RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW
NAME:  XXXXXXXXXXXXXXXX	CASE: PD-2017-06133
BRANCH OF SERVICE: ARMY	SEPARATION DATE: 20050615

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Psychological Operations Specialist, medically separated for “cervical myofascial pain syndrome with muscle contraction headaches and low back pain” with a disability rating of 0%.

CI CONTENTION: In addition to the neck, back and headache conditions, the CI requested review of other conditions not identified by the Medical Evaluation Board (MEB) or Physical Evaluation Board (PEB).  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 PEB to be unfitting for continued military service, and when specifically requested by the CI, those conditions identified by the 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 - 20050419	VARD - 20050804	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Cervical Myofacial Pain Syndrome with Muscle Contraction Headaches and Low Back Pain	5099-5003	0%	Cervical Myofascial Pain Syndrome and Back Pain	5299-5237	10%	20050506	
			Headaches	8100	10%	20050506	
COMBINED RATING: 0%	COMBINED RATING OF ALL VA CONDITIONS: 50%	

ANALYSIS SUMMARY:

Cervical Myofacial Pain Syndrome with Muscle Contraction Headaches and Low Back Pain. According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s neck condition began in October 2002 while performing airborne operations when the primary and reserve chute malfunction causing the CI to fall 800 feet. The CI reported back and neck pain

and a slight headache. The next morning he was seen in the emergency room where X-rays of his skull were normal and his back and neck showed bruising. Thoracic spine X-rays in February 2003 were normal and MRIs of the cervical and lumbar spines in November 2003 were normal. A neurology consult diagnosed headaches associated with neck spasms and prescribed headache prophylactic medication in the form of an antidepressant.

The 4 March 2004 MEB examination (recorded on DD Forms 2807-1 and 2808), 15 months prior to separation, showed tenderness at C6-7 with trapezius discomfort bilaterally. Diffuse tenderness at L3-L5 was present, but sensory function was intact. There was full muscle strength in the bilateral extremities, and the CI could heel, toe, and duck walk without pain. There was full range of motion (ROM) of the cervical spine with discomfort noted. During the 16 March 2004 MEB NARSUM examination, 15 months prior to separation, the CI complained of low back pain, neck pain and loss of feeling in the hands and feet, but nerve conduction studies were negative for radiculopathy and neuropathy. Physical examination showed full ROM of all major joints and no significant muscle spasms. Tenderness was noted to the right cervical spine. Neurological examination was normal as were reflexes. The physical therapy examination on 19 March 2004, 15 months prior to separation showed cervical spine flexion of 40 degrees (normal
45) and combined ROM of 215 degrees (normal 340). Thoracolumbar flexion was 60 degrees (normal 90) and combined ROM was 210 degrees (normal 240).

At the 27 April 2004 specialty care consult, 14 months prior to separation, the CI reported the headaches and neck spasm had not responded to medication. The headaches had persisted with occipital pain, and he had bilateral periorbital pain during more severe headaches that occurred at least one time per week and were associated with neck muscle spasms. Physical examination showed 0/10 headache pain. Cranial nerves were intact, motor strength was 5/5 with normal tone throughout. Finger to nose and heel to shin was normal. Gait showed normal heel, toe, and tandem walking.  Brain MRI showed no clinically significant pathology.

The 4 August 2005 VA rating decision (VARD) noted a C&P examination was completed on 6 May 2005, 1 month prior to separation. The VARD indicated the CI was unable to sit or stand for prolonged periods of time due to constant neck pain elicited by activity with radiation to the shoulders and upper back. Physical examination of the cervical spine showed no tenderness, muscle spasm or evidence of radiating pain on movement. Flexion of the neck was 45 degrees and combined ROM was 340 degrees. Motion was not additionally limited by pain, fatigue, weakness, lack of endurance, or incoordination after repetitive use. Lumbar spine examination showed no muscle spasm or tenderness. Flexion was to 90 degrees (normal) and combined ROM was 240 degrees (normal). The examiner found no pathology of the neck or back to render a diagnosis. The CI also complained of headaches that had caused him to miss 2 days from work. He was reportedly taking a migraine medication.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the cervical myofascial pain syndrome 0%, analogously coded 5099-5003 (arthritis, degenerative) citing rated for pain IAW the US Army Physical Disability Agency (USAPDA) pain policy with full ROM of all major joints and no significant muscle spasm. The VA rated the cervical myofascial pain syndrome 10%, analogously coded 5299-5237 (cervical strain), based on the pre- discharge examination, stating “your low back pain has been evaluated with the cervical myofascial pain syndrome because it is not separately compensable. Pain, in and of itself is not a disability for VA purposes.”  The 10% rating was granted for functional loss.

