RECORD OF PROCEEDINGS 

PHYSICAL DISABILITY BOARD OF REVIEW 

 

NAME: XXXXXXXXXXXXXXXXXXX BRANCH OF SERVICE: ARMY 

CASE NUMBER: PD1200329 SEPARATION DATE: 20050318 

BOARD DATE: 20121116 

 

 

SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this 
covered individual (CI) was an Army National Guard SSG/E-6 (88M/Motor Transport Operator), 
medically separated for low back pain (LBP) and headaches (tied to cervical, trapezius and 
shoulder region pain). The CI was in a motor vehicle accident (MVA) on 10 August 2002 
suffering a low back strain and a left leg contusion. He subsequently developed pain in the 
back, neck, and shoulder along with headaches. The CI did not improve adequately with 
treatment to meet the physical requirements of his Military Occupational Specialty (MOS) or 
satisfy physical fitness standards. He was issued a permanent P3/U3/L3 profile and referred for 
a Medical Evaluation Board (MEB). Neck pain, shoulder pain, LBP and intermittent headaches 
were forwarded by the MEB as medically unacceptable IAW AR 40-501. The Informal Physical 
Evaluation Board (IPEB) rated the LBP condition at 10% and rated migraine headaches at 0% on 
6 July 2004. The CI appealed via counsel to the Formal PEB (FPEB) which rated the LBP at 10% 
and headaches (tied to neck and shoulder pain) at 10% on 13 August 2004. The CI rebutted the 
FPEB adjudication via counsel. The FPEB upheld the adjudication upon reconsideration, but 
administratively modified the adjudication wording. The description of the headache condition 
was changed to “Headaches tied to cervical, trapezius and shoulder region pain…” The FPEB 
added two Axis I conditions as not unfitting. The FPEB (Reconsideration) adjudicated the LBP 
and headache conditions as unfitting, rated 10% each; with probable application of the US 
Army Physical Disability Agency (USAPDA) pain policy. The adjudication was forwarded to the 
USAPDA for automatic review; no further changes were made. The CI made no further appeals 
and was then medically separated with a 20% disability rating. 

 

 

CI CONTENTION: The CI elaborated no specific contention in his 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 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 FPEB Recon – Dated 20050119 

VA (VARD 18 Months Post-Separation) – All Effective Date 20050319 

Condition 

Code 

Rating 

Condition 

Code 

Rating 

Exam 

Low Back Pain 

5237 

10% 

DJD of the Lumbar Spine 

5237 

20% 

20050627 

Headaches tied to …pain 

5399-5323 

10% 

Headaches 

8100 

30% 

20050627 

Neck Pain 

Not Unfitting 

DDD of the Cervical Spine 

5242 

20% 

20050627 

Shoulder Pain 

Not Unfitting 

Mild Deg Change of the ACJ 

5010 

10% 

20050627 

.No Additional MEB/PEB Entries. 

TMJ Disease 

9999-9905 

10% 

20050627 

0% X 4 / Not Service-Connected x 12 

20050627 

Combined: 20% 

Combined: 60% 



 

 

ANALYSIS SUMMARY: The CI was in a MVA on 10 August 2002 when the truck he was driving 
rolled onto its left side as the CI tried to avoid another vehicle. He was seen in the emergency 
room (ER) that day for a left leg contusion and low back strain. He was unable to meet duty 
requirements due to chronic pain of the neck, shoulders, lower back, and headaches. A 
narrative summary (NARSUM) for a MEB was dictated on 15 September 2002, but there is no 
record that the CI had a MEB until 3 December 2003. At that time, he had been activated since 
January 2003. The commander’s assessment dated 20 November 2003 noted that he had been 
determined to be non-deployable immediately after activation. The CI was not able to meet 
the requirements of his MOS or meet physical fitness standards. Each condition is now 
considered separately. 

 

Low Back Pain Condition. There were 2 goniometric range-of-motion (ROM) evaluations in 
evidence, with documentation of additional ratable criteria, which the Board weighed in 
arriving at its rating recommendation; as summarized in the chart below. 

 

Thoracolumbar ROM 

Degrees 

PT ~15 Mo. Pre-Sep 

 

VA C&P ~3 Mo. Post-Sep 

 

Flexion (90 Normal) 

30 

40 

Combined (240) 

120 

150 

Comment 

Limited by pain 

+ Tenderness; painful motion 

§4.71a Rating 

40% 

20% 



 

As noted above, the CI was injured in an MVA in August 2002. The next treatment record in 
evidence was on 7 February 2003. It documented that he had been improving until he was 
reactivated and was wearing Kevlar and other protective equipment. Conservative 
management including medications, physical therapy (PT) and a TENS (transcutaneous electrical 
stimulation) unit did not improve his pain sufficiently to meet duty requirements. The MEB 
ROM measurements above were 15 months prior to separation and reduced from non-
goniometric assessments in prior PT appointments. A magnetic resonance imaging (MRI) test 
performed on 31 January 2004 showed a generalized annular bulge with severe right foraminal 
narrowing at L5-S1 contacting but not displacing the S1 nerve roots. The first narrative 
summary (NARSUM) was dictated 15 September 2002, a month after the MVA and 30 months 
prior to separation. The CI had chronic pain in the neck, shoulders and lower back as well as 
headaches and was thought to have myofascial pain syndrome. He was noted to have 
decreased motion of the back in flexion and extension as well as tender points in the right 
paraspinal area. His neurological examination was normal and provocative testing for nerve 
root irritation was negative. The MEB NARSUM was updated on 21 May 2004, 10 months prior 
to separation. It noted that he had continued pain and that he was in the medical holding 
company, unable to perform meaningful tasks. Treatment had included acupuncture, 
medications, PT and steroid injections, but had not been adequate for him to meet duty 
requirements. He was unable to sit for extended periods or perform repetitive movements 
with his upper extremities. On 13 October 2004, 3 months prior to separation, the CI had 


another MEB NARSUM dictated by a rheumatologist to evaluate for fibromyalgia, a diagnosis 
recently made by a civilian rheumatologist. The CI reported that he was unable to meet any of 
his occupational requirements or perform any kind of physical activity. He also had daily 
headaches. On examination of his back, he had a marked decrease in flexion. Strength was 
normal and there were no radicular symptoms. He was thought to have regional myofascial 
pain syndrome. A psychiatric evaluation was performed on 20 December 2004, 3 months prior 
to separation, to rule out somatoform disorder. This diagnosis was excluded, but the CI was 
determined to have a major depressive disorder and minimal symptoms of posttraumatic stress 
disorder (PTSD). The mental health diagnoses were thought to meet retention standards as 
separate diagnoses. The psychiatrist did note that the CI did not meet retention standard when 
the mental health conditions were combined with the physical conditions. The commander 
noted, on 20 November 2004, that the CI was unable to meet his MOS requirements due to his 
physical limitations. At the VA Compensation and Pension (C&P) exam performed on 27 June 
2005, 3 months after separation, the CI reported constant LBP. He had difficulty with 
prolonged sitting and driving. No incapacitation was noted. Examination of the back was 
documented as having “no external abnormalities” implying an absence of either spasm or 
atrophy. The neurological examination was normal. X-rays showed degenerative joint disease 
(DJD) at L5-S1. The ROM is above. The Board directs attention to its rating recommendation 
based on the above evidence. The PEB and VA both coded the back condition as 5237, 
lumbosacral strain, but rated it at 10% and 20% respectively. The PEB ROM measurements 
were remote from separation and the CI underwent extensive conservative treatment after 
they were taken. The C&P examination is within a few months of separation and therefore 
assigned a higher probative value. The limitation in flexion at 40 degrees supports a disability 
rating of 20%. After due deliberation, considering all of the evidence and mindful of VASRD 
§4.3 (reasonable doubt), the Board recommends a disability rating of 20% for the LBP 
condition, coded 5237. 

 

Headache Tied to Cervical, Trapezius and Shoulder Pain Condition. The PEB combined 
headaches tied to cervical, trapezius and shoulder pain as a single unfitting condition, coded 
analogously to muscle Group XXIII (head, shoulder and neck) and rated 10%, consistent with 
moderate symptom. The PEB may have relied on AR 635.40 (B.24 f.) and/or the USAPDA pain 
policy 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. 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. 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 independently 
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. 

 

Headaches. The CI noted that he did not have a history of frequent or severe headaches (HAs) 
on 10 February 2001 periodic history and physical. Headaches were noted after the MVA 
though. An emergency room record from 10 August 2002, the day of the MVA, mentioned left 
leg and lower back symptoms, but was silent for HAs or head trauma. A 26 August 2002 PT 
note did annotate that there had been left temporal contusion from the MVA without loss of 
consciousness. At a 15 January 2003 physical medicine and rehabilitation (PMR) visit, the CI 
stated that the HAs were left sided. At a 27 March 2003 neurology evaluation, he noted that 
HAs had been present prior to the MVA, but were now worse. He was diagnosed with common 
migraines. At a follow-up visit in neurology performed on 7 May 2003, the CI stated that the 
HAs had decreased since analgesic withdrawal (consistent with rebound headaches) and that 
they were aggravated by use of the left arm. A 4 June 2003 neurology visit documented 
improvement on Lexapro, but continued aggravation by use of the left arm. At a psychology 


visit on 12 June 2003, he reported that the use of the left arm led to shoulder and neck pain 
with subsequent development of a HA. He was taught relaxation techniques which were 
beneficial. The commander’s assessment performed on 20 November 2003 only mentions 
physical limitations and is silent for HAs. On 5 December 2003, he was given a P3/U3/L3 profile 
for neck, shoulder, back pain and headaches (myofascial pain syndrome). A neurological 
NARSUM dictated 14 April 2004 noted that the CI had common migraines in poor control. A 
21 May 2004 update to the initial NARSUM dictated 15 September 2002 noted only myofascial 
pain syndrome (MFPS) for the diagnosis in the assessment. A 19 August 2004 civilian 
rheumatological evaluation attributed all the symptoms including the HAs to fibromyalgia 
syndrome (FMS). Trigger points were noted along the cervical musculature and occiput (back 
of the skull), trapezius muscle and bicipital insertion and subacromial region of the left 
shoulder. 

 

Neck. Other than a remote visit for neck pain 13 years prior to the MVA, the CI was first 
documented with neck pain at the 1 November 2002 PT appointment. Over the next several 
years, the CI was treated with medications, dry needling of trigger points, PT including traction 
and steroid trigger point injections. The diagnosis consistently was MFPS. A MRI of the cervical 
spine on 4 June 2004 was normal other than straightening consistent with spasm. X-rays done 
for the C&P examination were also normal. 

 

Trapezius. The trapezius is a large muscle that extends from the neck to the scapula (shoulder). 
Although listed in the PEB adjudications, it is not considered separately in the treatment record. 

 

Shoulder. The left dominant CI was noted to have an acromion-clavicle joint (ACJ) separation 
on the day of the MVA although later records documented a shoulder dislocation. After the 
initial PT for this on 26 August 2002, there is no further mention of the ACJ separation in the 
record. No record showing a reduction of a possible shoulder dislocation was in evidence nor 
was the dislocation annotated other than in retrospect. The diagnosis was consistently MFPS in 
the record and restrictions in activity attributed to pain. A MRI performed on 31 January 2004, 
14 months prior to separation, was significant for a partial tear in the anterior supraspinatus 
tendon. Neither rheumatologist noted this as being clinically significant. The Board noted that 
this is a condition which would be expected to typically heal on its own with proper care. A 
rheumatological evaluation done for the PEB process 3 months prior to separation documented 
normal strength. The C&P examination noted a normal neurological examination although with 
reduced ROM. X-rays were normal at the time of the C&P examination. 

