RECORD OF PROCEEDINGS 

PHYSICAL DISABILITY BOARD OF REVIEW 

 

NAME: XXXXXXXXXXXXXXXX BRANCH OF SERVICE: ARMY 

CASE NUMBER: PD1200702 SEPARATION DATE: 20031112 

BOARD DATE: 20130129 

 

 

SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this 
covered individual (CI) was an active duty SGT/E-5 (63T/Bradley Fighting Vehicle System 
Mechanic), medically separated for chronic pain left posterior shoulder girdle. The CI first 
noted neck and shoulder pain in 2001 after lifting duffle bags all night. He was reinjured after a 
fall and developed chronic left posterior shoulder girdle pain condition. Despite treatment, the 
CI did not improve adequately to meet the physical requirements of his Military Occupational 
Specialty (MOS) or satisfy physical fitness standards. He was issued a permanent U3L3 profile 
and referred for a Medical Evaluation Board (MEB). The MEB determined the left posterior 
shoulder girdle myofascial pain and dysfunction to be medically unacceptable and forwarded it 
to the Physical Evaluation Board (PEB) for adjudication. The MEB forwarded no other 
conditions to the PEB. The PEB adjudicated the chronic left posterior shoulder girdle pain 
condition as unfitting, rated 20%, with application of the Veteran’s Affairs Schedule for Rating 
Disabilities (VASRD) and the US Army Physical Disability Agency (USAPDA) pain policy. The CI 
made no appeals and was medically separated with a 20% disability rating. 

 

 

CI CONTENTION: In Items #3 and 4, the CI entered “See Attachments.” 

 

 

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. The unfitting chronic pain left posterior 
shoulder girdle condition meets the criteria prescribed in DoDI 6040.44 for Board purview, and 
is accordingly addressed below. The remaining conditions rated by the VA at separation 
(lumbosacral strain and chronic daily headaches) and implied on the DD Form 294 are not 
within the Board’s purview. 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 20030806 

VA (2 Mos. Pre-Separation) – All Effective Date 20031113 

Condition 

Code 

Rating 

Condition 

Code 

Rating 

Exam 

Chronic pain L shoulder girdle 

5099-5003 

20% 

Myofascial pain … strains. 

5099-5025 

20% 

20030924 

.No Additional MEB/PEB Entries. 

0% X 2 / Not Service-Connected x 0 / Deferred x 1 

Combined: 20% 

Combined: 20% 



*VARD 20031117 awarded 0% for lumbosacral strain (5237) and chronic daily headache (8199-8100) and deferred and later 
denied (20040202) the rating of temporomandibular joint dysfunction (9999-9905). 

 

 


 

 

 

ANALYSIS SUMMARY: 

 

Chronic pain left posterior shoulder girdle condition. The CI first had upper back and neck pain 
in 2001 after lifting heavy bags. He responded well to conservative management, but then fell 
from an M-88 recovery vehicle with recurrence of his symptoms. Conservative management 
including medications, injections, physical therapy, biofeedback and narcotics failed to resolve 
his symptoms. His treatment was complicated by narcotic dependence. The Board noted that 
his initial accession was delayed by a positive urine drug screen for marijuana use and that he 
had denied use on the history. At a 27 March 2003 physical medicine visit, 8 months prior to 
separation, he diagnosed with myofascial pain syndrome (MPS) with multiple trigger points 
present. Two weeks later he was in a motorcycle accident, but had shown no improvement in 
his symptoms prior to the accident, leading to a U3 profile and referral to MEB. The narrative 
summary (NARSUM) was dictated 20 May 2003, 6 months prior to separation. The CI reported 
regional left thoracic paraspinal, interscapular and posterior shoulder girdle pain with multiple 
tender/trigger points. The pain was aggravated by all activities associated with his MOS. On 
examination, his sensation, strength and reflexes were normal in both upper extremities. The 
anterior musculature was well developed compared to the posterior. Trigger points were 
noted in the muscles of the left posterior shoulder. Overhead motion aggravated his pain. Two 
signs of non-organic pain were present. It was also noted that “radiological studies have 
revealed no attributable deformity.” At the MEB examination on 5 June 2003, 5 months prior 
to separation, the examiner noted no specific findings. On 22 August 2003, a magnetic 
resonance imaging (MRI) of the cervical spine was normal. The VA Compensation and Pension 
(C&P) examination was accomplished 24 September 2003, 3 months prior to separation. The CI 
reported continued pain in the left posterior shoulder and upper back. He was noted to be 
right dominant and to have a normal posture and gait. The extremities were symmetric on 
examination and without atrophy or swelling. The range-of-motion was full for the neck and 
bilaterally for both shoulders. Sensation, strength and reflexes were normal. There was no 
tenderness. 

 

The Board directs attention to its rating recommendation based on the above evidence. The 
PEB coded the shoulder pain as 5099-5003, analogous to degenerative arthritis, and rated it at 
20% using the VASRD and the, since rescinded, USA pain policy. The VA also rated the shoulder 
condition at 20%, but coded it as 5099-5025, analogous to fibromyalgia. The Board considered 
both coding options, but determined that neither provided an advantage to the CI. Board 
precedent is that the PEB code be retained unless a different code provides an advantage to the 
CI. The Board noted that the examination of the left shoulder was essentially normal other 
than the presence of trigger points. 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 left posterior 
shoulder girdle 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 chronic pain left posterior shoulder girdle was 
operant in this case and the condition was adjudicated independently of that policy by the 


Board. In the matter of the chronic pain left posterior shoulder girdle 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, therefore, recommends that there be no recharacterization of 
the CI’s disability and separation determination, as follows: 

 

UNFITTING CONDITION 

VASRD CODE 

RATING 

Chronic pain left posterior shoulder girdle 

5099-5003 

20% 

COMBINED 

20% 



 

 

The following documentary evidence was considered: 

 

Exhibit A. DD Form 294, dated 20120606, 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 / xxxxxxxxxxxxxxx), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557 

 

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for 
xxxxxxxxxxxxxx, AR20130007510 (PD201200702) 

 

 

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 xxxxxxxxxxxxxxxxxxxx 

 Deputy Assistant Secretary 

 (Army Review Boards)