RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXX	CASE:  PD-2017-01192
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20080606

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Health Care Specialist, medically separated for “myofascial pain syndrome evaluated as myositis” with a disability rating of 10%.  

CI CONTENTION:  “I do not feel the rating should change.” The complete submission is 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 - 20080221	VARD - NA	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Myofascial Pain Syndrome evaluated as Myositis	5099-5021	10%	No VA Rating Decision in Evidence	
COMBINED RATING:  10%	COMBINED RATING VA CONDITIONS:  NA	

ANALYSIS SUMMARY:  

Myofasical Pain Syndrome. The MEB forwarded myofascial neck pain and myofascial right shoulder girdle pain separately to the PEB as not meeting retention standards.  The PEB combined the neck and right shoulder conditions under a single disability rating, coded analogously to 5021 (myositis) and rated 0% for pain.  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’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 multiple conditions are presented together, with attendant recommendations regarding separate unfitness, and separate rating if indicated.

According to the service treatment record and MEB narrative summary (NARSUM), the CI’s myofascial pain syndrome began in March 2006 at basic training while doing push-ups.  The CI reported predominate pain of the right periscapular region with numbness and pain radiating down the right upper extremity at times.  Electrodiagnostic studies performed on 24 July 2007 of the CI’s dominant right upper extremity were normal, with no evidence of cervical radiculopathy, myopathy, plexopathy, mononeuropathy, or median neuropathy, and the examiner indicated the presentation was most consistent with myofascial pain.  Cervical MRI showed mild disc desiccation of the cervical spine without disc protrusion or herniation and no significant degenerative changes or spinal canal or neuroforaminal (area through which the spinal nerves exit) stenosis.  At a sports medicine examination on 24 August 2007, there was tenderness of the medial border of the scapula and the upper thoracic spine.  There was mild weakness of the shoulder girdle muscles.  Right shoulder range of motion (ROM) was flexion to 150 degrees (normal 180) and abduction of 120 degrees (normal 180).  Genetic testing for a form of inherited muscular dystrophy was negative.  

During the 19 November 2007 MEB examination (recorded on DD Forms 2807-1 and 2808), 8 months prior to separation, the CI reported shoulder and upper back pain with numbness and tingling of the right upper extremity.  Physical examination showed full ROM of the cervical spine and tenderness of the lower cervical muscles and right trapezius and rhomboid muscles.  There was decreased ROM of the scapulothoracic joint and right shoulder with tenderness of the medial scapular border with palpable crepitus and snapping.  There was mild right scapular winging (weakness).  Right shoulder X-rays showed mild degenerative changes of the acromioclavicular joint and were otherwise unremarkable.  The following day, physical therapy measured right shoulder ROM for the MEB and after three repetitions flexion was 160 degrees and abduction was 95 degrees, limited by pain and soft tissue tightness.  

The 4 December 2007 MEB NARSUM examination, 6 months prior to separation, noted complaints of right-sided neck pain and right shoulder girdle pain.  Physical examination cited the DD Form 2808 examination and PT ROM examinations summarized above.  Additionally, right upper extremity strength was decreased compared to the left, graded 4/5.  Reflexes were normal and sensation was intact.  The MEB NARSUM examiner determined the CI fell below retention standards due to myofascial neck and right shoulder girdle pain.  

At the 16 April 2008 VA Compensation and Pension (C&P) general medical examination, 2 months prior to separation, the CI reported pain, weakness, swelling, lack of endurance, numbness and tingling of the right shoulder.  She also reported constant, localized pain on the right side of the neck and stiffness that made it hard to turn her head.  She reported she was not receiving any treatment for the shoulder or neck, and at the time of pain she could function without medication. She denied any periods of incapacitation due to the neck condition. Physical examination noted the CI was right-hand dominant.  There was tenderness of the shoulder and muscles behind the shoulder and no swelling, weakness, guarding of movement or subluxation.  Shoulder ROM was flexion of 170 degrees and abduction of 150 degrees, with pain at the extremes of motion.  There was no additional limitation of motion after repetitive use.  Physical examination of the cervical spine showed no muscle spasm or radiating pain on movement.  Spinal curvatures were normal.  There was full ROM of the cervical spine in all planes and no additional limitation of joint function after repetitive use due to pain, fatigue, weakness, lack of endurance, or incoordination.  Right shoulder X-rays were normal and cervical spine X-rays showed loss of lordosis.  At the 6 November 2008 VA C&P examination, 5 months after separation, the CI reported pain medial to her right shoulder, pain in the trapezius and rhomboid regions above the scapula, and pain in the right neck.  Physical examination showed tenderness of the lower cervical muscles, trapezius and rhomboid muscle group and exquisite pain to pressure medial to the scapula.  Cervical spine flexion was normal and combined ROM was 315 degrees, with painful motion. 

The panel first considered if the myofascial neck and right shoulder girdle pain conditions, having been de-coupled from the combined PEB adjudication, each remained separately unfitting as established above.  Both conditions were listed on the profile, implicated in the commander’s statement and judged to separately fail retention standards.  The panel concluded there was not a preponderance of evidence in the service records which overcame the panel’s presumption that each of the bundled neck and right shoulder conditions was reasonably considered separately unfitting.  The panel next considered its rating recommendation for the unfitting neck condition at the time of separation based on the above evidence.

 The PEB rated the myofascial pain syndrome 10%, analogously coded 5099-5021 (myositis), citing slight limitation of motion of a major joint.   At the MEB NARSUM and C&P general medical examinations, cervical ROM was full which supports a 0% rating and no higher based on the absence of limitation of motion coded 5237-5021.  At the second C&P examination 5 months after separation, the CI did have mildly limited combined ROM and painful motion.  However, members agreed that the MEB NARSUM and C&P general medical examinations were more reflective of the CI’s disability at the time of separation and assigned greater probative value to them for the panel’s rating recommendations.  The panel considered other VASRD codes, but all were less applicable and the panel judged 5021 was the most appropriate code for the CI’s diagnosis of myofascial neck pain.  

The panel next considered a rating for the shoulder condition.  A 10% rating and no higher was supported coded 5201-5021 for painful, non-compensable limited motion of the shoulder.  Although the MEB PT ROM noted abduction limited to 95 degrees, the total evidence in record, including the pre-separation VA general medical examination, supports right shoulder ROM above shoulder level.  The panel considered a rating under other VASRD codes, but all were less applicable and/or not advantageous for rating.  There was therefore no higher rating than 10% supported for the shoulder condition.  After unbundling the two MEB conditions, the panel recommends the same combined 10% rating as the PEB.  Since this provides no ratings benefit to the CI, no change to the PEB’s combined adjudication is recommended.  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 bundled PEB adjudication for the myofascial pain syndrome.  

BOARD FINDINGS:  In the matter of the myofascial pain syndrome 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.  

XXXXXXXXXXXXXXX, 

Dear XXXXXXXXXXXXXXXXX

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found your separation disability rating and your separation from the Army for disability with severance pay to be accurate.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed), and I accept its recommendation.  I regret to inform you that your application to the DoD PDBR is denied.  

	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.