 

The Board considered if any of these conditions were separately ratable. The CI had headaches 
prior to the MVA per his history at the first neurology evaluation, but had denied them on the 
2001 periodic exam. He noted that they increased after the MVA and consistently linked the 
headaches to the left shoulder pain. There were no records found which indicated that the CI 
had sought care in an emergency room for the headaches nor were any found indicating that 
he had left work due to them. The commander did not comment on the headaches. The left 
shoulder had no findings other than trigger points and a partial tear of the supraspinatus 
tendon on MRI which apparently healed prior to separation. Examination of the neck was 
remarkable only for spasm noted on the MRI. The limitation in motion of both the shoulder 
and neck can be explained by the ongoing MFPS diagnosed by multiple clinicians. After due 
deliberation in consideration of the preponderance of the evidence, the Board concluded that 
there was insufficient cause to recommend that headache tied to cervical, trapezius and 
shoulder pain can be separated into individually unfitting conditions. The Board then 
considered the appropriate rating. The PEB coded the condition analogously, 5399-5323, for 
abnormal function of Group XXIII muscles and rated it at 10% for moderate symptoms. The VA 
rated the headaches, neck and shoulder separately. The Board considered the different coding 
options for the diagnosis of MFPS and determined that an analogous code 5323, as used by the 
PEB, for Group XXIII dysfunction (muscles of the head, neck and shoulder) best fit the clinical 


description of the underlying disability. The Board considered coding options for either a 
moderate or moderately severe disability. It noted that he was unable to meet the 
requirements of his MOS, but was allowed to walk at his own pace and distance. The 
neurological examination was consistently normal and atrophy was not noted as would be 
expected with significant disuse over a several year period. The Board determined that this 
best fit a moderate level of disability. 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 headaches tied to cervical, 
trapezius and shoulder 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 the USAPDA pain policy for rating the LBP was probably operant in this case and the 
condition was adjudicated independently of that policy by the Board. In the matter of the LBP 
condition, the Board unanimously recommends a disability rating of 20%, coded 5237 IAW 
VASRD §4.71a. In the matter of the headaches tied to cervical, trapezius and shoulder pain 
condition 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 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 his prior medical separation: 

 

UNFITTING CONDITION 

VASRD CODE 

RATING 

Low Back Pain 

5237 

20% 

Headaches Tied to Cervical, Trapezius and Shoulder Pain 

5399-5323 

10% 

COMBINED 

30% 



 

 

The following documentary evidence was considered: 

 

Exhibit A. DD Form 294, dated 20120423, w/atchs 

Exhibit B. Service Treatment Record 

Exhibit C. Department of Veterans’ Affairs Treatment Record 

 

 

 

 

 xxxxxxxxxxxxxxxxxxxx, DAF 

 President 

 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 xxxxxxxxxxxxxxxxxxxxxxxx, AR20130004939 (PD201200329) 

 

 

1. Under the authority of Title 10, United States Code, section 1554(a), I approve the enclosed 
recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) 
pertaining to the individual named in the subject line above to recharacterize the individual’s 
separation as a permanent disability retirement with the combined disability rating of 30% 
effective the date of the individual’s original medical separation for disability with Reserve 
retirement. 

 

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: 

 

 a. Providing a correction to the individual’s separation document showing that the 
individual was separated by reason of permanent disability retirement effective the date of the 
original medical separation for disability with Reserve retirement. 

 

 b. Providing orders showing that the individual was retired with permanent disability 
effective the date of the original medical separation for disability with Reserve retirement. 

 

 c. Adjusting pay and allowances accordingly. Pay and allowance adjustment will 
account for payment of permanent retired pay at 30% effective the date of the original medical 
separation for disability with Reserve retirement. 

 

 d. Affording the individual the opportunity to elect Survivor Benefit Plan (SBP) and 
medical TRICARE retiree options. 

 

 

 

 

 

 

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 xxxxxxxxxxxxxxxxxx 

 Deputy Assistant Secretary 

 (Army Review Boards)