RECORD OF PROCEEDINGS 

PHYSICAL DISABILITY BOARD OF REVIEW 

 
NAME:  XXXXXXXXXXXXX                                                                        BRANCH OF SERVICE:  ARMY 
CASE NUMBER:  PD1200470                                                                  SEPARATION DATE:  20080217 
BOARD DATE:  20130219 
 
 
SUMMARY  OF  CASE:    Data  extracted  from  the  available  evidence  of  record  reflects  that  this 
covered individual (CI) was an activated National Guard SPC/E-4 (13B10/Cannon Crewmember), 
medically separated for cervical spine strain and lumbosacral strain.  Neck pain began after a 
motor vehicle accident in 2000 while low back pain (LBP) was not a consequence of trauma.  
Neither  condition  was  associated  with  a  surgical  indication.    The  CI  could  not  be  adequately 
rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS) or 
satisfy physical fitness standards.  He was issued a permanent U3L3H3 profile and referred for a 
Medical Evaluation Board (MEB).  The MEB also identified and forwarded bilateral sensorineural 
hearing loss (BSNHL); transient hyperglycemia; breast hypertrophy, surgically treated, with right 
breast  gynecomastia  and  postoperative  pain;  low  testosterone  with  medical  replacement; 
posttraumatic stress disorder (PTSD), chronic; major depressive disorder (MDD), single episode, 
mild; and mild traumatic brain injury (TBI), screened, asymptomatic; all identified in the rating 
chart below as meeting retention standards.  The Physical Evaluation Board (PEB) adjudicated 
the cervical spine strain and lumbosacral strain conditions as unfitting, rated 0% and 0%, with 
application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The CI appealed 
the  PEB’s  decision  and  met  a  Reconsideration  Physical  Evaluation  Board  (RPEB).    The  RPEB 
adjudicated the cervical spine strain and lumbosacral strain conditions as unfitting, rated 10% 
and 10% respectively.  The remaining conditions were determined to meet retention standards 
and  therefore  not  unfitting  and  not  ratable.    The  CI  made  no  appeals  and  elected  to  be 
transferred to the Reserve Retirement List in lieu of discharge with disability severance pay.  
 
 
CI CONTENTION:  “My rating should be changer (sic) because I was found unfit for duty by the 
Army.  The VA and Social Security found me incompetent which made me unable to return to 
my  civilian  job.    Memorandum  for  Record  TO  Col  E---  October  4  2007      AEROMEDICAL 
EVACUATION RECORD FORM 3899” 
 
 
SCOPE  OF  REVIEW:    The  Board’s  scope  of  review  is  defined  in  DoDI  6040.44,  Enclosure  3, 
paragraph 5.e. (2). It is limited to those conditions determined by the PEB to be unfitting for 
continued military service and those conditions identified but not determined to be unfitting by 
the PEB when specifically requested by the CI.  Ratings for unfitting conditions will be reviewed 
in all cases.  The ratings for the unfitting cervical spine strain and lumbosacral strain conditions 
as requested for consideration meet the criteria prescribed in DoDI 6040.44 for Board purview, 
and  are  addressed  below.    Of  the  conditions  determined  to  be  not  unfitting  by  the  PEB, 
members  judged  that  the  BSNHL,  transient  hyperglycemia,  right  breast  gynecomastia  and 
postoperative pain, low testosterone with medical replacement, PTSD and MDD, and mild TBI 
conditions  were  specified  sufficiently  in  the  application  to  meet  the  DoDI  6040.44  scope 
requirements;  and  are  accordingly  addressed  below.    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. 
 

