RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW
NAME: XXXXXXXXXXXXXXXXXXXXXXXx	CASE: PD-2017-03991
BRANCH OF SERVICE: NAVY	SEPARATION DATE: 20070117

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E3, Corpsman, medically separated for “right cervical shoulder sprain/strain myalgia” with a disability rating of 20%.

CI CONTENTION: “My conditions have caused long term issues.” 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 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 - 20061003	VARD – 20070621	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Right Cervical Shoulder Sprain/Strain Myalgia, with Resulting Intercostal Myositis	5322	20%	
Myofascial Pain Syndrome, Right Shoulder and Neck	

5099-5025	

20%	
20060410
20060426	
Varying Degrees of Central Sensitization Due to this Injury and Sleep
Dysfunction	Cat II					
Intermittent Post-Traumatic Migraine
without Aura	Cat II	Migraine Headaches	8100	30%	20060410	
Thoracic Outlet Syndrome Symptoms	Cat II	No VA Placement	
Symptoms of Eustachian Tube
Dysfunction	Cat II	No VA Placement	
Right TMJ [Temporomandibular Joint] Disease that Reduces on Opening	Cat II	TMJ Disease	9905	30%	20060410	
Right Shoulder Muscle Spasms	Cat II	No VA Placement	
Anger and Anxiety	Cat III	No VA Placement	
COMBINED RATING: 20%	COMBINED RATING OF ALL VA CONDITIONS: 60%	

ANALYSIS SUMMARY:

Right Cervical Shoulder Sprain/Strain Myalgia. According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI fell 15 feet from a Jacob’s ladder and hit the right side of her head in October 2004. She sought medical care but was only sore initially and seemed to improve. Approximately 2 months later, she began to have headaches (HAs) and problems

with opening as well as locking of her jaw; X-rays were normal. A right auricular temporal nerve block (ATNB) alleviated the TMJ pain, but after it wore off, anti-inflammatory medications were not effective. The pain increased and she was given a mouth guard and Imitrex (selective serotonin receptor agonist) for the HAs. Repeated ATNBs were helpful, suggesting TMJ arthralgia. The CI was medically evacuated for further treatment.

On 12 September 2005, she was evaluated by the orofacial pain clinic where presented with a “perceived right TMJ complaint.” Pain was rated at 7/10, and she had right facial decreased sensation to light touch in the trigeminal first, second, and third divisions, right middle ear fullness, and a subjective sense of fogginess in her right eye. She also had reduced jaw opening, altered tooth contact patterns, and the inability to move her jaw to the left. Head rotation was also restricted, and both jaw and neck movement increased pain and a sense of right ear fullness. Palpation of the right sternocleidomastoid muscle (SCM) projected pain to the right ear, TMJ, and the temporal frontal regions, the site of the HAs. Palpation of the right temporal tendon also reproduced the chief complaint, and palpation of the masseter tendon caused hyperalgesia. Right SCM injections eliminated HAs, restored normal tooth contact, increased jaw range of motion (ROM), cleared the ear fullness, and reduced facial pain to 3/10 in the muscles/tendons. “It was a revelation to the patient that her neck and shoulder musculature were a major part of her TMJ complaint.” Later that evening, the CI’s symptoms returned with stress, and she was again treated with a mouth guard, muscle relaxants, pain medication, and Imitrex for migraines. Symptoms were unimproved after a period of leave, but electrodiagnostic studies in late November 2005 showed no evidence of brachial plexopathy or cervical radiculopathy, and cervical spine and brain MRIs showed no pathology.

At a 9 December 2005 chiropractic examination, 13 months prior to separation, the CI was diagnosed with right levator scapula myofascial pain and thoracic outlet syndrome (TOS) due to hypertonic right scalene and pectoralis muscles. The CI was treated with electrical stimulation and postural training. On 16 Decembers 2005, following additional muscle injections which lessened her pain, jaw function was normal and the right shoulder was looser, but still painful. Upon return from leave in January 2006, it was noted that her jaw and HA symptoms directly correlated with the intensity of cervical and shoulder pain aggravated by lifting, postural fatigue and any type of extreme ROM.

