RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-00645
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060305

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Food Service Operator, medically separated for “myofascial neck and back pain secondary to repetitive strain injury” with a disability rating of 10%.

CI CONTENTION:  He has not worked due to his back injuries.  The VA issued an 80% rating for his back and other disabilities.  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 - 20060202	VARD - 20060628	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Myofascial Neck and Back Pain	5099-5021	10%	Lumbosacral Strain	5237	20%	20060419	
			Cervical Strain	5237	10%		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Myofascial Neck and Back Pain.  The PEB combined the myofascial neck and back conditions under a single disability rating, coded 5099-5021, which refers to code 5003 for rating, at 10%.  This 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.  The panel noted that “bundling,” the combining of two or more major joints, may be permissible under the VASRD 5003 rating requirements, and that this approach does not compromise the VASRD §4.7 directive to choose the higher of two valid ratings.   The panel’s initial charge in this case was therefore directed at determining if 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 neck pain and back conditions are presented separately, with attendant recommendations regarding separate unfitness, and a separate rating for each condition, if indicated. 

According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s myofascial neck and back pain began in February 2003 while performing rushes.  He was treated with medication, profiles, and trigger point injections.  In May 2003, his pain increased while loading heavy armament during a deployment.  Multiple kidney stone episodes confounded the back and neck pain etiology.

Myofascial Neck Pain.  At a physical medicine and rehabilitation (PM&R) examination on 2 December 2005, 3 months before separation, there was cervical to sacral spine tenderness.  Neck range of motion (ROM) along with upper extremities sensation and strength were normal.  With approximately six positive tender points, the examiner ruled out a fibromyalgia diagnosis but assessed myofascial muscle tenderness, and bilateral trapezius, scapula and quadratus-lumborum muscle pain.   During the 21 November 2005 MEB examination (recorded on DD Forms 2807-1 and 2808), 4 months prior to separation, the CI reported extreme upper back cramping between the shoulder blades.  No neck examination was conducted.  The CI did not document a neck issue or symptoms on either form. 

The 16 December 2005 MEB NARSUM examination, 3 months prior to separation, noted complaints of upper and lower back pain exacerbated by physical activity particularly lifting.  Physical examination revealed back tenderness beginning from the lower margin of the neck and continuing downward.  Hand and arm sensation were normal as was arm strength.  A cervical spine examination was not addressed.  The commander’s statement dated 1 December 2005 noted pain throughout his back, which caused trouble when carrying more than 10 pounds and/or sleeping.  The pain prevented the CI from wearing an IBA vest, or carrying a rucksack, heavy boxes or food service equipment.  A U3/L3 profile was issued on 22 December 2005 for back pain.  The CI could not perform any physical fitness (primary or alternate) test events nor upper or lower body weight training; he could not move 2 miles with a fighting load, construct an individual fighting position, or perform 3 to 5 second rushes.  The CI could wear a protective mask and all chemical defense gear; Kevlar helmet limitations were not cited.

At the 19 April 2006 VA Compensation and Pension (C&P) examination, one month after separation, the CI reported constant neck cramping that radiated into the trapezius muscles and was aggravated by overhead reaching or material handling.  He denied upper extremity radicular symptoms and incapacitating episodes.  Physical examination showed normal neck and upper thoracic spinal contour.  There were muscle spasms at the trapezius muscle over the right shoulder and right side of C5-C6.  Neck flexion was 40 degrees (normal 45) and combined range of motion (ROM) was 300 degrees (normal 340).  Painful motion manifested as muscle spasms during rotation.

Myofascial Back Pain.  Lumbar spine X-rays performed on 12 May 2005 revealed piriformis syndrome and sacroiliac joint tenderness but no acute disease.  An MRI on 13 June 2005 was unremarkable.  An orthopedic examination on 18 August 2005 determined the CI was not a surgical candidate.  A whole body bone scan on nearly a month later revealed a normal back.  A clinic note on 14 October 2005, 5 months prior to separation, documented the ability to heel and toe walk. There was lumbar spine straightening without tenderness.  Flexion of approximately 25 to 30 degrees (normal 90) elicited pain-limited motion; combined ROM was incomplete.

At the previously referenced PM&R clinic visit a normal gait and lower cervical to sacral spine tenderness were documented.  “Back” flexion was approximately 70 degrees with painful motion elicited; combined ROM was incomplete.  The MEB NARSUM examination noted complaints of upper and lower back pain exacerbated by physical activity particularly lifting, but even twisting or lifting light objects aggravated the pain.  Physical examination showed back flexion to 45 degrees and incomplete combined ROM.  Painful motion was not addressed.  On 22 December 2005, a U3L3 profile was issued for back pain.   During the MEB physical therapy (PT) examination flexion was 40 degrees with painful motion and combined ROM was 175 degrees (normal 240).  The commander’s statement noted pain throughout his back, which caused trouble when sleeping and/or carrying more than 10 pounds.  