Not Unfitting 

TBI, 

Screened, 

Not Unfitting 

Gynecomastia, Bilaterally 

Code 
5237 
5299-5237 

Rating 
10% 
10% 

Not Unfitting 

Not Unfitting 

7699-7628 

0% 

20080425 

Rating 
10% 
10% 
10% 
10% 

Exam 
20080425 
20080425 
20080425 
20080425 

Code 
5237-5003 
5237-5003 
6100 
6260 

VA -  (2 Mos. Post-Separation)     
Condition 
DDD, Cervical Spine, Mild 
DDD at L4-S1, Mild…  
Bilateral  Sensorineural  Hearing 
Loss 
Tinnitus, Bilateral 
No VA Entry 

Service RPEB – Dated 20071206 
Condition 
Cervical Spine Strain 
Lumbosacral Strain 
Bilateral 
Hearing Loss 
Transient Hyperglycemia 
Breast 
Hypertrophy, 
Surgically  Treated,  with 
Breast 
Right 
Gynecomastia 
and 
Postoperative Pain 
Low  Testosterone  with 
Medical Replacement 
PTSD,  Chronic 
Not Unfitting 
MDD, Single Episode, Mild  Not Unfitting 
Mild 
Not Unfitting 
Asymptomatic 
No Additional MEB/PEB Entries 
Combined:  20% 
VARD 20080815 (most proximate to Date of Separation) 
  
 
 
ANALYSIS SUMMARY:   
 
Cervical Spine Strain Condition.  Although neck symptoms did not completely resolve after the 
motor vehicle accident in 2000, pain flared due to wear of gear in approximately 2006 while 
deployed.  Magnetic resonance imaging (MRI) revealed multilevel degenerative disc disease, a 
small central disc protrusion at C4-5 and moderate left neuroforaminal narrowing at C6-7.  The 
goniometric  range-of-motion  (ROM)  evaluations  in  evidence  which  the  Board  weighed  in 
arriving  at  its  rating  recommendation,  with  documentation  of  additional  ratable  criteria,  are 
summarized in the chart below. 
 

Erectile Dysfunction  Associated 
with Hypogonadism 
Hypogonadism 
PTSD 
No VA Entry 
Mild 
Headaches 
Other x 3 (NSC) 
Combined:  80% 

7522 
7914 
9434-9411 

20080425 
20080425 
20080425 

TBI,  with 

Reported 

8045 

0% 
0% 
70% 

10% 

20080425 
20080425 

 
 
 
RATING COMPARISON:   
 

Sensorineural 

Cervical ROM in degrees   NARSUM ~ 5 Mo. Pre-Sep 
Flexion 0-45 normal 
Extension 0-45 normal 
Combined 340 normal 
Comments 
4.71a Rating 

45 
45  
340 
+Painful motion 
10% 

VA C&P ~ 2 Mo. After Sep 
45 
45 
300 
 
10% 

 
At the orthopedic narrative summary (NARSUM) examination on 10 September 2007 (5 months 
prior to separation) the CI stated that his neck pain was “manageable” but that it prevented 
him from wearing gear or training.  The CI denied symptoms of upper extremity radiculopathy.  
Examination revealed normal curvature, no tenderness, normal muscle tone and normal upper 
extremity  neurologic  findings.    At  the  VA  Compensation  and  Pension  (C&P)  evaluation  on 
25 April 2008 (2 months after separation) the CI stated that his neck pain began as a result of an 
IED blast in 2006.  Examination showed a normal gait and spinal contour.  There was no spasm, 
guarding or painful motion.  Upper extremity strength reflexes and sensation was normal.  The 
Board directs attention to its rating recommendation based on the above evidence.  The PEB 

assigned a 10% rating under the 5237 code (lumbosacral or cervical strain) while the VA’s 10% 
rating was applied under the 5003 code (degenerative arthritis).  The Board noted that there 
was no loss of motion and  that the PEB’s approach was justified by the application of §4.59 
(Painful  motion).    There  was  no  avenue  to  a  rating  higher  than  10%  under  applicable  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 cervical spine strain condition.   
 
