DEPARlMENT OF THE NAVY
SECRETARY  OF THE NAVY COUNCIL  OF REVIEW   BOAPDS
720    KENNON  STREET  SE  STE   309
WASHINGTON NAVY YARD, DC 20374

From:
To:

Director, Secretary of the Navy Council of Review Boards
PD-2017-03224
IN   PErLY   l'EITR   T•J:
1850
CORB:003
27 Feb 20

Subj:	PHYSICAL DISABILITY BOARD OF REVIEW (PDBR)
Ref:	(a) DoDI 6040.44
(b) PDBR ltr of 2 Apr 19
1.	Pursuant to reference (a), the PDBR reviewed your case and forwarded its
recommendation to the Department of the Navy for appropriate action.

2.	On 21 February 2020, the Assistant General Counsel of the Navy (Manpower & Reserve  Affairs)  took action  in  your  case by    accepting the recommendation of the PDBR.	Accordingly, your records will be corrected to reflect an increase in the disability rating awarded by the Department of the Navy Physical Evaluation Board (PEB) from 0% to 10% without re-characterization of your discharge.
3.	For your information, since all disability ratings from 0% to 20% qualify for disability severance pay, the above stated increase will not result in your entitlement  to  additional  compensation.

4.	The Assistant Secretary's determination, which represents final action in your case by the Department of the Navy, has been forwarded to the office of the Deputy Commandant, Manpower and Reserve Affairs for appropriate changes to your personnel records and notification to you upon completion.

RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW
NAME:  XXXXXXXXXXXXXXXXXXXXXXXXXX	CASE: PD-2017-03224
BRANCH OF SERVICE: MARINE CORPS	SEPARATION DATE: 20060331

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Field Wireman, medically separated for “mild thoracolumbar scoliosis” and “myofascial pain syndrome,” rated for overall effect, with a combined disability rating of 0%.

CI CONTENTION:  Review of all conditions requested.  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 - 20060117	VARD - 20060606	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Mild Thoracolumbar Scoliosis	
Overall Effect	
0%	Thoracic Spine Degenerative Disc Disease	5242	10%	20060123	

Myofascial Pain Syndrome							
			Right Hip Subluxation	5252	10%	20060123	
			Left Hip Subluxation	5252	10%	20060123	
COMBINED RATING: 0%	COMBINED RATING OF ALL VA CONDITIONS: 30%	

ANALYSIS SUMMARY:

Mild Thoracolumbar Scoliosis and Myofascial Pain Syndrome. The PEB combined mild thoracolumbar scoliosis and myofascial pain syndrome under a single disability rating for “overall effect” as permitted by DoDI 1332.38 (E3.P3.4.4). The combination of multiple conditions as a single disability reflects the PEB’s determination that each condition was not separately unfit, but the functional impairment resulting from the conditions when considered together was unfitting. The panel’s initial charge in this case was therefore directed at determining if the PEB’s

single overall effect rating was justified in lieu of separate unfit determinations and ratings. If the panel judges that two or more separate ratings are warranted in such cases, however, it must satisfy the requirement that each “unbundled” condition was unfitting in and of itself as shown by a preponderance of evidence. The panel’s recommendations may not produce a lower combined rating than that of the PEB. The evidence for the mild thoracolumbar scoliosis and myofascial pain syndrome is presented separately; with separate fitness determinations and rating recommendations if indicated.

According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s back and hip conditions began during Basic Training after heavy exercise. She was placed on limited duty for chronic strain/myofascial pain. An orthopedic evaluation found no specific etiology for the pain as all radiographic studies “were normal.” Physical therapy and chiropractic care failed to improve the pain. Osteopathic manipulation, acupuncture, home stretches/exercises, and medication, initially caused the pain to plateau but then it worsened. Thoracic and lumbar X-rays and MRIs documented multiple Schmorl’s nodes, degenerative disk changes and minimal thoracolumbar scoliosis.

The 16 May 2005 neurology evaluation showed a normal gait, but there was muscle spasm of the hips, bilateral piriformis, bilateral gluteus maximus, and left iliopsoas. The diagnosis was myalgia and myositis-piriformis syndrome with a note about “good improvement.”  The 18 August   and
16 September 2005 neurology evaluations documented a normal gait with lumbosacral paraspinal muscles spasms bilaterally, and muscle spasm of the hips (bilateral gluteal and piriformis). The diagnosis was “myalgia and myositis” with improvement between the two examinations.

At the 6 October 2005 pain management evaluation, the CI complained of bilateral hip and low back pain that radiated to the heels. Physical examination documented hip tenderness in the groin bilaterally, “all down [the] lumbar paraspinals and in multiple spots in [the] buttocks.” Hip flexion, extension, and internal and external rotation were normal. There was a negative Faber's test (flexion, extension and external rotation of the leg did not cause pain) and a negative Trendelenburg (no pelvic drop on single leg standing).

