RECORD OF PROCEEDINGS 

PHYSICAL DISABILITY BOARD OF REVIEW 

 

NAME: XXXXXXXXXXXXXXXX CASE: PD1200428 

BRANCH OF SERVICE: ARMY BOARD DATE: 20130426 

SEPARATION DATE: 20041030 

 

 

SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this 
covered individual (CI) was a mobilized Reserve SSG/E-6 (92A/Supply Specialist) medically 
separated for low back pain (LBP) and chronic neck pain with tension headaches. He had 
chronic low back and neck pain over a 19 month period beginning in March 2003 with one 
injury to his neck due to blunt trauma in July 2003. His chronic low back and neck pain was 
treated non-operatively with one epidural steroid injection (ESI) to his lumbar spine. His low 
back and neck pain conditions could not be adequately rehabilitated to meet the physical 
requirements of his Military Occupational Specialty (MOS) or satisfy physical fitness standards. 
He was issued a permanent profile and referred for a Medical Evaluation Board (MEB). The low 
back and neck conditions, characterized as “low back pain, slight/intermittent, muscle strain” 
and “neck pain, slight, occasional, secondary to muscle spasm,” were forwarded to the Physical 
Evaluation Board (PEB) IAW AR 40-501. The MEB also identified and forwarded two other 
conditions, as identified in the rating comparison chart below, for PEB adjudication. The 
Informal PEB (IPEB) adjudicated the LBP and chronic neck pain with tension headaches 
(subsuming the headache condition within the neck condition) as unfitting and rated each 
condition at 10% (20% combined rating), with likely application of the Veteran’s Affairs 
Schedule for Rating Disabilities (VASRD). The remaining condition was determined to be not 
unfitting. The CI made no appeal, was released from active duty and transferred to the Retired 
Reserve List awaiting pay at age 60, pursuant to his request. 

 

 

CI CONTENTION: The application states simply, “Not all Conditions Developed and Aggravate 
By the Service While Activated for Mobilization Enduring Freedom were Considered During the 
MEB and PEB Proceedings.” The CI does not elaborate further or specify a request for Board 
consideration of any additional conditions. 

 

 

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 ratings for the unfitting LBP and chronic 
neck pain w/tension headache conditions are addressed below. The mild gastritis and 
esophagitis with esophageal ulcer condition, identified by the MEB and adjudicated as not 
unfitting by the PEB, as requested by the CI will be reviewed below. The other requested 
conditions (conditions developed/aggravated while mobilized and not listed by the MEB or PEB) 
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 Army Board for Correction of Military Records 
(ABCMR). 

 

 


 

RATING COMPARISON: 

 

Service IPEB – Dated 20040525 

VA – 3 Mos. Post-Separation 

Condition 

Code 

Rating 

Condition 

Code 

Rating 

Exam 

Low Back Pain 

5299-5237 

10% 

Lumbosacral Disc Disease L4-5 

5299-5242 

10% 

20050126 

Chronic Neck Pain w/ 
Tension Headache 

5299-5237 

10% 

Cervical spondylosis 

5299-5237 

10% 

20050126 

Tension Headache - Muscle Spasm 

8199-8100 

10% 

20050126 

Mild gastritis/Esophagitis 

Not Unfitting 

NO VA ENTRY 

No Additional MEB/PEB Entries 

Other x2 

20050126 

Combined: 20% 

Combined: 30% 



Derived from VA Rating Decision (VARD) dated 20050302 (most proximate to date of separation [DOS]) 

 

 

ANALYSIS SUMMARY: The Board acknowledges the CI’s assertions that his disability disposition 
did not address all conditions he believed developed and were aggravate by the Service. It is 
noted for the record that the Board has no jurisdiction to investigate or render opinions in 
reference to such allegations; and, redress in excess of the Board’s scope of recommendations 
(as noted above) must be addressed by the ABCMR and/or the United States judiciary system. 

 

Low Back Pain Condition. The service treatment records (STRs) in evidence document that the 
CI was taking non-steroidal anti-inflammatory drugs (NSAIDS) once weekly for his LBP in 
February 2003. There was no documentation of an injury to his low back, he continued to take 
NSAIDS and was treated regularly by physical therapy (PT) for myofascial pain and intermittent 
lumbar muscle spasm. In October 2003, he had magnetic resonance imaging (MRI) that 
revealed a normal thoracic spine and “small focal disc protrusions at L4-L5 of the lumbar spine.” 
In January 2004, he had a single ESI with some initial improvement however; his pain recurred 
within 2 months. There were no documented complaints of radicular symptoms or 
incapacitating episodes. The narrative summary (NARSUM) prepared 6 months prior to 
separation documented: 

 

“…he was evaluated by a Physical Medicine doctor from the Army Reserve who could not find 
any objective findings on physical examination to explain the symptoms. Because of persistence 
of symptoms, he was then referred to a Pain Control Clinic where he received injections to 
trigger points, epidural blocks, and acupuncture. Despite this treatment he continued to 
complain of persistent pain and in February 2004, on reevaluation at the Pain Control Clinic the 
assessment was that at that time he had reached maximum benefits from palliative treatment.” 

