RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-02319
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20070216

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Ground Radar Systems Craftsman, medically separated for “myofascial pain syndrome” with a disability rating of 20%.  

CI CONTENTION:  The CI submitted a lengthy contention stating the VA rated her much higher.  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 - 20061228	VARD - 20080118	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Myofascial Pain Syndrome Associated with Occipital Neuralgia	5099-5021-5003	20%	Myofascial Pain Syndrome	5099-5284	NSC	20071109	
Migraine Headaches	Category II	Migraine Headaches  	8100	30%	20071109	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

Myofascial Pain Syndrome Associated with Occipital Neuralgia.  The PEB combined myofascial pain syndrome and occipital neuralgia under a single disability rating, dual coded 5099-5021-5003 (analogous to myositis – degenerative arthritis) and rated 20%.  This approach by the PEB, not uncommonly, reflected its judgment the constellation of conditions was unfitting, and there was no need for separate fitness adjudications.  The panel noted “bundling,” the combining of two or more major joints, may be permissible under the VASRD 5003 rating requirements, and 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 myofascial pain syndrome and occipital neuralgia are presented together, with attendant recommendations regarding separate unfitness, and separate rating if indicated.  

According to the service treatment record (STR) and the MEB narrative summary (NARSUM), the CI’s myofascial pain syndrome and occipital neuralgia began following a November 2004 automobile crash where she hit her head on the headrest but did not suffer loss of consciousness.  Approximately two days later, she began complaining of back and neck pain with a frontal headache.  She was treated with physical therapy and chiropractic manipulations without improvement.  An MRI of the cervical spine was normal.  In January 2005, she presented complaining of severe headaches since the crash, which were different from her preexisting migraines.  In February 2005, she was evaluated by a neurologist who found she was tender over the occipital nerves (scalp behind the ears).  The CI later underwent occipital nerve ablation in August 2006, which resulted in complete resolution of headaches until approximately 6 months after separation when she underwent an additional occipital nerve ablation.  

The MEB NARSUM, written on 22 September 2006, was based on an examination from 17 March 2006, 11 months prior to separation, which noted good control of pain with occipital injections lasting six to eight weeks.  Physical examination showed a normal neurological examination, the neck was supple with tenderness noted in the trapezius and right occipital area.  The remainder of the spine showed full range of motion (ROM) without tenderness or deformity.  All extremities showed full ROM in all joints with normal strength.  

At the 6 November 2006 pain clinic evaluation, 3 months prior to separation, the CI noted she had not had a headache since her August 2006 surgery.  She continued to have lower neck pain.  Physical examination revealed midline lower cervical paraspinal tenderness without mention of spasm or abnormal spinal contour.  A 13 December 2006 neurology follow-up evaluation, 2 months prior to separation and 4 months after nerve ablation, noted continued cessation of occipital neuralgia headaches since the nerve ablation.  Physical examination showed decreased sensation in the distribution of the right greater occipital nerve and an otherwise normal neurological examination.  

During the 12 January 2007 separation physical, 1 month prior to separation, the CI reported she was feeling fine other than headaches and neck pain, both of which felt better after nerve ablation.  Physical examination revealed a normal appearing neck with no palpable abnormalities.  ROM was not measured but the examiner reported movement did not elicit pain.  The examiner concluded the CI’s migraine headaches and cervicalgia were well controlled with treatment.  

A 21 February 2007 pain management evaluation, 6 days after separation, noted the CI was doing well but rated her pain at 4/10.  Physical examination showed no occipital tenderness but there was diffuse rhomboid (between the shoulder blades) and trapezius tenderness.  The examiner cited results of a 30 November 2006 cervical spine X-ray that showed loss of normal cervical lordosis secondary to pain, positioning or muscle spasm.   

At the 9 November 2007 VA Compensation and Pension (C&P) evaluation, 9 months after separation, the CI reported having done well after her first occipital nerve ablation until April 2007 when symptoms returned.  She then underwent the same surgery again in August 2007 and although she still had head pain, it was not as bad.  She said it felt like there was a cap on her head that caused pressure.  The pressure came once per week and lasted one or two days and was relieved by massage or a heating pad.  There was no discussion of incapacitating episodes.  There were no reported flare-ups of neck pain.  Physical examination showed a normal neurological evaluation.  Cervical spine ROM was flexion to 45 degrees (normal) with combined ROM of 340 degrees (normal) with painful motion noted in all planes.  There were no abnormal spinal contours but there was tenderness noted at C7 as well as the upper trapezius and paraspinal area between the shoulder blades.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB combined the myofascial pain syndrome and occipital neuralgia conditions and rated 20%, dual coded 5099-5021-5003 (analogous to myositis - degenerative arthritis), citing DoD and VA Rating guidelines.  The VA combined migraine headaches and occipital neuralgia status post occipital nerve ablation (x2) conditions citing “VA laws and regulations that will not allow [them] to evaluate the conditions separately as they are evaluated under the same diagnostic codes for VA purposes.”  The VA rated the combined condition 30%, coded 8100, (migraine headaches), based on the C&P examination 9 months after separation and the STR, citing reports the condition occurred about 2 times per month in nature causing incapacitation requiring the CI to lie down.  The VA also cited reports documenting nausea and vomiting with light and sound sensitivity during attacks.  Additionally, the VA determined “myofascial pain syndrome” was not service connected and therefore was not rated, citing no medical evidence of a disability or treatment of the condition after separation.  

