RECORD OF PROCEEDINGS 

PHYSICAL DISABILITY BOARD OF REVIEW 

 

NAME: XXXXXXXXXXXXXXXXXXXXX BRANCH OF SERVICE: ARMY 

CASE NUMBER: PD1200852 SEPARATION DATE: 20011121 

BOARD DATE: 20130205 

 

SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this 
covered individual (CI) was an active duty Soldier, SPC/E-4 (91R/Veterinary Food Inspector), 
medically separated for undifferentiated connective tissue disease (UCTD) and migraine 
headaches. The CI had Raynaud’s symptoms and musculoskeletal pain, diagnosed as UCTD in 
2000, and chronic headaches diagnosed as migraine headaches in 2001. The CI 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 P3/U3/L3 
profile and referred for a Medical Evaluation Board (MEB). The MEB forwarded UCTD; bilateral 
radiocarpal joint synovitis; and bilateral subtalar joint synovitis as medically unacceptable IAW 
AR 40-501. Bilateral mild tibial stress reaction, gastro-esophageal reflux disease (GERD), and 
migraine headaches, identified in the rating chart below, were also identified and forwarded by 
the MEB as medically acceptable. The Physical Evaluation Board (PEB) combined the UCTD with 
the bilateral radiocarpal joint synovitis and the bilateral subtalar joint synovitis and adjudicated 
them as UCTD, unfitting, rated 20%, with application of the Veteran’s Affairs Schedule for 
Rating Disabilities (VASRD). The PEB adjudicated the bilateral mild tibial stress reaction, GERD, 
and migraine headaches as not unfitting. The CI appealed to the Formal PEB (FPEB), which kept 
the UCTD as unfitting, rated 20%, adding the migraine headaches as unfitting, rated at 0%. The 
FPEB adjudicated the mild tibial stress reaction and GERD as not unfitting. The CI was then 
medically separated with a 20% disability rating. 

 

 

CI CONTENTION: The CI states: “MEB gave me 20% for Connective Tissue Disease and 0% for 
Headaches, other medical conditions were not rated, even though they were present and even 
today I am still being treated for them. My first VA rating tripled the board's rating. I suffered in 
silence many times and did not go to hospital, because even though the doctors were doing 
what they could to make me better, I got worst [sic] with the different procedures or 
medication. The first time I went to hospital for headaches I was admitted and underwent a 
Spinal Tap/Lumbar Puncture. I was discharged, but returned to ER with more severe headaches 
they called Spinal Headaches, they said my spine was leaking fluid from Spinal Tap. In ER I 
underwent a Blood Patch to seal the leak in my spine, both those procedures left me with lower 
pack [sic] pain. I was discharged and returned back again and again. Other incident that got 
worst [sic] after being treated was after receiving injection in my ankle it got swollen and I 
unable to walk [sic]. Seen many times at regular clinic and dermatology for allergy and 
outbreak on my skin and profiled to stay out of grass because of severe allergy but was not 
rated. I had painful growth/cysts on both hands which got worst [sic] with pushups. I was to 
have surgery on both, left hand was schedule first. After surgery I was to wear a cast for 10 
days, but it was in a bad condition so they recast me for about 3 months, the pain was also 
excruciating and my hand never regain [sic] original strength even after therapy. I was so 
scared that I chose not to do the surgery on the right hand. Before surgery I was stuck 13 times 
before they could find a vein for the IV. I had to go to the lab almost every week and the visits 
were so stressful because a male civilian Lab Tech would reel insults at me when I entered the 
lab. He hated caring for me and would scream at me, "You know you are dead, you have no 
veins why you have to come and ruin my day.” At times I bypass the lab when I saw him 
because I feared his insults. I was stress by not knowing what was going on with my health and 
had to dealt [sic] with an insensitive medical personnel. Pulse almost doubled after Plaquenil 


and still don't know why [sic].” The CI also makes a statement in block 15, Remarks, of the 
PDBR 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. The conditions, bilateral mild tibial stress 
reaction and GERD, as requested for consideration meet the criteria prescribed in DoDI 6040.44 
for Board purview; and, are addressed below. The remaining conditions rated by the VA at 
separation and listed 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 FPEB – Dated 20010727 