Lumbosacral Strain Condition.  The NARSUM notes that LBP began during pre-mobility exercises 
in 2006.  Symptoms flared due to wearing gear and riding vehicles over rough terrain, and were 
sometimes  associated  with  symptoms  of  right  lower  extremity  radiculopathy.    MRI  revealed 
multi-level DDD and spondylitic changes with mild bilateral neuro-foraminal narrowing.  An old 
anterior vertebral body compression fracture of T12 was identified.  Electromyography studies 
(EMG) were negative for radiculopathy.  The goniometric range-of-motion (ROM) evaluations in 
evidence  which  the  Board  weighed 
its  rating  recommendation,  with 
documentation of additional ratable criteria, are summarized in the chart below. 

in  arriving  at 

 

Thoracolumbar  ROM  in 
degrees 
Flexion (90 Normal) 
Ext (0-30) 
R Lat Flex (0-30) 
L Lat Flex 0-30) 
R Rotation (0-30) 
L Rotation (0-30) 
Combined (240) 
Comment 
§4.71a Rating 

Pain Clinic ~7.5 Mos. Pre-Sep 
40 
15 
-- 
-- 
20 
20 
NA 
+tenderness; +Rt SLR 
20% 

PT ~7 Mos. Pre-Sep 
20 20 20 (20) 
10 11 10 (10) 
20 18 20 (20) 
14 18 15 (15) 
15 10 8 (10) 
10 10 8 (10) 
85 
See narrative 
40% 

VA C&P ~ 2 Mos. After-Sep 
80 
30 
30 
30 
30 
30 
230 
Radiographic  degenerative 
changes 
10% 

 
During  ROM  testing  by  physical  therapy  on  23  July  2007  (7  months  prior  to  separation) 
“cogwheel rigidity” was present and ROM was difficult to assess due to rigid movements.  There 
was no muscle spasm.  Guarding was present which appeared to be responsible for an antalgic 
gait,  but  spinal  contour  was  normal.    Superficial  tenderness,  pain  with  axial  loading,  over-
reaction, pain with shoulder and hip rotation, and non-anatomical tenderness were all present.  
Neurologic exam was normal and straight leg raise test (SLR) was normal.  At the C&P exam, the 
CI reported constant, daily LBP that imposed no limitation to walking, but prevented running.  
He did not require an assistive device for ambulation.  Pain sometimes radiated down his right 
leg.  Examination revealed normal posture, gait and spinal curves.  Muscle tone was normal.  
Lower extremity strength and reflexes were normal.  There was no tenderness or loss of motion 
on repetition. 
 
The Board directs attention to its rating recommendation based on the above evidence.  The 
PEB assigned a 10% rating under an analogous 5237 code while the VA’s 10% rating was applied 
under the 5003 code.  A re-evaluation note in the service treatment record on 8 February 2008 
(a week prior to separation) indicated that the examination evidence of non-physiologic pain 
was not consistent with the ROM in evidence, and therefore not supportive of a higher rating 
based on limitation of motion.  In deliberating a rating recommendation based on the above 
evidence,  the  Board  noted  the  significant  difference  in  ROM  measurements  between  the 
service exams and the VA exam.  Due to the inconsistent examination findings on the service 
exams and the fact that the VA exam was more proximal to separation, the Board relied more 
heavily on the VA exam in its assignment of probative value.  Board members agreed that this 

justified  for  symptoms  suggestive  of  right 

  After  due  deliberation 

exam  did  not  support  a  rating  higher  than  the  PEB’s  10%.    The  Board  further  deliberated  if 
additional  disability  was 
lower  extremity 
radiculopathy.  The Board concluded that normal muscle strength and a normal EMG did not 
support the presence of functional impairment with a direct impact on fitness, and therefore 
concludes  that  additional  disability  was  not  justified  on  this  basis.    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 lumbar spine strain condition. 
Other Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s 
determination  that  transient  hyperglycemia,  low  testosterone,  mild  traumatic  brain  injury, 
PTSD and MDD, bilateral sensorineural hearing loss and breast hypertrophy with right breast 
postoperative  pain  were  not  unfitting. 
  The  Board’s  threshold  for  countering  fitness 
determinations is higher than the VASRD §4.3 (Resolution of reasonable doubt) standard used 
for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” 
standard.  The hyperglycemia, low testosterone, and mild TBI conditions were not profiled or 
implicated in the commander’s statement and were not judged to fail retention standards. 
 