Occipital Neuralgia.  The panel first considered if the occipital neuralgia condition, when decoupled from the combined PEB adjudication, remained separately unfitting as established above.  The note from the primary care provider stated he believed “long-standing occipital neuralgia” was the only condition being considered by the MEB and PEB.  The commander stated she believed none of the conditions were unfitting and the CI should be retained.  Additionally, the profiles were not helpful in determining what conditions, if any, were unfitting.  Since undue speculation would be required to conclude impairment from any of the conditions presented by the MEB would not have unacceptably interfered with AFSC performance.  Panel members agreed that occipital neuralgia was reasonably justified as separately unfitting.  The panel then considered its rating recommendation for the unfitting occipital neuralgia based on the above evidence.  

The panel noted there are no applicable codes for occipital neuralgia.  The panel then considered other analogous codes for sensory involvement of the head and face.  The trigeminal nerve (fifth cranial nerve) provides sensation to the face and is similar in function to the occipital nerve.  The panel also noted the head pain or headaches associated with the occipital neuralgia had resolved prior to separation and there were no such headaches in the six months preceding separation.  Although there was minimal decrease in sensation over the area supplied by the occipital nerve, members agreed this did not constitute a disability.  The panel agreed that at separation the degree of disability justified a 0% rating coded 8299-8405 (analogous to fifth (trigeminal) cranial nerve neuralgia).  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 0% for the occipital neuralgia condition, coded 8299-8405.  

Myofascial Pain Syndrome.  The panel then considered if the myofascial pain condition, when decoupled from the combined PEB adjudication, remained separately unfitting.  Although no conditions are listed on Air Force profiles, the restrictions listed on profiles for the last 16 months the CI was on active duty were consistent with myofascial pain.  The two profile review forms in the STR list the reason for the mobility limiting profile as “cervical syndrome” which are the symptoms cited by the specialist diagnosing the myofascial pain syndrome.  The commander stated she believed none of the conditions were unfitting and the CI should be retained.  Since undue speculation would be required to conclude impairment from any of the conditions presented by the MEB would not have unacceptably interfered with AFSC performance, members agreed the myofascial pain syndrome was reasonably justified as separately unfitting and considered its rating recommendation.  

The panel noted the CI did not meet the criteria for rating using code 5025 (fibromyalgia).  Myositis (5021) requires rating on limitation of motion of the affective parts; in this case, the neck was the affected part.  The panel noted there were very few measurements of cervical spine ROM.  Those that were presented noted full or nearly full ROM.  Spasm of the trapezius and other neck muscles were present intermittently and tenderness was consistently present.  Although there was one X-ray that showed a decrease in the cervical lordosis (abnormal spinal contour) and the radiologist opined that spasm was one possible cause, this was not a consistent finding.  Therefore, the panel finds a 10% rating, but no higher was warranted for muscle spasms or tenderness of the cervical spine.  There was no evidence of flexion of 30 degrees or less, combined ROM of 170 degrees or less or consistent muscles spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour to justify the next higher 20% rating.  The panel noted this rating, combined with the occipital neuralgia rating above did not constitute a rating advantage to the CI.  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 associated with occipital neuralgia.  

Contended PEB Condition:  Chronic Migraine Headaches.  The panel’s main charge is to assess the fairness of the PEB’s determination the contended condition was not unfitting.  The migraines were not profiled, implicated in the commander’s statement or noted to fail retention standards.  The CI was working full shifts and only took time off for medical appointments.  There was no performance-based evidence from the record the condition significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded there was insufficient cause to recommend a change in the PEB fitness determination for the contended condition and so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the myofascial pain syndrome with associated occipital neuralgia and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the contended migraine headache condition, the panel recommends no change from the PEB determination as not unfitting.  There are no other conditions within the panel’s scope of review for consideration.  Therefore, the panel recommends there be no modification or re-characterization of the CI’s disability and separation determination. 

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170303, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record

SAF/MRB
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD 20762

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

	Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2017-02319.

After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was appropriate.  Accordingly, the Board recommended no re-characterization or modification of your separation.

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding and their conclusion that re-characterization of your separation is not warranted.  Accordingly, I accept their recommendation that your application be denied.

					Sincerely,

XXXXXXXXXXXXXXXXXX	
Director
	Air Force Review Boards Agency

Attachment:
Record of Proceedings