VA (1 Mo. Pre-Separation) – All Effective Date 20011122 

Condition 

Code 

Rating 

Condition 

Code 

Rating 

Exam 

 

Undifferentiated 
Connective Tissue Disease 

 

6399-5002 

20% 

Connective Tissue Disease 

6399-5002 

20% 

20011011 

Bilateral Carpal Joint Synovitis 

5099-5024 

10%** 

20011011 

Bilateral Talar Joint Synovitis 

5099-5024 

10% 

20011011 

Migraine Headaches 

8100 

0% 

Migraine Headaches 

8199-8100 

10%** 

20011011 

Bilat Tibial Stress Reaction 

Not Unfitting 

Bilateral Tibial Stress Reaction 

5099-5024 

0% 

20011011 

GERD 

Not Unfitting 

GERD/Cholecystectomy/ 
Chronic Constipation 

7346-7318 

10% 

20011011 

.No Additional MEB/PEB Entries. 

Ganglion Cyst, Right Wrist 

5288-7819 

10% 

20011011 

Ganglion Cyst, Left Hand 

7804 

10% 

20011011 

Alopecia Areata** 

7899-7806 

10% 

20020628 

0% X 3 / Not Service-Connected x 3 

20011011 

Combined: 20% 

Combined: 60%* 



*Includes a bilateral factor of 1%. 

**VARD of 9/27/02 increases Migraines to 30%, effective 5/8/02; adds the Alopecia, effective 11/22/01, decreases the bilateral 
carpal joint synovitis to 0%, effective 3/25/02, and adds Raynauds Syndrome, 7117, 20%, effective 3/25/02, increasing 
combined to 80%, effective 5/8/02 with a bilateral factor of 2.7%. 

 

 

ANALYSIS SUMMARY: The Board acknowledges the CI’s contention that suggests ratings should 
have been conferred for other conditions documented at the time of separation. The Board 
wishes to clarify that it is subject to the same laws for disability entitlements as those under 
which the Disability Evaluation System (DES) operates. While the DES considers all of the 
member's medical conditions, compensation can only be offered for those medical conditions 
that cut short a member’s career, and then only to the degree of severity present at the time of 
final disposition. However the Department of Veterans Affairs (DVA), operating under a 
different set of laws (Title 38, United States Code), is empowered to compensate all service-
connected conditions and to periodically reevaluate said conditions for the purpose of adjusting 
the Veteran’s disability rating should the degree of impairment vary over time. 

 

Undifferentiated Connective Tissue Disease. The CI was diagnosed with bilateral ankle synovitis 
in July 2000. Subsequent rheumatology evaluation identified Raynaud’s symptoms and positive 
anti-nuclear antibody testing which suggested an UCTD. An erythrocyte sedimentation rate 
(ESR) in November 2000 was 18 (ESR – a measure of generalized inflammation; normal 0 – 15). 
Specific anti-rheumatic medication was not started until March 2001. The narrative summary 
(NARSUM) rheumatology exam in March 2001, 8 months prior to separation, reported a history 


