RECORD OF PROCEEDINGS 

PHYSICAL DISABILITY BOARD OF REVIEW 

 

 

 
NAME:  XX                                                    
BRANCH OF SERVICE:  MARINE CORPS 
CASE NUMBER:  PD1201150                                                              SEPARATION DATE:  20060415 
BOARD DATE:  20130219 
 
 
SUMMARY  OF  CASE:    Data  extracted  from  the  available  evidence  of  record  reflects  that  this 
covered individual (CI) was an active duty LCpl /E-3 (0341/Mortarman), medically separated for 
a chronic pain disorder.  The CI was diagnosed with left rhomboid spasms in 2004 and cervical 
spondylosis  with  radiculopathy  in  2005.    Despite  extensive  evaluation  and  a  variety  of 
treatment  modalities  he  could  not  be  adequately  rehabilitated  to  meet  the  physical 
requirements of his Military Occupational Specialty (MOS) or satisfy physical fitness standards.  
He was placed on limited duty and referred for a Medical Evaluation Board (MEB).  The chronic 
pain  disorder,  characterized  as  “unspecified  myopathy,”  was  forwarded  to  the  Physical 
Evaluation Board (PEB).  Cervical spondylosis was identified by the MEB and also forwarded as 
disqualifying.    The  PEB  adjudicated  the  chronic  pain  disorder  as  myofascial  pain  syndrome, 
unfitting,  rated  10%,  with  application  of  the  Veterans  Administration  Schedule  for  Rating 
Disabilities  (VASRD).    The  cervical  spondylosis  was  determined  to  be  a  Category  II  condition, 
contributing to the unfitting condition.  The CI made no appeals, and was medically separated 
with a 10% disability rating.  
 
 
CI CONTENTION:   “Because I was not properly diagnosed.  My life (health and physical abilities) 
has  drastically  changed  due  to  the  injuries  I  suffered  while  on  active  duty.    The  VA  has 
recognized me as a 40% disabled Vet.  I am seeking the oppurtunity to have my case re-visited, 
re-examined, and hopefully changed to better reflect the reality of my injuries.  My neck, back, 
head, L-arm, L-shoulder, and L-rib cage continue to give me significant amounts of pain.” [sic] 
 
 
SCOPE  OF  REVIEW:    The  Board  wishes  to  clarify  that  the  scope  of  its  review  as  defined  in 
Department of  Defense Instruction  (DoDI)  6040.44  Enclosure  3, paragraph  5.e.2  is  limited  to 
those conditions which were determined by the PEB to be specifically unfitting for continued 
military service; or, when requested by the CI, those conditions “identified but not determined 
to be unfitting by the PEB.” The rating for the unfitting myofascial pain syndrome and related 
cervical spine condition is addressed below.  The requested head and left rib cage conditions 
are not within the DoDI 6040.44 defined purview of the Board.  Any conditions or contention 
not  requested  in  this  application,  or  otherwise  outside  the  Board’s  defined  scope  of  review, 
remain eligible for future consideration by the Board for Correction of Naval Records.    
 
RATING COMPARISON:  
 

VA (9 Mo. Post-Separation) – Effective 20060416 
Rating 
Condition 
10%  Migraine Headaches 

Code 
8100 
5203 
5242 

Rating 
30%* 
10%* 
10%* 

Exam 

20070117 
20070117 
20070117 
20070117 

Service IPEB – Dated 20060123 

Condition 

Code 

Myofascial Pain Syndrome 

5099-5021 

Cervical Spondylosis 

Cat II 
↓No Additional MEB/PEB Entries↓ 

Combined:  10% 

Chronic Strain Left Scapula 
Cervical Degenerative Disc 
Disease 

0% X 2 / Not Service Connected x 19 

Combined:  40% 

*DRO decision of 20091223, effective from 20060416 changed the VA rating as follows: 5242 changed from Myofascial Pain 
Syndrome  to  Cervical  Degenerative  Disc  Disease;  8100  identified  as  separate  disability  from  Myofascial  Pain  Syndrome;  and 
5203 identified as a separately ratable disability from Myofascial Pain Syndrome 

ANALYSIS SUMMARY:  
 
