RECORD OF PROCEEDINGS 

PHYSICAL DISABILITY BOARD OF REVIEW 

 

NAME: XXXXXXXXXXXXXXXX BRANCH OF SERVICE: ARMY 

CASE NUMBER: PD12-00480 SEPARATION DATE: 20030107 

BOARD DATE: 20130227 

 

 

SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this 
covered individual (CI) was an active duty SGT/E-5 (92A20 / Warehouse and Supply), medically 
separated for chronic migraine headaches and chronic pain (in the) neck, left shoulder, upper 
back and both knees. The chronic neck, left shoulder, upper back and bilateral knee pain and 
chronic migraine headaches conditions did not improve adequately with treatment to meet the 
physical requirements of her Military Occupational Specialty (MOS) or satisfy physical fitness 
standards. She was issued a permanent U3L3 profile and referred for a Medical Evaluation 
Board (MEB). Chronic neck pain, myofascial pain syndrome, chronic upper back pain, chronic 
left shoulder rotator cuff tendonitis, chronic migraine headaches and bilateral retropatellar 
pain syndrome (RPPS) conditions, identified in the rating chart below, were forwarded to the 
Physical Evaluation Board (PEB) as medically unacceptable. The PEB adjudicated the chronic 
pain (of the) neck, left shoulder, upper back and both knees and chronic migraine headache 
(after heavy lifting) conditions as unfitting, rated 20% and 0% respectively, with application of 
the US Army Physical Disability Agency (USAPDA) pain policy. The CI appealed to the Formal 
PEB (FPEB), which downgraded the IPEB 20% rating for the chronic pain condition to 10%. The 
CI made no further appeals and was then medically separated with a 10% disability rating. 

 

 

CI CONTENTION: The CI elaborated no specific contention in her application. 

 

 

SCOPE OF REVIEW: The Board wishes to clarify that the scope of its review as defined in 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 condition(s) “identified but not determined to be unfitting by the PEB”. The Service 
ratings for unfitting conditions will be reviewed in all cases. 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 the Correction of Military Records 
(BCMR). 

 

 

RATING COMPARISON: 

 

Service FPEB – Dated 20020920 

VA (8 Mos. Pre-Separation) – All Effective Date 20030107 

Condition 

Code 

Rating 

Condition 

Code 

Rating 

Exam 

Chronic Pain, Neck, Lt 
Shoulder, Upper Back & 
Both Knees 

5099-5003 

10% 

TOS w/ CTS & LUE radiculopathy 

8599-8510 

20% 

20030128 

Lt Shoulder Tendinitis… 

5024-5201 

20% 

20030128 

Rt Knee PFS 

5099-5014 

10% 

20030128 

Lt Knee PFS 

5099-5014 

10% 

20030128 

DJD and DDD Cervical Spine 

5010-5290 

10% 

20030128 

Chronic Migraine HAs 

8100 

0% 

Migraine Headaches 

8100 

50% 

20030128 

.No Additional MEB/PEB Entries. 

TOS w/ CTS & RUE radiculopathy 

8599-8510 

20% 

20030128 

MPS, Lumbar Spine 

5299-5295 

10% 

20030128 

Post-op Residuals Rt Great Toe… 

5299-5280 

10% 

20030128 

0% X 4 / Not Service-Connected x 3 

 

Combined: 10% 

Combined: 90% 



 


ANALYSIS SUMMARY: The PEB combined the chronic pain of the neck, left shoulder, upper 
back and both knees as a single unfitting condition, coded analogously to degenerative arthritis 
and rated 10%. The PEB apparently relied on the USAPDA pain policy for not applying 
separately compensable VASRD codes. 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 must apply separate codes and ratings in its 
recommendations if compensable ratings for each condition are achieved IAW VASRD §4.71a. 
Not uncommonly, this approach by the PEB reflects its judgment that the constellation of 
conditions was unfitting and that there was no need for separate fitness adjudications rather 
than a judgment that each condition was separately unfitting. Thus, the Board must exercise 
the prerogative of separate fitness recommendations in this circumstance, with the caveat that 
its recommendations may not produce a lower combined rating than that of the PEB. 