of episodic Raynaud’s symptoms when exposed to cold; joint pain in her hands, wrists, and 
ankles; and fatigue, painful nodules over the lower extremities, an episode of oral ulcers, and 
exertional dyspnea. The physical exam noted a weight of 167. There was tenderness to 
palpation (TTP) of the bilateral wrists, but there was no evidence of synovitis, inflammation or 
other joint abnormalities. Muscle strength was normal. The exam described “FROM” (full 
range-of-motion [ROM]) except for decreased left wrist flexion of 60 degrees. Pulmonary 
function tests (PFTs) and X-rays of the hands, ankles and chest were all normal. There was no 
laboratory evidence of anemia. At the MEB orthopedic surgery consultation in April 2001, 7 
months prior to separation, the CI reported that her bilateral wrist and ankle pain had 
worsened over time, and that braces for her wrists and ankles had not improved her symptoms. 
Her wrist pain was worsened by cold exposure. She reported that her bilateral wrist pain 
limited her in lifting and that her bilateral ankle pain was worsened by moderate amounts of 
walking. The physical exam of the wrists noted bilateral TTP over the radiocarpal joints without 
instability or deformity. The exam of the bilateral ankles noted normal subtalar motion, no 
discomfort with right subtalar motion, and mild discomfort with axial loading and ROM of the 
left subtalar joint. The anterior drawer and talar tilt (tests of stability) were unremarkable. The 
ROM of the bilateral subtalar joints was normal. Measured ROM showed mildly limited wrist 
dorsiflexion bilaterally and mildly limited ankle plantar flexion and dorsiflexion bilaterally. At 
the VA Compensation and Pension (C&P) exam in October 2001, a month prior to separation, 
the CI reported continued migratory joint pain without joint inflammation. The CI reported 
occasional wrist swelling and difficulty with activities such as opening doors and jars, which 
resulted in “cramping” of the joints; walking was limited to about half an hour comfortably. 
The physical exam noted some bilateral wrist tenderness and painful motion. The exam of the 
ankles noted tenderness bilaterally without crepitus. The measured ROM of wrists and ankles 
was normal. A military rheumatology evaluation in December 2001, less than a month after 
separation, noted that the connective tissue condition was asymptomatic at that time. Her 
anti-rheumatologic medication therapy had been discontinued a month earlier due to possible 
side effects. Weight was 192 pounds. A VA rheumatology examination in March 2002 (4 
months after separation) reported normal appearance of hands with no evidence of synovitis. 
Ankle ROM was normal and there was no tenderness of the feet. Lab testing revealed no 
anemia. Follow-up in April 2002, 5 months after separation, noted that the Raynaud’s 
symptoms had improved without treatment. The examiner stated that the CI was not taking 
medication for the connective tissue disease condition. Because it was “not doing too badly” it 
was decided to not institute anti-rheumatic therapy. A C&P exam in June 2002, 7 months after 
separation, noted intermittent pain in the right wrist and chronic discomfort of the left wrist. 
The examiner reported that the CI could lift a gallon of milk with her left wrist. Physical exam 
noted a normal gait, no TTP of the right wrist and tenderness of a surgical scar of the left wrist. 
Painful wrist ROM was noted. The measured wrist ROM was normal. 

 

The Board directs attention to its rating recommendation based on the above evidence. The 
PEB and the VA used the 5002 code, but approached the rating in different ways. Under the 
analogous coding approach used by the PEB, the rating is based on the number of 
incapacitating disease exacerbations and overall impairment of health. The PEB’s 20% rating 
reflected an assessment that the CI’s condition was most accurately described by “one or two 
exacerbations a year.” Although the 5002 code allows an option to rate individually affected 
joints as chronic residuals, the rating for the active process should not be combined with the 
residual ratings (i.e. the higher evaluation should be chosen). The VA assigned a 20% rating for 
the active process, and then combined 10% ratings from two chronic residuals (bilateral carpal 
and subtalar synovitis); a separate rating for Raynaud’s was later added, effective 4 months 
after separation. The Board agreed that the PEB’s coding approach was appropriate, and 
considered the severity of the CI’s condition based on the evidence at hand. All members 
agreed that the 60% criteria were not approached (“…with weight loss and anemia productive 
of severe impairment of health or severely incapacitating exacerbations occurring 4 or more 
times a year or a lesser number over prolonged periods”), and that “incapacitating 


exacerbations occurring 3 or more times a year” (supportive of the next higher 40% rating) 
were not in evidence. The Board also concluded that “symptom combinations productive of 
definite impairment of health objectively supported by examination findings” (also supportive 
of a 40% rating) was not described by the reports near the time of separation that indicated 
improvement in Raynaud’s symptoms, no objective evidence of synovitis, and an overall 
condition that was quiescent and not in need of anti-rheumatic therapy. Finally, the Board 
considered separate ratings for the history of wrist and ankle synovitis based on either VASRD 
§4.59 (painful motion) or §4.40 (functional loss); given that these joints were intermittently 
symptomatic at separation. It must be noted, however, that to do so would entail a judgment 
that each separately rated joint was independently unfitting. Members concluded that the 
latter requirement could not be reasonably supported by the evidence. Likewise, the Board 
concluded that the described status of the Raynaud’s syndrome at the time of separation did 
not support its inclusion as an additionally unfitting condition separate from the unfitting 
rheumatologic condition. 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 undifferentiated connective tissue disease 
condition. 