The 26 October 2005 neurology evaluation documented complaints of lower back and bilateral hip pain. Physical examination showed muscle spasms with significant tenderness bilaterally for the paraspinal and hips. Prior evaluations in May, August, and September 2005 were similar for back and hip muscle spasms with no evidence of an abnormal gait. The diagnosis was myalgia and myositis, with prior notes adding the clarifier of “piriformis syndrome.”

The MEB NARSUM examination was conducted on the same day as the neurology evaluation, 5 months prior to separation, and noted complaints of back and hip pain exacerbated by running, use of a stair stepper, and leg-raises. Pain was nearly constant, usually mild, but severe approximately twice a month. Physical examination showed a normal gait. The CI was able to heel and toe walk without difficulty. There was tenderness to the lower thoracic and lumbar paravertebral and hip musculature. Range of motion (ROM) of the thoracolumbar spine was cited as full and active. Forward flexion was over 90 degrees (normal), extension was not recorded, bilateral rotation was over 30 degrees (normal) and bilateral side bending was 30 degrees (normal). There was no muscle atrophy. During the 21 November 2005 MEB examination (recorded on DD Forms 2807-1 and 2808), 4 months prior to separation, the CI reported back and bilateral hip pain. Physical examination revealed lumbar and thoracic spine tenderness without deformity. Lower extremities, and bilateral hip X-rays in January 2006, were all normal.

At the 23 January 2006 VA Compensation and Pension (C&P) examination, 2 months after separation, the CI reported development of pain radiating to the back without radiation to   the

legs. She also reported not having pain with walking, but with climbing stairs, running, and using a stair-stepper. Physical examination showed minimal (5 degrees) thoracic scoliosis with mild compensatory lumbar curvature. There was pain on percussion over the spinous process of T4 and L5, without paravertebral musculature tenderness. Flexion was over 90 degrees and combined ROM was 210 degrees with painful motion. Repetitive motion did not worsen the pain or further limit ROM. Straight leg raise testing was to 90 degrees without back pain but with slight inguinal pain on the right side. Repetitive bilateral hip ROM measured in degrees showed flexion of 70/80 (normal 125), extension of 30/30 (normal), external rotation of 60/70 (normal 60), abduction of 30/30 (normal 45) internal rotation of 30/35 (normal 40), and adduction of 40/40 (normal 25). There was no pain with ROM except adduction was noted to be pain-limited at 40 degrees, but normal adduction is only 25 degrees. The diagnosis was bilateral hip subluxation; X-rays were non-diagnostic.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the back and hip conditions 0%, citing “overall effect” as noted above. The VA rated the back condition 10%, coded 5242 (degenerative arthritis of the spine), based on the C&P examination, citing localized tenderness, painful motion, and combined thoracolumbar ROM of 210 degrees. Also, the VA rated each hip condition 10%, coded 5252 (thigh, limitation of flexion), based on the C&P examination, citing limited and painful motion. The evidence showed that the CI was initially seen for bilateral hip and low back pain with MEB diagnoses of “mild thoracolumbar scoliosis” and “myofascial pain syndrome.” STR notes indicated the myofascial pain syndrome included the lower back and pelvic/hip muscles (gluteal and piriformis muscles specified). Panel members agreed the preponderance of evidence justified that the functional limitations of the thoracolumbar spine condition contributed to the CI’s inability to perform her military duties, and accordingly a separate disability rating is recommended. There was radiographic evidence of thoracolumbar spine pathology and the preponderance of examinations documented back tenderness or spasm, or limited motion, warranting a 10% rating. The panel agreed a 10% rating was justified for the presence of tenderness, spasm, or painful motion. There was no muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour, nor was limitation of ROM beyond the 10% criteria, thus the next higher 20% rating was not justified on this basis. There was no documentation of intervertebral disc syndrome with incapacitating episodes which would provide for a higher rating under that formula.

The panel next deliberated if the myofascial pain syndrome, when separated from the thoracolumbar spine condition, was separately unfitting and ratable. The spine rating, under the general spine rating criteria, specifically states “with or without symptoms such as pain (whether or not it radiates)” and also includes the sacroiliac joint (§4.66) and muscles of the pelvis. There was no specific hip joint pathology and the myofascial pain was predominately related to the muscles of the back or pelvis functioning. The panel noted that pain is a symptom rather than a diagnosis. There was no rheumatologist diagnosis of fibromyalgia (5025). The panel did not find a preponderance of evidence to determine that any specific hip condition was unfitting and noted that, in fact, no specific hip diagnosis was made during the PEB process. The panel adjudged that to avoid pyramiding IAW §4.14, impairment from the myofascial pain syndrome was subsumed under the rating for the back condition. After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a separately unfit determination with a disability rating of 10% for the back condition, coded 5299-5242.

BOARD FINDINGS: In the matter of the mild thoracolumbar scoliosis and myofascial pain syndrome, the panel recommends a disability rating of 10%, analogously coded 5299-5242, IAW VASRD §4.71. 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	
Mild Thoracolumbar Scoliosis with Myofascial Pain Syndrome	5299-5242	10%	

The following documentary evidence was considered: