RECORD OF PROCEEDINGS 

PHYSICAL DISABILITY BOARD OF REVIEW 

 

NAME: XXXXXXXXXXXXXXXXX BRANCH OF SERVICE: ARMY 

CASE NUMBER: PD1200982 SEPARATION DATE: 20030325 

BOARD DATE: 20130220 

 

 

SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this 
covered individual (CI) was an active duty SGT/E-5 (77F20/Petroleum Supply), medically 
separated for chronic right thoracolumbar myofascial pain. The CI had a history of right-sided 
back pain which began during field training in March 2001, with no associated trauma. The 
back condition could not be adequately rehabilitated. The CI did not improve adequately with 
treatment to meet the physical requirements of her Military Occupational Specialty or satisfy 
physical fitness standards. She was issued a permanent L3 profile and referred for a Medical 
Evaluation Board (MEB). The MEB forwarded no other conditions for Physical Evaluation Board 
(PEB) adjudication. The PEB adjudicated the chronic back pain condition as unfitting, rated 10% 
with application of the Department of Defense Instruction (DoDI) 1332.39 and Army Regulation 
635-40, and the likely application of the US Army Physical Disability Agency (USAPDA) pain 
policy. The CI made no appeals, and was medically separated with a 10% disability rating. 

 

 

CI CONTENTION: “still has daily pain (chronic), change of lifestyle, change of jobs (resulting to 
less income)” 

 

 

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 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 Correction of Military Records. 

 

 

RATING COMPARISON: 

 

Service IPEB – Dated 20030224 

VA (7 Mos. Post-Separation) – All Effective Date 20030326 

Condition 

Code 

Rating 

Condition 

Code 

Rating 

Exam 

Chronic Rt Thoracolumbar 
Myofascial Pain 

5299-5295 

10% 

Myofascial Pain Syndrome 
Thoracolumbar Area 

5021-5237 

10%* 

20031020 

No Additional MEB/PEB Entries 

0% X 0 / Not Service-Connected x 1 

20031020 

Combined: 10% 

Combined: 10% 



*Rating increased to 20% 

 

 

ANALYSIS SUMMARY: The Board acknowledges the sentiment expressed in the CI’s application 
regarding the significant impairment with which his service-incurred condition continues to 
burden him. The Board wishes to clarify that it is subject to the same laws for service disability 
entitlements as those under which the Disability Evaluation System (DES) operates. The DES 
has neither the role nor the authority to compensate members for anticipated future severity 


or potential complications of conditions resulting in medical separation. That role and 
authority is granted by Congress to the Department of Veterans Affairs (DVA), operating under 
a different set of laws (Title 38, United States Code). The Board evaluates DVA evidence 
proximal to separation in arriving at its recommendations, but its authority resides in evaluating 
the fairness of DES fitness decisions and rating determinations for disability at the time of 
separation. 

 