 

Migraine Headaches. At the MEB neurology consultation in April 2001, 7 months prior to 
separation, the CI reported migraine headaches occurring approximately 2-3 times per week, 
many lasting up to a week. The headaches were associated with characteristic migraine 
symptoms, but without premonitory symptoms (aura). The examiner noted that the CI 
“typically retreats to a quiet, dark room, and lies down.” The neurological exam showed no 
abnormalities. The CI began a trial of prophylactic and abortive anti-migraine medications at 
that time. She presented to an emergency room in June and August 2001 for acute care of a 
headache. A supervisor’s statement in July 2001 (4 months prior to separation) indicated that 
at least once per week she would be sent home from work because the severity of her 
headaches made her unable to function. A neurology examiner in August 2001, 3 months prior 
to separation, reported minimal improvement of the headache condition with prophylactic 
medication therapy. A follow-up with the same examiner on 12 September 2001 however 
stated that except for a recent two day headache, she had been headache free for one month. 
At a VA exam on 11 October 2001, a month prior to separation, the CI reported migraine 
headaches twice per week that responded to abortive medication and did not interfere with 
her ability to function. “Full blown” migraines with nausea and vomiting occurred every 2-3 
weeks and lasted up to 3 days if she did not use abortive medication. These rendered her 
unable to function. However, follow-up with the service neurologist on 22 October 2001 only 
referred to a two day headache from 22-24 September. At a VA rheumatology outpatient visit 
in April 2002, 5 months after separation, the CI reported that, “…her headache…puts her down 
3 to 4 times a week for hours.” The examiner noted that, “She mostly gets relief with time, cold 
compressed [sic] and a dark room.” The VA neurology consult in May 2002, 6 months after 
separation, noted throbbing headaches occurring about once a month and lasting two or more 
hours. The examiner noted that those headaches, “Prevent her daily workouts” and that, “Rest 
and dark quiet places are of some help along with medications and sleep.” The C&P exam in 
June 2002, 7 months after separation, reported migraine headaches approximately twice a 
month lasting 2 hours to 3 days at a time. 

 

The Board directs attention to its rating recommendation based on the above evidence. When 
rating headaches under the diagnostic code 8100 (migraine headaches), VA guidance uses the 
clear English definition of prostrating. The standard dictionary definition of “prostration” is 
“utter physical exhaustion or helplessness,” and does not indicate that seeking medical 
attention is required. The Board noted that the frequency of headaches as reported by several 
examiners was inconsistent. For example, the service neurologist reported that she was 
“headache-free” during the prior month, except for one headache, while a VA examiner the 
following month stated that headaches occurred twice per week. The VA rheumatologist 


indicated her headache “puts her down 3 to 4 times per week” while the VA neurologist stated 
headaches occurred once per month. In debating the frequency of prostrating attacks during 
the several month period leading up to separation, the Board noted the two emergency room 
visits for acute headaches as well as the statement by a supervisor about the frequency of 
being sent home due to headaches. A Board majority ultimately agreed that the described 
clinical picture most closely approximated the 10% criteria (“characteristic prostrating attacks 
averaging one in 2 months over last several months”). After due deliberation, considering all of 
the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board majority recommended 
a disability rating of 10% for the migraine headache condition. 

 

Contended PEB Conditions. The contended conditions adjudicated as not unfitting by the PEB 
were bilateral mild tibial stress reaction and GERD. The Board’s first charge with respect to 
these conditions is an assessment of the appropriateness of the PEB’s fitness adjudications. 
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 orthopedic surgery consult in April 2001 noted 
mild bilateral tibial tenderness without neurologic abnormalities. The C&P exam in October 
2011 reported that the bilateral tibial pain occurred rarely and the GERD condition was 
controlled with medication therapy. These conditions were not profiled or implicated in the 
commander’s statement, and were not judged to fail retention standards. The two conditions 
were reviewed by the action officer and considered by the Board. There was no indication from 
the record that these conditions 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 conditions; and, therefore, no additional disability ratings can 
be 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. The Board did not 
surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD 
were exercised. In the matter of the UCTD condition 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 vote of 2:1 recommends a disability rating of 10%, coded 
8100 IAW VASRD §4.124a. The single voter for dissent (who recommended no change in the 
PEB adjudication) submitted the addended minority opinion. In the matter of the contended 
bilateral mild stress reaction and GERD conditions, 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; 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 