Posttraumatic Stress Disorder and Major Depressive Disorder.  The CI had no prior history of 
psychiatric illness, but after return from deployment in October 2006 he developed symptoms 
of  depression  and  PTSD.    He  was  treated  with  two  psychotropic  medications  and  also 
completed  an  outpatient  post  deployment  group  therapy  process.    A  psychiatric  NARSUM 
addendum concluded that he suffered from mild PTSD with depression which would cause no 
impairment  in  his  MOS.    The  condition  was  profiled  S2,  was  not  judged  to  fail  retention 
standards and was not implicated in the commander’s statement. 
 
Hearing Loss.  A screening audiologic evaluation in October 2006 identified a bilateral mild to 
moderately severe high frequency hearing loss.  The CI also complained of constant bilateral 
tinnitus in quiet environments.  A Speech Recognition In Noise Test analysis recommended that 
he be retained in his current assignment with restrictions.  He was provided hearing aids and 
was assigned an H3 profile that restricted noise exposure without use of hearing protection, 
and prohibited duties that required acute hearing (point, sentry, scout etc.).  This condition was 
not judged to fail retention standards and was not implicated in the commander’s statement. 
 
Breast  Hypertrophy  Condition.    The  CI  underwent  a  bilateral  subcutaneous  mastectomy  for 
simple gynecomastia, left greater than right, in August 2006.  Within 6 months he complained 
that  breast  growth  had  returned,  especially  on  the  right  which  was  also  associated  with 
discomfort.  At a NARSUM addendum exam on 7 August 2007 (6 months prior to separation) 
the  CI  noted  that  any  touching  or  rubbing  of  clothing  over  the  right  breast  caused  pain.    A 
profile was written to allow the use of protective padding when wearing body armor.  At the VA 
exam the CI denied breast symptoms and examination findings were remarkable only for right 
sided enlargement.  This condition was not judged to fail retention standards. 
 
All  the  above  conditions  were  reviewed  by  the  action  officer  and  considered  by  the  Board.  
There  was  no  performance  based  evidence  from  the  record  that  any  of  these  conditions 
significantly 
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 any of the 
contended conditions and therefore, no additional disability ratings are recommended. 
 
 

interfered  with  satisfactory  duty  performance. 

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 cervical spine strain condition and IAW VASRD §4.71a, the 
Board  unanimously  recommends  no  change  in  the  PEB  adjudication.    In  the  matter  of  the 
lumbar spine strain condition and IAW VASRD §4.71a, the Board unanimously recommends no 
change in the PEB adjudication.  In the matter of the contended transient hyperglycemia, low 
testosterone,  mild  TBI,  PTSD  and  MDD,  bilateral  hearing  loss  and  breast  hypertrophy 
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, therefore, recommends that there be no recharacterization of 
the CI’s disability and separation determination, as follows:   
 

VASRD CODE  RATING 
5237 
5299-5237 
COMBINED 

10% 
10% 
20% 

UNFITTING CONDITION 
Cervical Spine Strain 
Lumbar Spine Strain 

 
 
The following documentary evidence was considered: 
 
Exhibit A.  DD Form 294, dated 20120601, w/atchs 
Exhibit B.  Service Treatment Record 
Exhibit C.  Department of Veterans’ Affairs Treatment Record 
 
 
 
 
 

 

 

XXXXXXXXXXXXXXXXXX, DAF 
Acting Director 
Physical Disability Board of Review 

 
 
 

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 XXXXXXXXXXXXXXXX, AR20130003824 (PD201200470) 
 
 
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 
 
 

     XXXXXXXXXXXXXXXXX 
     Deputy Assistant Secretary 
         (Army Review Boards)