The panel noted the PEB combined the back and headache conditions under the neck condition and rated them 0% IAW the USAPDA pain policy. The panel undertook to determine if the PEB’s approach of combining conditions under a single rating was justified in lieu of separate ratings. The panel must apply separate codes and ratings in its recommendations if compensable ratings for each condition are  achieved IAW VASRD §4.71a.   If the panel  judges  separate ratings    are

warranted, however, it must satisfy the requirement that each ‘unbundled’ condition was unfitting in and of itself.

Neck. The panel first considered if the neck condition, having been de-coupled from the combined PEB adjudication, remained unfitting. The panel reviewed the evidence and noted radiographic evidence of the cervical spine was unremarkable. The panel considered the only complaint the CI made in regards to the neck was musculoskeletal pain with radiation and numbness to the upper extremity. Due to the complaint of radiating pain and numbness, a nerve conduction study was ordered and there was no evidence of neuropathy or radiculopathy. The cervical ROM at the MEB NARSUM was recorded as full; however, the panel placed higher probative value on the C&P examination since it was most proximate to separation. That C&P examination recorded normal cervical ROM without painful motion, and a neck condition was not assessed. The CI’s profile included cervical myofascial pain syndrome with muscle contraction headaches; however, he was able to walk, bike, swim at own pace and distance, and he was allowed to participate in both upper and lower body weight training. The commander’s statement noted the CI’s complaint of neck “soreness,” without noting functional impact. However, it was stated that despite his diminished capacity, the CI remained “a solid performer.” The panel could not find evidence in the commander’s statement or elsewhere in the STR that documented any significant interference of neck pain with the performance of duties at the time of separation. After due deliberation, members agreed that the evidence did not support a conclusion that the functional impairment from the neck condition was integral to the CI’s inability to perform his military duties and, accordingly, cannot recommend a separate rating for it.

Back. The panel next considered if the back condition, having been de-coupled from the combined PEB adjudication, remained unfitting. Radiographs of the thoracolumbar spine were unremarkable. The only recorded complaint was back pain. There was no pathological finding on any objective test or study. The C&P examination documented full ROM of the thoracolumbar spine. The only finding identified at the NARSUM was tenderness, but the C&P examination documented no tenderness or painful motion. The panel noted the back condition was not profiled, and although it was mentioned in the commander’s statement as back soreness, the commander indicated that despite the CI’s back condition, he was a solid performer. The panel could not find evidence in the commander’s statement or elsewhere in the STR that documented any significant interference of back pain with the performance of duties at the time of separation. After due deliberation, members agreed that the evidence did not support a conclusion that the functional impairment from the back condition was integral to the CI’s inability to perform his military duties and, accordingly, cannot recommend a separate rating for it.

Headaches. The panel next considered if the headache condition, having been de-coupled from the combined PEB adjudication, remained unfitting. The neurologist indicated the headaches were associated with neck spasm. The 27 April 2004 addendum recorded headaches had not caused any loss of work in February or March 2004, but severe ones occurred at least once a week. The VARD indicated a loss of 2 days from work due to headaches. Although headaches were mentioned in the commander’s statement, the panel could not find evidence there or elsewhere in the STR that documented any significant interference of headaches with the performance of duties at the time of separation. The commander wrote the CI was a solid performer. After due deliberation, members agreed that the evidence did not support a conclusion that the functional impairment from the headache condition was integral to the CI’s inability to perform his military duties and, accordingly, cannot recommend a separate rating for it. Therefore, the panel concluded, unbundling the conditions was of no benefit to the CI. Therefore, 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 cervical myofascial pain syndrome with muscle contraction headaches and low back pain.

BOARD FINDINGS: In the matter of the cervical myofascial pain syndrome with muscle contraction headaches and low back pain 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.

		PD-2017-06133

ARXXXXXXXXXXXX, XXXXXXXXXXXXXXXXXX 

Dear XXXXXXXXXXXXXXXXXX

	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.

Sincerely,					      

Enclosure

	PD-2017-06133