RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00819
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20040117

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E6, Prime Power Production Specialist, and Automated Logistical Specialist, medically separated for “chronic myofascial neck pain” with a disability rating of 0%.

CI CONTENTION:  The VA’s rating less than 12 months supports a higher rating.  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 – 20031125	VARD - 20040803	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Myofascial Neck Pain	5099-5021	0%	Chronic Myofascial Neck Pain	5099-5021	10%	20040426	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:

Chronic Myofascial Neck Pain.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s neck pain condition began in August 1995 after being hit on the head with a ball.  The CI also hit his head on a military vehicle in December 1995.  He was treated with medication and returned to duty.  The record then falls silent until December 2002 when the CI reported a 14-year history of left shoulder and neck pain with numbness to the left shoulder and arm associated with overhead work and wearing Kevlar.  He was noted to have a full range of motion (ROM) and X-rays of the neck and left shoulder were normal.  He was treated with medications and duty restrictions, but had continued symptoms.  Despite injections and physical therapy, he was not able to return to full duty and entered into the MEB process.  

The 8 September 2003 MEB NARSUM examination, noted complaints of continued neck area pain which radiated to the left shoulder if ignored.  The physical examination showed spinal tenderness.  Flexion was full and with the chin to the chest (normal 45 degrees) and the combined ROM was 315 degrees (normal 340), but motion was painful.  The gait, muscle spasm and spinal contour were not addressed.  

At the 26 April 2004 VA Compensation and Pension (C&P) Spine evaluation, 3 months after separation, the CI reported continued neck area pain which became sharp if the left arm was used above horizontal (shoulder level).  Physical examination showed a normal gait without neck deformity or lordosis.  Spinal tenderness was present.  Upper extremity sensory testing was normal.  The ROM was flexion to 40 degrees and combined ROM to 310 degrees without painful motion, incoordination or fatigue.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the myofascial neck pain condition 0%, analogously coded 5099-5021 (myositis), citing without significant loss of spine motion.  The VA rated the myofascial neck pain condition 10%, also coded 5099-5021, based on the C&P examination 3 months after separation, citing painful or limited motion of a major joint or group of minor joints.  The panel agreed that a 10% rating, but no higher, was justified for limitation of flexion (greater than 30 degrees but not greater than 40 degrees as reported by the MEB NARSUM and VA exams, most proximate to separation.  There was no muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour, thus the next higher 20% rating was not justified on this basis.  There was no documentation of intervertebral disc syndrome (IVDS) with incapacitating episodes which 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 recommends a disability rating of 10% for the myofascial neck pain condition, coded 5021.

BOARD FINDINGS:  In the matter of the chronic myofascial neck pain condition, the panel unanimously recommends a disability rating of 10%, coded 5021 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, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic Myofascial Neck Pain	5021	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160915, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment

AR20170018005, 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