 

Neck and Upper Back Condition. The CI first developed neck and upper back pain in January 
1991 after she had been in a motor vehicle accident (MVA) while deployed. Her pain persisted 
despite conservative treatment. A cervical spine x-ray was normal and a MRI in May 1991 
showed minimal degenerative disease without herniated discs. She was in a second MVA in 
June 1991 with exacerbation of her symptoms. Electrodiagnostic studies that fall were 
consistent with a chronic left C6-7 radiculopathy. She was seen regularly over the next five 
years for her neck and upper back pain. In 1996, she was lifting heavy objects repetitively as 
part of her duties and developed significant pain in the neck and upper back with numbness 
and tingling in her left arm. A MRI showed an Arnold Chiari malformation with a C7-T1 syrinx 
(congenital conditions). The narrative summary (NARSUM) was dictated on 19 April 2002, a 
little over eight months prior to separation, noted that the CI was involved in a second (? Third) 
MVA in December 2001 and had further aggravation of her symptoms. The CI reported that the 
pain was a constant cramping aching tightness and that she also had left upper back pain. On 
examination, she was noted to have normal reflexes, 4/5 strength of the left supraspinatus and 
also with external rotation and reduced sensation from C5-T1 on the left. A MEB neurology 
examination done specifically for migraine headaches four months later, on 4 August 2002, was 
significant for a normal motor examination, normal reflexes and a sensory loss on the left 
attributed to a carpal tunnel syndrome. The VA Compensation and Pension (C&P) examination 
was on 28 January 2003, three weeks after separation. The CI reported 9/10 sharp, dull achy 
pain which was constant and did not benefit from medications or chiropractic treatment. On 
examination, gait, posture, motor and reflex testing was normal. Sensation was reduced on the 
radial aspect of the left forearm. The examiner noted that ulnar neuropathy of the right arm 
had been diagnosed in October 2002. The Board considered if the neck and upper back pain 
was a separately unfitting condition. It noted that the motor and reflex examinations were 
typically normal and the sensory examinations most consistent with a peripheral neuropathy. 
The findings on x-ray and MRI were minimal and not atypical for someone her age. The MEB 
examiner noted that the cervical symptoms were acceptable for retention in isolation from her 
other symptoms. The Board determined that the preponderance of evidence did not support a 
presence of a separately unfitting condition due to the neck and upper back pain. 

 

Left Shoulder Condition. According to the NARSUM, the CI suffered a dislocation of the left 
clavicle during the initial MVA and it was not successfully reduced. She was transferred out of 
theater for treatment, but still suffered permanent nerve damage to her left arm. Review of 
contemporaneous records does not support this history. X-rays of the left shoulder, done for a 
history of popping and pain with abduction, were normal two months after the MVA and again 
on 17 September 1999. A MR arthrogram on 7 September 2001 was normal. The ROM was 
noted by an orthopedist three weeks later to be normal. Examination by a physical therapist 
three weeks after the orthopedic examination showed full ROM for both upper extremities. At 
the time of the NARSUM, the CI noted that she had moderate pain of the left arm and shoulder 
associated with weakness. As noted, the NARSUM examination showed weakness in left 
rotation and of the supraspinatus, but the subsequent motor examinations by the neurologist 


and C&P examiners were normal. On the NARSUM examination, the CI also had a positive 
Hawkins, Neer and Cross Arm test on the left, for impingement and subluxation. The VA C&P 
examiner documented a history of restrictions in daily activities and a limitation of 20 pounds 
for lifting. She was noted to have tenderness bilaterally and painful, but full, motion bilaterally 
as well. The Board considered if the left shoulder condition was a separately unfitting 
condition. The ROM and motor examinations were typically normal. The findings on x-ray and 
MRI were normal. The Board determined that the preponderance of evidence did not support 
a presence of a separately unfitting condition due to the left shoulder. 