The 28 February 2006 MEB NARSUM examination, 11 months before separation, listed the CI’s medications to include: Flexeril (muscle relaxant) as needed, Imitrex as needed, and tramadol (opiate analgesic) 3 times per day, which was effective at keeping pain levels at 5/10, except for exacerbations. There had been some improvement in the TMJ pain and migraines, but little improvement in the right side cervical and shoulder myalgia. The examiner stated “exacerbations of her right cervical/shoulder myalgia affect exacerbations of all her other conditions. Unless the cervical shoulder myalgia improves, she is likely to be plagued by continued exacerbations of migraines, jaw pain, jaw dysfunction, ear fullness, and right hand and arm spasms.” When spasms occurred her head contracted to her right shoulder and she became incapacitated and unable to move her arm. The prognosis for improvement was only fair and the conditions adversely affected her ability to remain on active duty.

The 28 February 2006 behavioral health addendum indicated the CI was not characteristically angry but very angry at her current situation. Anger profile results indicated that she suppressed her anger rather than expressing it verbally or behaviorally. The provider discussed research that supported the adverse effects of anger on chronic pain conditions, and she was deemed highly motivated and fully compliant with her relaxation training and cognitive behavioral therapy.

The 23 March 2006 neurology addendum examination, 10 months prior to separation, noted that since her fall, the CI had a history of HAs occurring 3-8 times a month that were effectively treated by Imitrex, but caused her to sleep for 24 hours. Physical examination showed bilateral neck

muscle stiffness and spasms, but normal cranial nerves as well as facial sensation, motor strength and tone. There was no evidence of arm weakness, with normal coordination and reflexes in all extremities; gait was normal. The provider assessed HAs occurring 3-8 times a month that prevented the CI from functioning. A trial of gabapentin (nerve pain) at bedtime was initiated.

At the 10 April 2006 VA Compensation and Pension (C&P) examination, 9 months before separation, the CI reported right neck and shoulder pain aggravated by arm motions above the head or behind the back, and that she was unable to lift objects with the right arm. She was taking tramadol for more severe pain and used Vicodin (analgesic-narcotic) twice a week on average. Physical examination showed a normal gait, posture and cervical spine curvature. There was tenderness of the right trapezius from the neck to the interscapular region, and measured ROM showed cervical spine flexion to 30 degrees (normal 45) and a combined ROM of 255 degrees (normal 340). There was pain on the right side with left lateral flexion and right rotation; repetitive motion could not be tested due to pain and guarding. The right shoulder was minimally lower than the left with anterior tenderness noted. Shoulder flexion and abduction were both to 120 degrees (180 normal for each), and repetition could not be accomplished due to pain and guarding. At a physical therapy follow-up visit on 12 July 2006, findings were essentially the same, and the provider indicated the CI’s symptoms and examination were consistent with shoulder impingement and adhesive capsulitis, and that she was slowly progressing in shoulder strength and ROM with therapy.

At the VA C&P neurological examination the same day, the CI reported bi-temporal and retro- orbital HAs with throbbing pain 4-6 times a month, which lasted 1-2 days if untreated. When she used Imitrex, she slept for 24 hours and woke up without a HA. She could not yet tell if the gabapentin was helping. Physical examination showed the CI was right-handed and had decreased sensation in the radial aspect of the right arm, thumb and index finger. Strength was normal except for 5-/5 strength of the right deltoid (axillary nerve, upper trunk of brachial plexus). There was spasm of the right trapezius, and cervical spine ROM showed flexion to 45 degrees and a combined ROM of 275 degrees, with pain with all motions. Repetitive flexion and extension caused increased pain, but no change in strength, sensation, or coordination.

The 24 May 2006 chiropractic addendum, 8 months prior to separation, summarized that the CI had been evaluated on 12 December 2005 and was felt to have right neck and shoulder symptoms attributable to right scalene and pectoralis minor hypertonicity. She was seen on 25 January 2006 with complaints of right shoulder and arm weakness and HAs (bi-temporal pain), and the provider documented muscle hypertonicity and trigger points in the pectoralis minor and levator scapula. She was treated with electrical stimulation and prescribed shoulder exercises to increase ROM, but returned the next day with severe upper back and neck muscle spasms. She had been talking on the phone outdoors in the extreme cold the day before, and had difficulty taking a deep breath. Physical examination revealed reduced motion and tenderness of the third and fourth ribs on the right, and she was treated with heat and manipulation. The CI was treated again on 22 February 2006, and then returned on 10 April 2006 with neck and shoulder pain and HAs from a motor vehicle accident on 7 April 2006; she was also treated on 17 April 2006. The diagnosis was right cervical/shoulder sprain/strain with intercostal myositis, muscle spasm, and myalgia with a note that she was typically seen for acute flare-ups rather than ongoing treatment.

On 24 July 2006, the Informal PEB (IPEB) rated a Category I condition of “cervical shoulder sprain/strain myalgia, with resulting intercostal myositis” 10%, coded 5322 (muscle group 22 injury) for moderate muscle injury. There were six additional diagnoses listed as related Category II conditions (contribute to the primary unfitting condition but not separately ratable), and anger and anxiety was determined to be a Category III (not unfitting) condition. The CI appealed to the Formal PEB (FPEB) and requested to be rated at 20% for the unfitting Category I condition. She submitted a MEB NARSUM addendum and specific treatment records (cited by the FPEB), which are summarized below:

At a physical therapy examination on 16 June 2006, 7 months prior to separation, physical examination showed rounded shoulders, forward head posture, increased muscle guarding and cautious movements of the right shoulder. Active ROM of the cervical spine was within normal limits with painful motion. Shoulder ROM was flexion of 112 degrees and abduction of 136 degrees with painful motion. There was right scapular weakness noted. Sensation of the RUE was intact and the CI denied paresthesias at the time. There was pain and weakness in the cervical myotomes from C1, 2 (neck flexion) and C3 (side bending) and pain in C4, 5 (shoulder elevation and abduction). Strength was normal except for neck muscles as noted. There was decreased flexibility of the pectoralis muscles, upper trapezius and levator scapula. There was tenderness of the RC tendons of the anterior shoulder, pec minor, pec muscle belly, UT, levator scap and teres minor- all on the right. Trigger points were noted in the right levator scapula and UT. The therapist noted there were variable muscle spasms of the neck and shoulder that limited ROM throughout the examination.

A 13 September 2006 MEB NARSUM addendum, 4 months prior to separation, noted that the CI’s TMJ and HA symptoms were minimal on some days, but the right shoulder/neck pain was always present. The CI had been moved to working at the orofacial pain center so that severe spasms which were exceedingly difficult to abort could be treated promptly. Medications were gabapentin at night, tramadol as needed, physical self-regulation and TENS. The orofacial pain specialist noted flares caused the CI to miss many work days – usually one to three days per week, most but not all weeks. When her pain was less he reported she was a good worker, however, she required a work environment where it was possible to miss 20% to 30% of a normal 40 hour work week.

The 17 October 2006 FPEB, 3 months prior to separation, considered the CI’s case with the additional information and found the CI unfit based on the Category I diagnosis as determined by the IPEB, rated 20%, coded 5322, for a moderately severe group 22 muscle injury and the same six Category II conditions and single Category III condition.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the right shoulder condition 20%, coded 5322, and also adjudicated varying degrees of central sensitization due to this injury and sleep dysfunction, intermittent post-traumatic migraine without aura, TOS, symptoms of Eustachian tube dysfunction, right TMJ disc displacement that reduces on opening, and right shoulder muscle spasms as related Category II conditions. The VA rated myofascial pain syndrome 20%, coded 5099-5025, analogous to fibromyalgia (FM), citing symptoms that were episodic, with exacerbations often precipitated by environmental or emotional stress or by overexertion, but present more than one-third of the time. The VA also rated the migraines 30%, coded 8100 (migraines), citing prostrating attacks on average once per month; and TMJ disease 30%, coded 9905 (temporomandibular articulation, limited motion of), based on the STR and C&P examination.

The panel agreed that the myalgia/myositis condition could be analogously coded 5099-5025 analogous to FM syndrome, subsuming the Category I myalgia/myositis and all Category II conditions as the FM code subsumes fatigue, sleep disturbance, headaches, paresthesias, irritable bowel syndrome, and depression, and provides a single rating. Despite all treatment, the CI’s cervical and shoulder pain was noted to be present constantly with exacerbations that were incapacitating more than once per month with associated migraines and TMJ dysfunction, and documented lost work time of on average one day per week up to 30% of a normal work week. Panel members adjudged that the CI’s disability due to the cervical/shoulder myalgia with intercostal myositis was more nearly approximated by the 40% rating criteria than the 20% criteria IAW VASRD §4.7 (higher of two evaluations) for symptoms that were “constant, or nearly so and refractory to therapy.” The panel considered the contributions to the CI’s impairment by the Category II conditions in its 5025 rating recommendation and no additional ratings for Category II conditions can be recommended IAW VASRD 4.14 (avoidance of pyramiding). After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 40% for the right cervical shoulder myalgia with myositis, coded 5099-5025.

Contended PEB Condition: Anger and Anxiety. The panel’s main charge is to assess the fairness of the PEB determination that the contended anger and anxiety condition was not unfitting. The contended condition was not noted on limited duty forms or implicated in the non-medical assessment (NMA), and did not fail retention standards. The NMA noted the CI had performed well despite her condition, but she was not worldwide assignable. There was no performance- based evidence from the record that the condition significantly interfered with satisfactory duty performance at separation. Additionally, the panel noted that anger and anxiety, while not recommendable as a separately unfitting condition, would be accounted for under the panel’s 5299-5025 rating recommendation above. After due deliberation, the panel concluded there was insufficient cause to recommend a change in the PEB fitness determination for the contended condition, so no additional disability rating is recommended.

BOARD FINDINGS: In the matter of the “chronic right cervical shoulder sprain/strain myalgia, with resulting intercostal myositis,” the panel recommends a disability rating of 40%, coded 5099- 5025 IAW VASRD §4.71a. In the matter of the contended anger and anxiety condition, the panel agrees that it cannot recommend it for additional disability rating. 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; 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	
Chronic Right Cervical Shoulder Sprain/Strain Myalgia, with Resulting Intercostal Myositis	5099-5025	40%	

The following documentary evidence was considered:

DEPARTMENT OF THE NAVY
SECRETARY OF TI-IE NAVY COUNCIL OF REVIEW BOARDS 720 KENNON STREET SE STE 309
WASHINGTON NAVY YARD, DC 20374-5023

IN REPLY REFER TO:
1850
CORB:003 12 Oct 20

From: To:

Subj:

Ref:

Director, Secretary of the Navy Council of Review Boards 

PHYSICAL DISABILITY BOARD OF REVIEW {PDBR)

{a) DoDI 6040.44
{b) PDBR ltr of 13 Apr 20

1.	Pursuant to reference {a), the PDBR reviewed your case and forwarded its recommendation (reference (b)) to the Department of the Navy for appropriate action.

2.	On 7 October 2020, the Assistant Secretary of the Navy took action in your case by accepting the correct recommendation of the PDBR.	Accordingly, your records will be corrected to reflect an increase in the disability rating awarded by the Physical Evaluation Board from 20 to 40 percent with assignment to the Permanent Disability Retired List.

3.	The Assistant Secretary's determination, which represents final action in your case by the Department of the Navy, was sent to the Navy Personnel Command, for correction of your records as stated above.	You will be notified once those changes are complete.