 

At the VA Compensation and Pension (C&P) exam performed 3 months after separation, the CI 
reported that he “rarely” had low back pain prior to active military service. The goniometric 
range-of-motion (ROM) evaluations in evidence which the Board weighed in arriving at its 
rating recommendation, with documentation of additional ratable criteria, are summarized in 
the chart below. 

 

Thoracolumbar ROM 

NARSUM 6 Mos. Pre-Sep 

VA C&P 3 Mos. Post-Sep 

Flexion (90° Normal) 

75° 

90° 

Combined (240°) 

200° 

240° 

Comment 

Normal gait, strength, sensation and reflexes bilat. 
legs; Slight tenderness to palpation bilat. lumbar 
paravertebral area; Neg. straight leg raise bilaterally; 
ROM limited by stiffness & poor effort; Waddell's 
signs pos. for axial loading & rotation 

Normal posture; No kyphosis, lordosis or 
scoliosis; Pos. waist corset use; Positive 
painful motion; No tenderness in lumbar 
area; Pos. mild muscle spasm at L2 to L5 

§4.71a Rating 

10% 

10%* 



* IAW VASRD §4.59, Painful Motion 


 

The Board directs attention to its rating recommendation based on the above evidence. Both 
the PEB and VA rated the CI’s low back condition as 10% disabling. While the PEB applied the 
analogous VASRD code 5299-5237, lumbosacral strain, and the VA applied VASRD code 5299-
5242, degenerative arthritis of the spine, both coding options utilize the same rating guideline, 
the general rating formula for diseases and injuries of the spine. The PEB’s rating was reflective 
of the documented NARSUM ROM measurements that were compensable at the 10% level, 
while the 10% rating granted by the VA was supported by their application of VASRD principle 
§4.59 (Painful Motion), as the ROM measurements documented in the C&P exam were non-
compensable. There was no evidence of incapacitating episodes (bed rest and treatment 
prescribed by a physician) or functionally limiting radiculopathy for separate peripheral nerve 
rating that would be necessary for higher or additional rating options. All data present for 
review supports a 10% disability rating for the CI’s LBP. 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 for the chronic LBP 
condition. 

 

Chronic Neck Pain with Tension Headache Condition. The PEB combined chronic neck pain and 
tension headache as a single unfitting condition, coded analogously to 5237, cervical strain, and 
rated 10%. The PEB may have relied on AR 635.40 (B.24 f.) for not applying separately 
compensable VASRD codes. The Board must apply separate codes and ratings in its 
recommendations if compensable ratings for each condition are achieved IAW VASRD §4.71a 
and §4.124a. If the Board judges that two or more separate ratings are warranted in such 
cases, however, it must satisfy the requirement that each ‘unbundled’ condition was unfitting 
in and of itself. The Board first considered if neck pain, having been de-coupled from the 
combined PEB adjudication, remained independently unfitting as established above. The CI’s 
chronic neck pain was the cause for at least 39 medical encounters over the 18-month period 
prior to separation. There was an injury to his cervical spine and MRI revealed cervical spasm. 
The STRs document the CI was missing too much duty time attending PT sessions for his neck 
pain. Although the CI’s commander’s statement does not specifically implicate neck pain, 
members agree that neck pain, as an isolated condition, would have rendered the CI incapable 
of continued service within his MOS, and accordingly merits a separate service rating. Next, the 
Board considered whether tension headache remains separately unfitting, having de-coupled it 
from a combined PEB adjudication. In analyzing the intrinsic impairment for appropriately 
coding and rating the tension headache condition, the Board is left with a questionable basis for 
arguing that it was indeed independently unfitting. There are only two episodes of headache 
documented in the STR which was mentioned only in conjunction with visits for neck pain. The 
headache condition was not implicated by the commander’s statement and was only profiled in 
preparation for the MEB. There was no indication that the CI’s headache independently caused 
any functional limitation or missed duty time. After due deliberation, members agreed that 
evidence does not support a conclusion that tension headache, as an isolated condition, would 
have rendered the CI incapable of continued service within his MOS, and accordingly cannot 
recommend a separate rating for it. 

 

The CI’s chronic neck pain condition began in March 2003 and continued unabated to the date 
of separation. He suffered a contusion (bruise) to his cervical spine in July 2003 when a “heavy 
metal plate” struck him in the posterior neck. His neck pain persisted despite continued 
treatment by PT and trigger point injections. Radiographic imaging in October 2003 revealed 
cervical spasm but no disc herniation. He did not complaint of any radicular symptoms or had 
any periods of incapacitation. The NARSUM noted that the CI had LBP, complicated by neck 
pain that was further exacerbated by blunt trauma to his posterior neck while he was working 


during the mobilization of his unit. At the C&P exam performed 3 months after separation, the 
CI reported a similar history to the one summarized above. The goniometric ROM evaluations 
in evidence which the Board weighed in arriving at its rating recommendation, with 
documentation of additional ratable criteria, are summarized in the chart below. 

