RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW
NAME: XXXXXXXXXXXXXXXXXXXX	CASE: PD-2017-04150
BRANCH OF SERVICE: NAVY	SEPARATION DATE: 20080624

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Maintenance Technician, medically separated for “complex regional pain syndrome (CRPS) of the right neck, shoulder and arm” with a disability rating of 20%.

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 - 20080304	VARD - 20080822	
Condition	Code	Rating	Condition	Code	Rating	Exam	
CRPS of Right Neck, Shoulder and Arm	8799-
8713	
20%	DJD, Right Shoulder	5021-5003	10%	20080421	
			Sprain, Cervical Spine	5237	10%	20080421	
			Sprain, Right Elbow	5206-5024	10%	20080421	
Superimposed Myofascial Pain in the form of a
Trigger Point, Right Shoulder	CAT II	No VA Placement	
Sleep Apnea	CAT III	OSA and Airway Obstruction	6847	50%	20080421	
Mild Scoliosis of the Thoracic and Lumbar Spine	CAT III	DDD, Lumbar Spine	5242	10%	20080421	
COMBINED RATING: 20%	COMBINED RATING OF ALL VA CONDITIONS: 80%	

ANALYSIS SUMMARY:

CRPS of the Right Neck, Shoulder and Arm. According to the service treatment record (STR) and MEB narrative summary (NARSUM), the right-handed CI’s right neck, shoulder, and arm pain condition began in approximately October 2005 after he performed extended overhead work with lifting and pushing equipment. Initially, he reported awakening with a stiff, painful right neck, but he continued overhead work, and then developed pain and tingling radiating down the right arm. Treatment consisted of a nonsteroidal anti-inflammatory drug (NSAID). A civilian neurologist reportedly found no organic disease. Within 4-5 months the pain resolved; however, when he returned to overhead work, he reported mild swelling of the right hand along with right neck pain and tingling radiating down his right arm. X-rays of the right elbow dated 2 November 2006, ordered for pain at the right elbow and numbness of the hand, were normal. The CI’s condition on 6 November 2006 was assessed to be cervical radiculopathy and he was treated with an NSAID, acetaminophen (a pain reliever), and a muscle relaxer.

At an emergency room visit on 7 January 2007, he continued to report right arm pain, which was assessed as right thoracic outlet syndrome. Treatment consisted of a sling, light duty, an NSAID, and a muscle relaxer. A vascular surgery work-up was negative including a normal venogram in February 2007. Electrodiagnostic studies of the right arm/neck were normal in April 2007. A chest X-ray was normal. X-rays of the thoracolumbar spine showed a dextrocurvature (curvature to the right) with a spur at the superior and anterior endplates of L2. Thoracic X-rays demonstrated a mild compression deformity of a midthoracic vertebral body only with a mild lower thoracic levocurvature (left curvature). An MRI of the cervical spine was unremarkable. Pain persisted but was not controlled by anti-inflammatory medication, however Neurontin (for nerve pain) provided some relief. CRPS was considered at a clinic visit on 23 May 2007. X-rays  of the cervical spine showed the right cervical rib and loss of the cervical lordosis. Rest, several months of physical therapy (PT), and chiropractic treatment improved his pain, but when he resumed his duties, pain returned. A bone scan did not reveal the classic findings for reflex sympathetic dystrophy (RSD); however, it did not rule out the possibility from a clinical perspective since there was slightly more uptake on the right than the left. There was also a question whether the CI had early signs of an arthropathy.

At a PT clinic visit on 25 September 2007, it was difficult to localize the arm pain, which began in the glenohumeral joint when actively moved and worsened with extended activity. Flexion and abduction of the right shoulder were 180 degrees each (normal 180 each) with pain on motion and with impingement testing. At a physical medicine clinic visit on 27 September 2007 the CI’s right arm was still slightly swollen and the skin had a shine to it on the right. Despite responding somewhat to the Neurontin, he was still unable to use his arm with very much functionality. Same-day X-rays of the right elbow showed no bone or joint abnormality, while X-rays of the right shoulder showed minor acromioclavicular degenerative changes.

A physical medicine and rehabilitation consultation dated 4 October 2007 reiterated the clinical history and findings including a full range of motion (ROM) in the neck and upper limbs bilaterally, a negative Spurling’s test (to determine nerve root irritation) bilaterally, normal shoulder strength, diminished grip on the right, intact sensation in the upper limbs, and swelling in the right hand and shine on the skin. The examiner noted the CI’s diagnosis was CRPS with superimposed myofascial pain in the form of a trigger point. TENS (transcutaneous electrical nerve stimulation) helped and a unit was ordered for the CI. Additionally, he had mild scoliosis of the thoracic and lumbar spine, which was being treated by chiropractic. He was unable to lift without pain and was unable to complete his duties. An MRI of the right shoulder was normal on 9 October 2007. A note dated 21 December 2007 indicated the only objective finding for the CI’s complaints of pain in his right arm was the cervical rib; however, he was not interested in a surgical referral to remove it.

The 19 February 2008 MEB NARSUM examination, 4 months prior to separation, noted complaints of right neck pain with tingling down the right arm with mild swelling of the right hand associated with frequent lifting more than 15 pounds or overhead work. Physical examination showed the appearance of the neck was normal without tenderness. The carotid arteries were normal and the thyroid showed no abnormalities. There was no lymphadenopathy. There was normal movement of all extremities except slightly diminished right hand grip. Neurological evaluation revealed normal cranial nerves, sensation, muscle bulk, tone, and strength except for a slightly diminished hand grip. There were no coordination or cerebellum abnormalities noted. Balance, gait, and stance were normal as were the reflexes of the upper and lower extremities, and there was no clonus. The examiner’s final diagnosis was CRPS of the right neck, shoulder, and arm and myofascial pain, right shoulder.

At the 21 April 2008 VA Compensation and Pension (C&P) examination, 2 months before separation, the CI reported pain in the right arm and swelling in the right hand with numbness and tingling. Physical examination of the cervical spine showed evidence of radiating pain on movement to the right shoulder with no evidence of muscle spasm. ROM measurements were normal with pain at the end of the motions without limitation of motion after repetition. Physical examination of the right shoulder and right elbow showed there was no tenderness, edema, effusion, weakness, redness, heat, or guarding of movement. The ROMs of the right shoulder and right elbow were normal with pain at the end of the motions, but with no limitation of motion with repetition. He could tie his shoelaces and pick up a piece of paper without difficulty, but had difficulty fastening buttons with both hands. Neurological evaluation of the upper extremities was within normal limits as were X-rays of the chest, cervical and thoracic spine, and the right elbow and wrist. .  Right shoulder X-rays showed degenerative arthritic changes.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the CRPS of the right neck, shoulder and arm 20%, analogously coded 8799-8713 (all radicular groups-neuralgia). The PEB listed superimposed myofascial pain in the form of a trigger point, right shoulder as related Category II diagnosis, which contributed to or related to the Category I disability in this case. The panel concluded the Category II diagnosis was not a separate condition that could be reasonably justified as separately unfitting; nor would a separate rating be achievable without violation of VASRD §4.14 (avoidance of pyramiding).

The VA rated the neck condition 10%, coded 5237 (cervical strain), based on the C&P examination, citing painful motion with evidence of repetitive loss due to pain, fatigue, weakness, and lack of endurance. The VA rated the right shoulder condition 10%, coded 5201-5003 (arm, limitation of motion- degenerative arthritis), based on the C&P examination, citing painful motion with evidence after repetitive motion due to fatigue, weakness, and lack of endurance. The VA rated the right elbow condition 10%, coded 5206-5024 (forearm, limitation of flexion - tenosynovitis), based on the C&P examination, citing functional loss due to pain, fatigue, and weakness after repetitive use. The VA rated the right wrist condition 10%, coded 5215-5024 (wrist, limitation of motion-tenosynovitis), based on the C&P examination, citing painful motion.

The panel noted the PEB diagnosis and rating of 20% for the CRPS of right neck, shoulder and arm versus the VA separately diagnosing and rating cervical spine sprain, right shoulder degenerative joint disease (DJD), right elbow sprain, and right wrist tendonitis. Multiple examinations prior to separation raised the diagnosis of CRPS or RSD, but neither of those diagnoses were made at the VA examination, which based its rating of each of its diagnoses on painful motion at the end of normal ROMs, although there were degenerative arthritic changes of the right shoulder. The panel did find the service diagnosis of CRPS to be adequately evaluated, although the CI did have a right cervical rib, albeit small. The panel then considered whether the CRPS rose to a moderate or severe disability. The fact that the CI had full ROMs of the neck, right arm, right elbow, and right wrist with normal strength and sensation as well as normal imaging, but for the degenerative changes in the right shoulder, favors a mild condition rather than a moderate or

severe disability, especially since the pain was exacerbated with heavy lifting or overhead work, both of which are avoidable or limited in many civilian occupations. 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 PEB adjudication for the CRPS of right neck, shoulder and arm condition.

Contended Category III Conditions: Sleep Apnea, Mild Scoliosis of the Thoracic and Lumbar Spine. The panel’s main charge is to assess the fairness of the PEB determination that the contended conditions were not unfitting. Neither condition was explicitly noted in the non-medical assessment. There was no performance-based evidence from the record that any of the conditions 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 either of the contended conditions, so no additional disability ratings are recommended.

BOARD FINDINGS: In the matter of the complex regional pain syndrome of the right neck, shoulder and arm condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication. In the matter of the contended sleep apnea and mild scoliosis of the thoracic and lumbar spine conditions, the panel recommends no change from the PEB determinations as not unfitting. 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.

The following documentary evidence was considered:

DEPARTMENT OF THE NAVY
SECRETARY OF THE NAVY COUNCIL OF REVIEW BOARDS XXX XXXXX XXXXXX XX XXX XXX
XXXXXXXXXX XXXX XXXX XX  XXXXX

IN   REPLY   REFER TO,

1850
CORB: 003 20May20

From: Director, Secretary of the Navy Council of Review Boards

Subj:  PHYSICAL DISABILITY  BOARD OF REVIEW (PDBR)

Ref:	(a) DoDI 6040.44
(b) PDBRltr

1.	Pursuant to reference (a), the PDBR reviewed your case and forwarded its recommendation (reference (b)) to the Department of the Navy on 5 Mar 2020 for appropriate action.

2.	On 20 March 2020, the Assistant Secretary of the Navy (Manpower & Reserve Affairs) accepted the recommendation of the PDBR of no change to your characterization of separation or disability rating assigned by the Department of the Navy's Physical Evaluation  Board.

3.	The Secretary's decision on your PDBR application is final and is not subject to appeal or additional review by the Board for Correction of Naval Records.