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AF | PDBR | CY2013 | PD-2013-02358
Original file (PD-2013-02358.rtf) Auto-classification: Approved
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXX  CASE: PD-2013-02358
BRANCH OF SERVICE: Army  BOARD DATE: 20140911
SEPARATION DATE: 20050220


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SPC/E-4 (74D10/Chemical Operations Specialist) medically separated for a myofascial pain condition, which could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty (MOS) or satisfy physical fitness standards. She was issued a permanent U3 profile and referred for a Medical Evaluation Board (MEB). The condition characterized as “chronic cervicalgia secondary to trapezius [left shoulder] myofascial pain and dysfunction,” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. The Informal PEB adjudicated “myofascial pain syndrome affecting cervical region and trapezius muscles without neurological abnormality” as unfitting, rated at 20%, with presumptive application of the U. S. Army Physical Disability Agency (USAPDA) pain policy. The CI made no appeals and was medically separated.


CI CONTENTION: “herniated disk from LMTV truck accident in Iraq”


SCOPE OF REVIEW: The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e.(2). It is limited to those conditions determined by the PEB to be unfitting for continued military service and those conditions identified but not determined to be unfitting by the PEB when specifically requested by the CI. The rating for the unfitting myofascial pain syndrome (subsuming cervical and trapezial [left shoulder] conditions) is addressed below and no additional conditions are 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 Military Records.


 RATING COMPARISON :

Service IPEB – Dated 200412156
 VA (2½ Mo. Post-Separation)
Condition
 Code Rating Condition Code Rating Exam
Myofascial Pain Syndrome (Cervical and Left Trapezius) 5021 20% Cervical Strain with Headaches 5237 20% 20050503
Left Shoulder AC Separation 5201 0% 20050503
No Other Item in Scope
 Other x 4 (Not in Scope) 20050503
Combined: 20%
 Combined: 40%
Derived from VA Rating Decision (VA RD ) dated 200 50615 (most proximate to date of separation ).


ANALYSIS SUMMARY: The PEB combined the cervical and trapezial (left shoulder) conditions under a single disability rating, coded analogously to 5003 (default criteria for 5021, myositis). Although VASRD §4.71a permits combined ratings of two or more joints under code 5003 (in this case encompassing cervical spine), it allows separate ratings for separately compensable joints. The Board must follow suit (IAW DoDI 6040.44) if the PEB combined adjudication is not compliant with the latter stipulation, provided that each “unbundled” condition can be reasonably justified as separately unfitting in order to remain eligible for rating. If the members judge that separately ratable conditions are justified by performance based fitness criteria and indicated IAW VASRD §4.7 (higher of two evaluations), separate ratings are recommended; with the stipulation that the result may not be lower than the overall combined rating from the PEB. The Board’s initial charge in this case was therefore directed at determining if the PEB’s combined adjudication was justified in lieu of separate ratings. To that end, the evidence for the cervical and left shoulder conditions are presented separately; with attendant recommendations regarding separate unfitness and separate rating if indicated.

Cervical Myofascial Condition. In the CI’s service treatment records (STR) there’s documented evidence that the onset of symptoms associated with this condition are related to vehicular accident (rear-ended) during a deployment to Iraq in April 2003 and to load bearing requirements during the same deployment. The earliest clinical entry in the available STR is from May 2004 (with references to earlier care) and documents cervicalgia of 8 months duration, associated with left upper extremity (LUE) radiation and paresthesias. Strength and neurological findings were normal. Magnetic resonance imaging (MRI) of the cervical spine, an LUE electrodiagnostic study and a bone scan were obtained; all with normal results. An orthopedic entry of August 2004 (7 months prior to separation) documents “50% improvement” following an epidural injection and normal cervical range-of-motion (ROM). Measured ROM from a physical therapy (PT) note the following month documented flexion of 45 degrees (normal) and combined ROM of 315 degrees (normal 340 degrees). The final STR entry by the MEB orthopedist is from November 2004 (3 months prior to separation) and documents “full range-of-motion without bony tenderness”, detailing normal neurological findings. The formal ROM measurements for the MEB were performed by PT in December 2004 (a month later than the preceding note and 2 months prior to separation) and documents flexion of 30 degrees and combined ROM of 255 degrees. There are numerous STR entries documenting normal LUE neurological findings and several (in addition to above) commenting on grossly normal ROM. There are none documenting significant ROM impairment (preceding the MEB PT evaluation) and none documenting significant neurological findings, abnormal contour or other ratable findings except spasm, tenderness and painful motion.