 

Cervical ROM 

MEB 6 Mo. Pre-Sep 

VA C&P ~3 Mo. Post-Sep 

Flex (45° Normal) 

35° 

45° 

COMBINED (340°) 

275° 

340° 

Comment 

All ROM limited by stiffness 
& poor effort; Normal 
strength bilateral upper 
extremities 

Pos. discomfort at bilateral rotation & lateral flexion, more marked 
to the right; cervical spasm is detected bilaterally, extending from 
shoulder area to back of the neck; Pos. mild tenderness to 
palpation; No scoliosis, kyphosis, lordosis or contracture; No lack of 
endurance or fatigue with repetitive movement 

§4.71a Rating 

10% 

10%* 



* IAW VASRD §4.59, Painful Motion 

 

The Board directs attention to its rating recommendation based on the above evidence. The 
PEB combined chronic neck pain with tension headaches, applied the analogous VASRD code of 
5299-5237 (cervical strain) and rated it 10% disabling. As discussed earlier, the chronic neck 
condition was found separately unfitting and will be recommended for a disability rating. The 
VA also applied VASRD code 5237 and rated it 10% based on painful motion as the ROM 
measurements documented on the C&P exam were non-compensable. Properly coding the CI’s 
chronic neck pain is best achieved by applying VASRD code 5237 as evidenced by the PEB’s and 
VA’s utilization of that code. The general rating formula for diseases and injuries of the spine, 
which uses ROM measurements to assign disability levels, is used for rating 5237 IAW §4.71a. 
Both exams contain goniometric measurements, were complete for rating purposes and were 
within 6 months of separation. The ROM measurements documented by the MEB exam are 
consistent with a 10% disability rating, while those documented by the C&P exam were non-
compensable. Application of an acceptable alternate coding and rating method to the C&P 
exam, utilizing VASRD code 5003 (degenerative arthritis), would also result in a 10% rating due 
to painful motion IAW VASRD §4.59. There was no evidence of incapacitating episodes (bed 
rest and treatment prescribed by a physician) or functionally limiting radiculopathy for separate 
peripheral nerve rating that would be necessary for higher or additional rating options. All data 
present for review supports a 10% disability rating for the CI’s chronic neck pain. After due 
deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the 
Board recommends a disability rating of 10% for the chronic neck pain condition. 

 

Contended PEB Condition. The Board’s main charge is to assess the fairness of the PEB’s 
determination that mild gastritis and esophagitis with esophageal ulcer condition was not 
unfitting. The Board’s threshold for countering fitness determinations is higher than the VASRD 
§4.3 (reasonable doubt) standard used for its rating recommendations, but remains adherent 
to the DoDI 6040.44 “fair and equitable” standard. The mild gastritis and esophagitis with 
esophageal ulcer condition was not profiled or implicated in the commander’s statement and 
were not judged to fail retention standards. It was reviewed by the action officer and 
considered by the Board. There was no performance based evidence from the record that this 
condition significantly interfered with satisfactory duty performance. After due deliberation in 
consideration of the preponderance of the evidence, the Board concluded that there was 
insufficient cause to recommend a change in the PEB fitness determination for the contended 
condition and so no additional disability rating is recommended. 

 

 


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. 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 for 
the LBP condition. As discussed above, probable PEB reliance on AR 635.40 for rating chronic 
neck pain w/tension headache was operant in this case and the condition was adjudicated 
independently of that regulation by the Board. In the matter of the chronic neck pain 
condition, the Board unanimously recommends a disability rating of 10%, coded 5237 IAW 
VASRD §4.71a. In the matter of the tension headache condition, the Board unanimously 
recommends that it was not unfitting and therefore cannot recommend it for additional 
disability rating. In the matter of the contended mild gastritis and esophagitis with esophageal 
ulcer condition, the Board unanimously recommends no change from the PEB determinations 
as not unfitting. 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 his prior medical separation: 

 

UNFITTING CONDITION 

VASRD CODE 

RATING 

Lumbosacral Strain 

5299-5237 

10% 

Cervical Strain 

5237 

10% 

Tension Headache 

NOT UNFITTING 

COMBINED 

20% 



 

 

The following documentary evidence was considered: 

 

Exhibit A. DD Form 294, dated 20120504, w/atchs 

Exhibit B. Service Treatment Record 

Exhibit C. Department of Veterans’ Affairs Treatment Record 

 

 

 

 

 xxxxxxxxxxxxxxxxxxxxxxxxx, DAF 

 Director of Operations 

 Physical Disability Board of Review 

 


SFMR-RB 


 

 

MEMORANDUM FOR Commander, US Army Physical Disability Agency 

(TAPD-ZB / xxxxxxxxxxxxxx), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557 

 

 

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation 

for xxxxxxxxxxxxxxxxxxxxxx, AR20130011058 (PD201200428) 

 

 

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 xxxxxxxxxxxxxxxxxxxxx 

 Deputy Assistant Secretary 

 (Army Review Boards)