At the C&P examination the CI reported constant sharp lumbar spine pain that intermittently radiated to the right sacroiliac joint and right knee.  The CI denied bowel or bladder incontinence and incapacitating episodes.  Physical examination showed a normal spinal contour with L4-S1 muscle spasms.  A straight leg-raising test for radiculopathy was negative.  Motor function was normal and lower extremity reflexes were 1+ bilaterally.  Thoracolumbar flexion was 60 degrees, and combined ROM was 210 degrees.  Painful motion was not addressed.  Heel and toe gait mechanics were normal.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the myofascial neck and back pain 10%, analogously coded 5099-5021 (myositis), citing spine tenderness from the neck down and myositis with some loss of spinal motion.  The VA rated the lumbosacral strain condition 20%, coded 5237 (lumbosacral strain), based on the C&P examination, citing limitation of flexion.  The VA also rated the cervical strain condition 20%, again coded 5237, citing limitation of flexion and combined motion.

The panel first considered if the myofascial neck pain, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The panel majority agreed that the CI experienced neck pain; however, the preponderance of STR evidence did not show performance-based evidence that the myofascial neck pain was unfitting.  The commander’s statement only implicated the back condition, which rendered the CI unable to wear an IBA vest and/or carry heavy objects.  Although the CI received a permanent U3 profile, he was able to wear a protective chemical mask and no Kevlar helmet limitation was cited.  The CI did not document neck symptoms on the medical history 4 months before separation and the MEB and NARSUM examinations did not record neck symptoms, functional limitations or a neck-specific examination.  The MEB proceedings judged that the “myofascial back pain involving the cervical thoracic lumbosacral lower coccygeal spine” failed retention standards.  Therefore, the panel concluded that the preponderance of evidence showed the myofascial neck pain would not have caused the CI to be referred into the DES or be found unfit and no separate myofascial neck pain disability rating is recommended.

The panel then considered if the myofascial back pain, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  Back pain was given an L3 profile, the commander implicated the back condition, and the MEB NARSUM examination proximate to separation recorded functional limitations.  Panel members agreed that the myofascial back pain rendered the CI unable to perform his military duties, and accordingly a separate disability rating is recommended.  

In considering a rating recommendation, the panel agreed that a 20% rating, but no higher, was justified for limitation of flexion (greater than 30 degrees but not greater than 60 degrees), as reported on the MEB NARSUM, MEB PT and VA ROM examinations proximate to separation.  There was no documentation of intervertebral disc syndrome with incapacitating episodes which would provide for a higher rating under that formula.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 20% for the myofascial back condition, coded 5237.

BOARD FINDINGS:  In the matter of the myofascial neck condition and IAW VASRD §4.71a, the panel majority agrees that it cannot recommend the condition as separately unfitting and warranting a separate rating.  In the matter of the myofascial back condition, the panel recommends a separately unfit determination with a disability rating of 20%, coded 5237 IAW VASRD §4.71a.  The single voter for dissent submitted the appended minority opinion.  There are no other conditions within the panel’s scope of review for consideration.  

The panel recommends the CI’s prior determination be modified as follows, effective the date of medical separation:

CONDITION	VASRD CODE	PERMANENT RATING	
Myofascial Back Pain	5237	20%	
COMBINED	20%	

Minority Opinion.  The myofascial neck pain is separately unfitting and warrants a 10% rating.  While the MEB and NARSUM examinations were deficient in failing to address the CI’s neck condition, a permanent U3 profile was issued, and the VA examination, the most precise and proximate examination to separation, noted the CI’s complaint of cramping at the base of the neck with radiation to the trapezius muscles.  Anatomically, the trapezius muscle inserts on the C7 vertebra and is considered a muscle of the neck.  Other references in the STR indicated the CI had pain from the cervical area to the sacral area.  Furthermore, the CI had difficulty lifting, and while it can be argued that lifting involves muscles of the shoulders as well as the muscles of the thoracic and lumbar regions, nevertheless, it also involves the trapezius, the upper portion of which involves the neck and its movements.  The CI did specifically receive injections to the trapezius muscles to alleviate his pain, which limited his ability to fully function especially when performing overhead work.  Therefore, when the VA found that forward flexion of the neck was limited to 40 degrees, the 5 degrees shortfall could well be attributed to muscle spasm in the neck.  Therefore, the preponderance of evidence reasonably justified that the functional limitations of the condition contributed to the CI’s inability to perform his military duties, and accordingly a separate disability rating is recommended by the minority voter.

As noted above, the PEB bundled the myofascial neck and back pain condition and applied a single 10% rating, coded 5099-5021.  The VA examination, one month after separation, was the most precise and proximate examination.  Therefore, based on a forward flexion of the neck of 40 degrees and combined ROM of 300 degrees, a 10% rating is warranted based on forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees; or, combined ROM of the cervical spine greater than 170 degrees but not greater than 335 degrees.  There was no documentation of IVDS with incapacitating episodes which would provide for a higher rating under that formula.  

The minority voter recommends the ROP be modified to read:

After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the myofascial neck condition, coded 5237.  

The minority voter recommends the Board Findings be modified to read:

In the matter of the myofascial neck condition, the panel recommends a disability rating of 10%, coded 5237 IAW VASRD §4.71a.  

The panel recommends 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 the date of medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Myofascial Neck Pain	5237	10%	
Myofascial Back Pain	5237	20%	
COMBINED	30%	

AR20190002402, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX

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 and to the counsel you listed on your application.