A neurological addendum to the NARSUM was prepared in August 2004 (6 months prior to separation). This documents cervical pain from the base of the skull to the thoracic spine with radiation to the “left shoulder and arm with tingling in her fingers.” The examination noted paracervical tenderness “with pain on flexion and torsion” (implying, but not specifying, full ROM) and detailed normal LUE neurological findings (5/5 strength all groups) except for a mild sensory deficit (decreased pinprick compared to right). The MEB NARSUM documented persistent neck pain with “numbness and tingling of left arm,” quantified as “constant moderate,” listing significant profile limitations and adding “medications get her to the point where she is able to sleep most of the time, do activities of daily living but she still is limited in her recreation and social activities due to pain.” The NARSUM physical examination noted paraspinal tenderness, “full active [ROM] with pain on flexion and left rotation” and normal neurological findings. The commander’s performance statement did not differentiate cervical from shoulder impairment and the permanent U3 profile listed only “chronic neck pain secondary to myofascial pain syndrome.”

The VA Compensation and Pension (C&P) examination was performed 10 weeks after separation and documented a complaint of headache associated with the condition. A complaint of headache did not surface in the CI’s STR, were being specifically denied in various entries and on the MEB’s DD Form 2901-1, Report of Medical History. The VA exam noted constant neck pain, with bi-weekly flares of an hour each (rated at 10/10) and “radiation of intermittent tingling pain down the shoulder and left arm.” The VA examiner opined that there were no occupational limitations other than heavy lifting and prolonged computer work. The VA physical exam noted tenderness without spasm and normal neurological findings with 5/5 strength. The VA ROM measurements were flexion of 30 degrees and combined ROM of 210 degrees; specifying painful motion but no degradation with repetitive motion (negative DeLuca criteria). VA outpatient ROM measurements 8 months post-separation were completely normal (flexion >45 degrees and combined ROM >340 degrees), with tenderness as the only ratable finding.

The Board directs attention to its recommendations based on the above evidence. The Board first considered if the cervical condition, having been de-coupled from the combined PEB adjudication, was reasonably justified as separately unfitting as established above. Given the profile limitations specified for the cervical condition, members agreed that the functional limitations in evidence justified the conclusion that it was integral to the CI’s inability to perform her MOS and accordingly a separate rating is recommended.

Having so decided, the Board turned to deliberation regarding the appropriate coding and rating recommendation for the condition. All members agreed that the PEB’s 5003 based coding and rating criteria were not appropriate and that a cervical spine code with rating under the VASRD §4.71a general spine formula was indicated. The VA’s code 5237 (cervical strain) is a good clinical fit and the VA’s rating was based on the C&P flexion of 30 degrees which meets the 20% threshold under the spine formula. It is noted that the MEB PT measurement of flexion was the same and the Board deliberated the probative weight of these two exams compared to the total evidence. Although most proximate to separation, these two exams contrast sharply with all other evaluations in the probative time frame of this case. There are preceding STR entries reflecting normal ROM, competing PT measurements documenting near normal ROM, three physician examiners (MEB examiner, neurology consultant and orthopedic consultant) in close proximity to the MEB PT ROM evaluation who documented normal ROM, and a (non-rating) VA ROM evaluation 8 months from separation which documents greater than normal ROM measurements. After due deliberation, members agreed that the combined probative weight of the MEB PT and proximate VA formal ROM measurements, both compliant with VASRD §4.46 (accurate measurement), would be the fairest basis for the Board’s recommendation. Having so decided, with consideration of all of the evidence and conceding VASRD §4.3 (reasonable doubt), the Board recommends a 20% rating for the cervical condition under code 5237.

Left Trapezius (Shoulder) Condition. The onset of this condition is linked to that of the cervical component, as elaborated above and both are addressed concomitantly (albeit separately) in STR entries. The earliest STR entry states “hurt left shoulder about 8 months ago,” in addition to the complaint of cervicalgia as noted above. The earliest physical exam in evidence describes “multiple tender points ... posterior left shoulder as well as left arm and anterior shoulder.” The first orthopedic note dates to July 2004 (7 months prior to separation) and documents “tender trapezius extended down to shoulder,” negative signs of shoulder impingement or instability, and flexion/abduction both to 150 degrees (normal 180 degrees; minimum compensable 90 degrees). An MRI was obtained which was interpreted as “mild tendinosis” (supraspinatus) with no other abnormalities. A follow-up orthopedic note (5 months prior to separation) documented a normal shoulder exam (no ROM comment) and related “50% improvement” with a joint injection. The final orthopedic entry in the STR (3 months prior to separation) documented “still diffuse tenderness over the trapezius” with otherwise normal exam findings and expressed doubt that there was an intrinsic joint etiology for the pain. Of note, the MEB PT cervical ROM evaluation noted that cervical flexion was associated with “pain into left upper trapezius [and] shoulder.” There is no STR entry suggesting instability, impingement, or significant ROM limitation of the left shoulder.