Undifferentiated Connective Tissue Disease 

6399-5002 

20% 

Migraine Headache 

8100 

10% 

COMBINED 

30% 



 

 

 


The following documentary evidence was considered: 

 

Exhibit A. DD Form 294, dated 20120620, w/atchs 

Exhibit B. Service Treatment Record 

Exhibit C. Department of Veterans’ Affairs Treatment Record 

 

 

 

 

 xxxxxxxxxxxxxxxxxxxxxxxxx, DAF 

 President 

 Physical Disability Board of Review 

 

 

 


MINORITY OPINION: 

 

The CI’s migraine headache condition, determined to be unfitting by a FPEB, and rated at 0%, 
was adjudicated fairly. The history of the condition as outlined in the CI’s file was very 
inconsistent; additionally, the only profile written for headaches was temporary and issued 
after the FPEB. 

 

The initial neurology consult written over a month after the NARSUM indicated that the 
migraines meet retention criteria as the CI “had not received an adequate trial of anti-migraine 
therapy”. Based on this analysis, the MEB identified the migraine headaches as meeting 
retention standards, to which the CI concurred. The initial PEB adjudicated the migraines as not 
unfitting; however, the CI non-concurred and requested a FPEB. 

 

The FPEB, conducted in the same month as the PEB and four months prior to separation, used a 
neurology addendum to the NARSUM, written 11 days prior to the FPEB, reversed the meets 
retention criteria based on the statement that “despite compliance with this therapy she 
continues to have 2 to 3 severe migraines per week”. The FPEB also used a statement by the 
CI’s Operations NCO that her headaches caused her to be sent home at least once a week. 
Based on this information, the FPEB found the migraines unfitting, but at the 0% rating. 

 

Neurology exams following the FPEB were inconsistent. The first, a month after the FPEB, 
indicated minimal improvement in the headache condition with prophylactic medication 
therapy. The second, two months after the FPEB stated that except for a two day headache, 
the CI had been headache free for one month. Also, there was no indication as to the severity 
of the two day headache. 

 

The VA C&P exam was a month after the second neurology exam and a month prior to 
separation. The examiner identified retro-orbital headaches occurring twice a week and full 
blown migraines occurring every two to three weeks. However, the examiner noted that with 
the use of medications, the CI was able to abort the retro-orbital headaches, and function 
normally when the full blown migraine headaches occurred. 

 

The crux of this case and foundation for the majority recommendation is the 10% criteria for 
migraine headaches: with characteristic prostrating attacks averaging one in 2 months over last 
several months. While the FPEB adjudicated the headaches as unfitting, its basis for the 0% 
rating was one documented prostrating headache in the past two years. Review of the 
documentation indicates that the CI was having headaches; however, as documented by the VA 
C&P exam one month prior to separation, use of the prescribed medications enabled the CI to 
function normally. Given the inconsistent reports of headaches, that may or may not have been 
prostrating, from the FPEB until the VA C&P exam indicates that the medications were most 
likely effective in abating the “prostrating” effect of the migraines. As the VA exam clearly 
documents that use of the medications enabled the CI to function normally, and that exam was 
prior to separation, I believe the FPEB rendered a fair rating of 0%. 

 

RECOMMENDATION: The minority voter therefore, recommends that there be no 
recharacterization of the CI’s disability and separation determination, as follows: 

 

UNFITTING CONDITION 

VASRD CODE 

RATING 

Undifferentiated Connective Tissue Disease 

6399-5002 

20% 

Migraine Headache 

8100 

0% 

COMBINED 

20% 



 

 


SFMR-RB 


 

 

MEMORANDUM FOR Commander, US Army Physical Disability Agency 

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

 

 

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation 

for xxxxxxxxxxxxxxxxxxxxxxxxx, AR20130004607 (PD201200852) 

 

 

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 severance 
pay. 

 

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 severance pay. 

 

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

 

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

 

 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 xxxxxxxxxxxxxxxxx 

 Deputy Assistant Secretary 

 (Army Review Boards)