the CI reported neck pain, and numbness and tingling in the hands and feet. Physical examination showed limited cervical range of motion (ROM) and tenderness to the trapezoid region of the neck. The cervical spine ROM measurements performed by primary care on 10 July 2006, 4 months before separation showed flexion of 30 degrees (normal 45) and combined ROM of 265 degrees (normal 340). At the 8 August 2006 rheumatology examination, 3 months prior to separation, the CI reported chronic cervical spine spasms. Physical examination demonstrated paraspinal cervical muscle spasms.

At the 12 February 2007 VA Compensation and Pension (C&P) examination, 3 months after separation, the CI reported squeezing, aching, 6/10 pain. The pain could be elicited by physical activity and stress. On examination, there was tenderness without muscle spasm, and gait and spinal contour were normal. The cervical spine ROM measurements showed flexion of 45 degrees and combined ROM of 340 degrees associated with painful motion. There was an additional limitation of 5 degrees forward flexion and extension with repetitive motion.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the neck condition 20%, analogously coded 5099-5021 (myositis), citing limitation of motion, and forward flexion of the cervical spine greater than 15 degrees, but not greater than 30 degrees. The VA also rated the neck condition 20%, analogously coded 5299-5237 (cervical spine strain), based on the C&P examination, citing muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour with objective painful motion. There was no evidence of forward flexion of the cervical spine 15 degrees or less for a 30% rating. There was no documentation of intervertebral disc syndrome (IVDS) with incapacitating episodes which would provide for a higher rating under that formula. The panel concluded there was no evidence to support a rating higher than that adjudicated by the PEB. After due deliberation, considering all 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 neck condition.

BOARD FINDINGS: In the matter of the neck condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication. There are no other conditions within the panel’s scope of review for consideration. Therefore, the panel recommends no modification or re- characterization of the CI’s disability and separation determination.

	

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U.S. Department o ·
Homeland Security

Commandant
United States Coast Guard

Mail Stop 7907
2703 Martin Luther King Jr. Ave SE

United States	-	-
Coast Guard

Washington, DC 20593-7907 Staff Symbol: CG-1
Phone: (202) 475-5000

1850

Dear XXXXXXXXXX,

NAY 18 2020

I am the Designated Decision Authority for the Coast Guard on applications submitted to the Department of Defense Physical Disability Board of Review (PDBR). Under the authority of Title 10, United States Code, section 1554a, I accept the PDBR's recommendation in your case (Case Number PD-2016-00470) and decline to modify your findings.

Enclosed for your information are a copy of the PDBR's recommendation and a copy of the record of proceedings.

A copy of this decision has also been provided to Coast Guard Enlisted Personnel Management Branch, the PDBR, and the Department of Veterans Affairs.

If you have any further questions, please contact the Coast Guard Personnel Service Center at (202)795-6645.