The NARSUM did not differentiate the pain severity and limitations between the cervical and trapezial/shoulder components. The examiner stated, “examination was normal to include shoulder examination.” The cervical examination was further elaborated as above, but the shoulder was not. As noted above, the U3 profile did not incorporate shoulder or LUE impairment. The post-separation VA C&P examination references a VA orthopedic consult on the same day which is not in evidence, with an opinion that there was mild (Grade II) acromioclavicular (collar bone attachment to shoulder girdle) separation without surgical indications. The cited X-ray findings in support of this opinion, however, note degenerative changes and a prior clavicular head resection that does not comport with the STR clinical history or imaging evidence. Although members suspect a patient identity error with regards to the X-ray diagnosis, the remaining rating evidence from the C&P evaluation is assumed to be valid. The examiner noted “daily pain” without exacerbations and opined that there were no occupational limitations except heavy lifting and overhead work. The VA physical exam noted tenderness and some guarding with shoulder movement (no comment on stability) and recorded flexion to 140 degrees and abduction to 120 degrees (specifying painful motion).

The Board directs attention to its recommendations based on the above evidence. The Board first considered if the left trapezial/shoulder condition, having been de-coupled from the combined PEB adjudication, was reasonably justified as separately unfitting as established above. Members agreed that, based on the above evidence, there was a questionable basis for arguing that it was separately unfitting. The well-established principle for fitness determinations is that they are performance-based. There was no specified profile for the condition, although it is conceded that the shoulder impairment would have been sheltered by the U3 limitations imposed for the cervical condition. There is no evidence from the commander’s statement, NARSUM, or STR that documented any significant interference of shoulder impairment with performance of duties. Strength and grasp were normal and mobility was sufficient for MOS requirements. It is possible that it interfered with sit-ups and extended use of protective gear (flak), but that is speculative. These issues notwithstanding, it is important to consider in this case that the unfitting pain associated with this condition is closely linked to the cervical radicular pain and, largely subsumed by the cervical spine rating IAW the §4.71a stipulation that said rating is “with or without symptoms such as pain (whether or not it radiates)[.]” Especially considering the lack of evidence for specific joint pathology (the MEB orthopedist concurring), members concluded that any residual impairment (i.e., any not subsumed under the spine rating) would be difficult to rationalize as separately unfitting. After due deliberation in consideration of the totality of the evidence, members agreed that the left trapezial/shoulder condition was not reasonably justified as separately unfitting and, accordingly, no additional disability rating can be recommended for it.


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. As discussed above, PEB reliance on the USAPDA pain policy for rating was operant in this case and the conditions were adjudicated independently of that policy by the Board. In the matter of the PEB-combined cervical and trapezial/left shoulder conditions, the Board unanimously recommends a rating of 20% for an unfitting cervical spine condition coded 5237 IAW VASRD §4.71a; but, unanimously agrees the left trapezial/shoulder condition was not separately unfitting and thereby not subject to disability rating. There were no other conditions within the Board’s scope of review for consideration.


RECOMMENDATION: The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of her prior medical separation:
UNFITTING CONDITION VASRD CODE RATING
Cervical Myofascial Strain 5237 20%
Trapezial/Left Shoulder Myofascial Strain Not Unfitting
COMBINED 20%
The following documentary evidence was considered:
Exhibit A. DD Form 294, dated 20 1 3 1030 , w/atchs
Exhib it B. Service Treatment Record
Exhibit C. Department of Veterans ’ Affairs Treatment Record



                 
XXXXXXXXXXXXXXXXX
President
Physical Disability Board of Review

 SAMR-RB                   

MEMORANDUM FOR Commander, US Army Physical Disability Agency
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557

 SUBJECT: Department of Defense Physical Disability Board of Review Recommendation
for XXXXXXXXXXXXXXXXX, AR20150002618 (PD201302358)
1. I have reviewed the enclosed Department of Defense Physical Disability Board of Review (DoD PDBR) recommendation and record of proceedings pertaining to the subject individual. Under the authority of Title 10, United States Code, section 1554a, I accept the Board’s recommendation to modify the individual’s disability description without modification of the combined rating or recharacterization of the individual’s separation. This decision is final.

2. I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum.

3. I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures.

BY ORDER OF THE SECRETARY OF THE ARMY:

Encl                                                  XXXXXXXXXXXXXXXXX
                                                      Deputy Assistant Secretary of the Army
                                                      (Review Boards)

CF:
( ) DoD PDBR
 ( ) DVA

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