Myofascial Pain Syndrome/Cervical spondylosis. The CI began experiencing left shoulder and rib 
pain after an injury in May 2004.  He was diagnosed with left rhomboid strain and spasms.  He 
reported doing well with physical fitness modifications until September 2004 when his upper 
back pain worsened after a 6 mile hike.  In January 2005 he reported the onset of occasional 
left arm and hand numbness and tingling.  X-ray studies of the cervical spine revealed loss of 
cervical  lordosis.    He  was  diagnosed  with  left  rhomboid  spasms  and  an  associated  nerve 
impingement.  The CI was treated with physical therapy and activity modification with transient 
relief  of  his  left  upper  back,  arm,  and  hand  pain.    The  CI  was  evaluated  by  neurosurgery  in 
March  2005  with  findings  consistent  with  chronic  rhomboid  muscle  spasms.    He  continued 
physical therapy, pain medications, and activity modification without pain relief.  A magnetic 
resonance imaging (MRI) study in July 2005 revealed “mild right sided cervical spondylosis plus 
degenerative  changes  to  the  right  C  5-6  and  C  6-7  levels  with  normal  appearing  cord  and 
remainder of the spine.  There were no left sided abnormalities demonstrated.”  The narrative 
summary  (NARSUM)  documented  that  the  CI  was  participating  in  pain  management  (COPE) 
classes and receiving chiropractic care.  The NARSUM addendum, prepared 6 months prior to 
separation, indicated that the CI’s pain was “primarily myofascial in nature” and documented 
normal electro-diagnostic studies.  The examination documented tenderness to palpation over 
the left trapezius, left scapula, left latissimus dorsi and paraspinal muscles C5-L1.  There were 
no paraspinal muscle texture changes palpated.  There was 5/5 right upper extremity and 4/5 
left upper extremity strength.  Left forearm and hand decreased sensation to light and sharp 
touch  was  noted.    At  the  VA  Compensation  and  Pension  (C&P)  examination  (9  months  after 
separation), the CI reported daily neck pain.  He reported a baseline pain level of 8/10 and pain 
flare-ups twice a month.  He reported weakness, stiffness, swelling, heat, redness, instability, 
locking, fatigue, and lack of endurance in his cervical spine region with intermittent use of a 
neck brace for pain relief.  The physical exam revealed mild pain from the mid to lower cervical 
spine  region,  pain  at  the  left  shoulder  and  scapula  without  evidence  of  spasms,  “no  current 
radiculopathy,”  and  gait  coordinated  and  smooth.    Radiographic  evaluation  demonstrated  a 
normal  left  shoulder  and  multilevel  cervical  spine  degenerative  disc  disease  (DDD).    The 
examiner noted the DDD as “mild with subjective radiculopathy.”  The Board directs attention 
to  its  rating  recommendation  based  on  the  above  evidence.    The  MEB  forwarded  two 
conditions  as  disqualifying,  “unspecified  myopathy”  and  “cervical  spondylosis.”    The  PEB 
adjudicated the “unspecified myopathy” condition as “myofascial pain syndrome” and cervical 
spondylosis  was  determined  to  be  a  Category  II  condition,  contributing  to  the  unfitting 
condition.  Both conditions have similar manifestations including cervical neck, upper back, and 
shoulder (scapula) pain or muscle spasms; and radicular or nerve impingement symptoms that 
characterize the CI”s functional impairment and pathology.  The Board considered the NARSUM 
addendum which identified the CI’s pain as primarily myofascial, the normal electro-diagnostic 
studies for peripheral nerve damage, and the VA documentation of mild cervical DDD without 
“current radiculopathy” as indicative of the myofascial pain syndrome as the primarily disabling 
condition.  In avoidance of pyramiding, IAW VASRD §4.14, the Board determined that the PEB’s 
approach  of  identifying  the  myofascial  pain  syndrome  as  the  unfitting condition  and  cervical 
spondylosis as contributing to the unfitting condition was appropriate for rating purposes.  The 
left scapula strain rated by the VA is addressed in the PEB’s characterization of the myofascial 
pain syndrome.  The PEB and VA chose different coding options for the condition, but this did 
not bear on the rating.  The PEB coded the myofascial pain syndrome analogous to myositis, 
5099-5021,  rated  at  10%.    The  VA  coded  the  myofascial  pain  syndrome  with  degenerative 
changes  of  the  cervical  spine,  5242,  rated  at  10%.    The  NARSUM  examination  performed  4 
months prior to separation and the VA examination 7 months post separation met criteria for a 
10% rating under the General Rating Formula for Diseases and Injuries of the Spine or § 4.59 
painful motion left upper extremity, coded 5021. 
 

2                                                           PD1201150 
 

After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable 
doubt), the Board concluded that there was insufficient cause to recommend a change in the 
PEB adjudication of the myofascial pain syndrome condition. 
 
 
BOARD FINDINGS:  IAW DoDI 6040.44, provisions of DoD or Military Department regulations or 
guidelines relied upon by the PEB will not be considered by the Board to the extent they were 
inconsistent  with  the  VASRD  in  effect  at  the  time  of  the  adjudication.    The  Board  did  not 
surmise  from  the  record  or  PEB  ruling  in  this  case  that  any  prerogatives  outside  the  VASRD 
were  exercised.    In  the  matter  of  the  myofascial  pain  with  related  cervical  spondylosis 
conditions and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB 
adjudication.    There  were  no  other  conditions  within  the  Board’s  scope  of  review  for 
consideration. 
 
 
RECOMMENDATION: The Board, therefore, recommends that there be no recharacterization of 
the CI’s disability and separation determination, as follows: 
 

Myofascial Pain Syndrome 

UNFITTING CONDITION 

VASRD CODE  RATING 
5099-5021 
COMBINED 

10% 
10% 

 

 

The following documentary evidence was considered: 
 
Exhibit A.  DD Form 294, dated 20120611, w/atchs. 
Exhibit B.  Service Treatment Record. 
Exhibit C.  Department of Veteran’s Affairs Treatment Record. 
 
 
 
 
 
 
 
 
 

 

           xx 
           Acting Director 
           Physical Disability Board of Review 

3                                                           PD1201150 
 

MEMORANDUM FOR DIRECTOR, SECRETARY OF THE NAVY COUNCIL OF REVIEW  
                                        BOARDS  

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS 

Ref:   (a) DoDI 6040.44 

             (b) CORB ltr dtd 26 Feb 13 
 

      In accordance with reference (a), I have reviewed the cases forwarded by reference (b), and, for 
the reasons provided in their forwarding memorandum, approve the recommendations of the PDBR 
that the following individual’s records not be corrected to reflect a change in either characterization 
of separation or in the disability rating previously assigned by the Department of the Navy’s 
Physical Evaluation Board: 
 
 

 

 

 

     
 
 
 
 

-   former USMC 
-   former USN  
-   former USMC 
-   former USMC 
-   former USN  
-   former USMC 
  
 

 
      
 

 
 
 

 
 
 

 
 
 

 
 
 

  xx 
  Assistant General Counsel 
     (Manpower & Reserve Affairs) 

4                                                           PD1201150