 

Bilateral Knee Condition. The CI first was seen for left knee pain during training in August 1986, 
two months after accession. She was treated with duty modification and crutches and was able 
to continue duty. The NARSUM noted that a MRI showed a patellar fracture; however, this was 
not found in the contemporaneous records available for review. An arthrogram on 18 February 
1987 was negative. In 1989, the CI requested a downgrade in her profile from a P3 to P2. Per 
the NARSUM, this was to allow her to reenlist. There were no further entries for the left knee 
or any for the right knee until she entered the DES process. At the NARSUM, she reported left 
greater than right knee pain which was daily and aggravated by activity. It was intermittent and 
slight. On examination, a patellar grind was positive bilaterally; this is a non-specific test. Both 
knees were tender to palpation on the medial and lateral aspects. Testing for instability and 
meniscal irritation was negative bilaterally. The ROM was normal. No x-rays were 
accomplished. At the VA C&P examination, she noted bilateral knee pain since 1986 and that 
she had had arthroscopy in 1987. The Board found no evidence of this in the record, but did 
note foot surgery. Her gait was noted to be normal. All motion was painful, but full. Testing 
for meniscal irritation was positive bilaterally. However, she was able to heel, toe and heel to 
toe walk as well as hop on one foot. She was thought to have bilateral patello-femoral pain 
syndrome. The Board considered if the chronic pain of either knee was a separately unfitting 
condition. It noted that the ROM was normal, that the CI had not been seen solely for her 
knees the last few years of service and had an essentially normal examination. An arthrogram 
of the left knee was normal four years prior to separation and no x-rays were repeated by 
either the military or VA clinicians. The Board determined that the preponderance of evidence 
did not support a presence of a separately unfitting condition due to either knee. The Board 
directs attention to its rating recommendation based on the above evidence. The PEB rated the 
bundled conditions at 10% citing the USAPDA pain policy. The Board did not rely upon the pain 
policy, but did determine that none of the conditions was separately unfitting or ratable. 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 pain of the neck, left shoulder, upper back and both knees. 

 

Migraine Headache Condition. The CI endorsed a long history of migraine headaches that 
increased after her MVA, aggravated by another MVA five months prior to separation. At the 
time of separation, she was undergoing changes to her medical regimen in an attempt to 
achieve better control. Her commander did not specifically comment on her headaches, but 
the record contained formal statements from the PltSgt that she had to be taken home 
numerous times a week for major headaches, that resulted in her having to be placed in a quite 
dark room. The neurology NARSUM, accomplished to address the migraine headache 
condition, noted that the CI reported that she needed to leave work every other week due to a 
flare in her pain. The neurologists letter to the FPEB indicated that following the PEB 
determination indicating “no severe HA since initiation of Fluoxetine” (trade name Prozac), that 
the CI had been in an MVA attributed to medication side effects, was hospitalized, and had her 
HA medications significantly limited (Fluoxetine stopped) due to concerns over side effects. 
The neurologist stated the CI’s migraine HAs were severe and that decreasing the medications 
due to the side effects of mental status changes indicated the CI was “between the proverbial 
rock and a hard place.” The FPEB determination was that the CI had “Chronic migraine 
headaches occurring only after heavy lifting in excess of physical profile limits. (MEBD DIAG 5, 


NARSUM, NEUROLOGY ADDENDUM, 4 AUG 02, SWORN TESTIMONY AND EVALUEE EXHIBITS)” 
[profile lifting restriction was 20 pounds]. 

 

At the VA C&P examination, the CI reported headaches 2-3 times a week that included “spots in 
front of her eyes, nausea, vomiting, light sensitivity, and noise sensitivity;” were treated with 
Indocin, Percocet, and Phenergan as needed; and would last anywhere from 2-3 days. The 
examiner did not specifically comment on prostration. 