Chronic Right Thoracolumbar Myofascial Pain. The 2003 Veterans Affairs Schedule for Rating 
Disabilities (VASRD) coding and rating standards for the spine, which were in effect at the time 
of separation, were changed to the current §4.71a rating standards in 2004, and were identical 
to the 2003 VASRD standards used by the VA in its initial rating decision. IAW DoDI 6040.44, 
this Board must consider the appropriate rating for the CI’s back condition at separation based 
on the VASRD standards in effect at the time of separation. The narrative summary (NARSUM), 
completed on 27 December 2002, 3 months prior to separation, noted weekly back spasms 
requiring large doses of muscle relaxant or anti-inflammatory medications. Trigger points in 
her right paraspinal musculature were treated with steroid injections without benefit. The CI 
reported constant, moderately severe, aching pain. The pain was worse in the morning; caused 
difficulty sleeping and sitting up; and increased with sitting or standing for more than 15 
minutes. There was no radiation of pain to the legs, lower extremity weakness, numbness or 
tingling, or bowel or bladder incontinence. The physical exam noted spasm with palpation of 
the low back; tenderness to palpation (TTP) of the right paraspinal area from T11 to L2; and 
palpation of a large trigger point in the same area reproduced the CI’s symptoms. Muscle tone 
was normal in the lower extremities bilaterally. The straight leg raise (SLR), cross SLR, and 
reverse SLR tests were negative bilaterally. The facet compression test was positive bilaterally. 
The Patrick (FABER) and Lewin-Gaenslen (sacroiliac joint) tests were negative. All range-of-
motion (ROM) measurements were normal by current standards except for slight decreased 
rotation. Muscle spasm and painful motion were present. The neurological exam noted intact 
pin prick and light touch sensation bilaterally; patellar, Achilles, and plantar reflexes were 
normal bilaterally. The examiner cited a bone scan in September 2002 which reportedly 
showed no uptake in the thoracolumbar spine. An X-ray in April 2001 showed no scoliosis 
greater than 10 degrees. At the VA Compensation and Pension exam in October 2003, 7 
months after separation, the CI described sharp mid-low back pain. The pain occurred about 
twice a month with flare-ups, lasted up to hours, and was 6-7/10 in intensity. Her pain was 
worse with bending, lying down, and lifting more than five pounds. She could walk 2-3 miles 
without difficulty and without assistive device. She reported no numbness or tingling, or 
bladder or bowel dysfunction. The examiner noted normal appearance of the thoracolumbar 
spine, and no tenderness, spasm, or weakness at the time of the exam. There was no apparent 
scoliosis. The neurological exam noted no sensory or motor abnormalities, and normal deep 
tendon reflexes, bilaterally. The straight leg test was negative to 70 degrees. The gait was 
normal. The ROM was normal, with pain at extremes of ROM for forward flexion, right lateral 
flexion, and right rotation. The examiner cited undated X-rays of the thoracic spine which 
reportedly showed kyphoscoliosis, without fracture, slippage or disk narrowing; and undated X-
rays of the lumbar spine which were reportedly normal. 

 

The Board directs attention to its rating recommendation based on the above evidence. The 
PEB applied code 5299-5295 (Lumbosacral strain) and cited “characteristic pain on motion” as a 
basis for a 10% rating. The VA’s initial 10% rating decision did not specify a VASRD code under 
the old spine rules. The VA’s subsequent rating increase to 20% was implemented under new 
spine codes which were not in effect at the time of separation, and were thus not applicable to 
the Board’s deliberation. The Board agreed that the 10% criteria were met under the 5295 
code, but debated if a higher rating was justified by right-sided paraspinal muscle spasm 


present at the NARSUM exam. However, loss of lateral spine motion was not present and 
therefore the next higher 20% criteria were not met under the 5295 code. The Board agreed 
that there was no route to a higher rating under other spine codes. After due deliberation, 
considering all of the evidence and mindful of VASRD §4.3 (Resolution of reasonable doubt), the 
Board concluded that there was insufficient cause to recommend a change in the PEB 
adjudication for the chronic right thoracolumbar myofascial pain 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. As discussed above, PEB 
reliance on DoDI 1332.39 and the USAPDA pain policy for rating 5299-5295 was operant in this 
case and the condition was adjudicated independently of that policy by the Board. In the 
matter of the chronic right thoracolumbar myofascial pain condition and IAW VASRD §2003 
VASRD, 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: 

 

UNFITTING CONDITION 

VASRD CODE 

RATING 

Chronic Right Thoracolumbar Myofascial Pain 

5299-5295 

10% 

COMBINED 

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 Veterans’ Affairs Treatment Record 

 

 

 

 

 XXXXXXXXXXXXXXXXXXXX, DAF 

 Acting Director 

 Physical Disability Board of Review 

 


SFMR-RB 


 

 

MEMORANDUM FOR Commander, US Army Physical Disability Agency 

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

 

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for 
XXXXXXXXXXXXXXX, AR20130003975 (PD201200982) 

 

 

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 and hereby deny the individual’s application. 

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 XXXXXXXXXXXXXXXXXX 

 Deputy Assistant Secretary 

 (Army Review Boards)