 

The Board directs attention to its rating recommendation based on the above evidence. The 
PEB and VA both coded the migraine headaches as 8100, migraine headaches, but rated it at 
0% and 50% respectively. The VA awarded a 50% rating noting that the record showed very 
frequent, completely prostrating and prolonged attacks productive of severe economic 
inadaptability. The rating options under 8100 Migraine, which are open to consideration in this 
case, rely on the frequency of ‘prostrating’ attacks. The DoDI 1332.39 (in effect at separation, 
but since rescinded) required that “the Service member must stop what he or she is doing and 
seek medical attention.” However, VASRD §4.124a does not require seeking medical attention 
for an attack to be considered prostrating and a common (court-sanctioned) approach is to 
apply the clear English definition of prostrating. The Board carefully considered the frequency 
and nature of the CI’s headaches including objective evidence and corroborating subjective 
evidence. 

 

The Board carefully considered the frequency of prostrating headaches following the MEB and 
the changes in medication, neurologist statement of severity/medication side-effects, and the 
FBEB exhibits and determination, as well as the post-separation VA exam indicating continued 
migraine HAs. 

 

The Board majority resolved the disparity between the FPEB determination that there were no 
prostrating headaches absent heavy lifting, with the short timeframe of medication changes, 
the neurologists exhibit, as well as the VASRD 8100 criteria for rating over the last several 
months in the favor of the CI. The entirety of the record supported the CI’s condition as closest 
to that envisioned under the 30% criteria of “With characteristic prostrating attacks occurring 
on an average once a month over last several months.” 

 

After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable 
doubt), the Board majority recommends a disability rating of 30% for the migraine headache 
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. PEB reliance on the 
USAPDA pain policy for rating the chronic neck, upper back, left shoulder and bilateral knee 
pain conditions was operant in this case and the condition was adjudicated independently of 
that policy by the Board. In the matter of the chronic neck, upper back, left shoulder and 
bilateral knee pain conditions and IAW VASRD §4.71a, the Board unanimously recommends no 
change in the PEB adjudication. In the matter of the migraine headache condition, the Board 
by a 2:1 vote recommends a disability rating of 30%, coded 8100 IAW VASRD §4.124a. The 
minority voter, who recommended a 10% rating, did not elect to submit a minority opinion. 
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; and, that the discharge with severance pay be recharacterized to reflect permanent 
disability retirement, effective as of the date of her prior medical separation: 


 

UNFITTING CONDITION 

VASRD CODE 

RATING 

Chronic Pain – Neck, Left Shoulder, Upper Back & Both Knees 

5099-5003 

10% 

Chronic Migraine Headaches 

8100 

30% 

COMBINED 

40% 



 

 

The following documentary evidence was considered: 

 

Exhibit A. DD Form 294, dated 20120604, w/atchs 

Exhibit B. Service Treatment Record 

Exhibit C. Department of Veterans’ Affairs Treatment Record 

 

 

 

 

 XXXXXXXXXXXXXXXXX, DAF 

 Acting Director 

 Physical Disability Board of Review 

 


SFMR-RB 


 

 

MEMORANDUM FOR Commander, US Army Physical Disability Agency 

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

 

 

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation 
for XXXXXXXXXXXXXXXXX, AR20130005519 (PD201200480) 

 

 

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 reject the Board’s recommendation and hereby deny the individual’s application. 
There is insufficient justification to support the Board’s recommendation in accordance 
with Army and Department of Defense regulations. 

 

2. The Board’s recommendation to increase the rating for migraine headaches from 0% 
to 30% is not supported by a preponderance of the evidence. I concur with the 
assessment of the minority member that the totality of the evidence provides ample 
support for a conclusion that the Physical Evaluation Board’s (PEB) adjudication of the 
unfitting migraine headache condition was neither unreasonable nor unfair. 
Accordingly, I also reject the minority member’s unsupported recommendation to 
change the 0% rating to 10%. 

 

3. This decision is final. The individual concerned, counsel (if any), and any Members 
of Congress who have shown interest in this application have been notified of this 
decision by mail. 

 

BY ORDER OF THE SECRETARY OF THE ARMY: 

 

 

 

 

Encl XXXXXXXXXXXXXXXXXXX 

 Deputy Assistant Secretary 

 (Army Review Boards)