RECORD OF PROCEEDINGS 

PHYSICAL DISABILITY BOARD OF REVIEW 

 

NAME: XXXXXXXXXXXXXXXX CASE: PD 13-00015 

BRANCH OF SERVICE: ARMY BOARD DATE: 20130503 

SEPARATION DATE: 20030723 

 

 

SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this 
covered individual (CI) was an active duty SGT/E-5 (11B, Infantry) medically separated for 
chronic neck pain. The CI injured his neck in March 2000, while riding in a military truck that lost 
contact with the road. Conservative measures, including physical therapy (PT), failed to relieve 
his pain. The neck condition 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 U3-H2 profile and referred for a Medical Evaluation Board (MEB). 
The neck condition, was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. 
Several other conditions, identified below, were also submitted by the MEB. The informal PEB 
adjudicated the chronic neck pain as unfitting, rated 10%, citing criteria of the Veterans’ 
Administration Schedule for Rating Disabilities (VASRD). The CI made no appeals, and was 
medically separated with a 10% Service disability rating. 

 

 

CI CONTENTION: “I feel that my cervical spine injury was rated low in an effort to prevent 
medical retirement. And my other injuries ignored completely as an injustice. I incurred several 
injuries and conditions that should have been considered and rated under the VASRD, and in 
accordance with Title I0, Section 1222, I repeatedly requested these conditions be included and 
rated, but was ignored and instructed to only focus on my cervical spine.” 

 

 

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 unfitting chronic neck pain condition meets the criteria prescribed in DoDI 
6040.44 for Board purview. The back pain, headaches, knee pain, ankle pain, hearing loss, and 
aortic insufficiency are likewise addressed below. Any conditions not requested in his 
application, or otherwise outside the Board’s defined scope of review, may be eligible for future 
consideration by the Army Board for Correction of Military Records. 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 


RATING COMPARISON: 

 

Service IPEB – Dated 20030401 

VA – (1 mo. Pre-Separation) 

Condition 

Code 

Rating 

Condition 

Code 

Rating 

Exam 

Chronic Neck Pain 

5299-5295 

10% 

Disc Disease of Cervical Spine, 
with Episodic Ulnar Radiculitis 
and Cervicogenic Cephalgia 

5290 

20% 

20030602 

Back Pain 

Not Unfitting 

Episodic Lumbosacral Strain 

5295 

0% 

20030602 

Headaches 

Not Unfitting 

No VA Entry for Headaches 

 

 

 

Bilateral Knee Pain 

Not Unfitting 

Bilateral Overuse Knees 

5024 

0% 

20039692 

Bilateral Ankle Pain 

Not Unfitting 

Ligamentous Laxity, Both Ankles 

5299-5271 

0% 

20030602 

Left Ear Hearing Loss 

Not Unfitting 

Bilateral Hearing Loss 

6100 

0% 

20030602 

Mild Aortic Insufficiency 

Not Unfitting 

Aortic Insufficiency 

7199-7110 

NSC 

20060602 

No Additional MEB/PEB Entries 

Other x 4 

20030602 

Combined: 10% 

Combined: 20% 



Derived from VA Rating Decision (VARD) dated 20030728(most proximate to date of separation) 

 

 

ANALYSIS SUMMARY: The Board acknowledges the CI’s assertion that certain improprieties 
may have occurred while the Army was processing his case. It is noted for the record that the 
Board has neither the jurisdiction nor authority to scrutinize or render opinions in regard to 
suspected Service improprieties. The Board’s role is confined to the review of medical records 
and all evidence at hand to assess the fairness of PEB fitness and rating determinations, based 
on severity at the time of separation. 

 

Chronic Neck Pain. In March 2000, the CI developed symptoms after a very rough truck ride. 
His symptoms included neck pain and headache, as well as numbness of the right hand and left 
shoulder. Magnetic resonance imaging (MRI) revealed cervical degenerative disc disease 
(DDD), with evidence of cervical spinal stenosis (CSS) and mild to moderate foraminal 
narrowing. He was treated with conservative measures, but had very little improvement. The 
CI was not a surgical candidate, and an MEB was initiated. His MEB clinical evaluation was at 
Madigan Army Medical Center on 7 February 2003. Physical examination (PE) revealed a heart 
murmur and alopecia (hair loss), but was otherwise unremarkable. On 27 February 2003, the CI 
was seen by Neurosurgery. The examiner stated, “The patient, at no time, has had evidence of 
radiculopathy.” PE showed intact deep tendon reflexes (DTRs), with no focal motor weakness 
in the extremities. Range of motion (ROM) testing showed that lateral turning was intact (60 
degrees), and neck flexion was 45 degrees. The diagnosis at that visit was “Chronic neck pain 
related to C5-C6 cervical disc protrusion.” 

 

On 2 June 2003, seven weeks prior to separation, the CI had a VA compensation and pension 
(C&P) exam. He reported daily neck pain which was aggravated by lifting heavy objects or 
prolonged standing. He also reported some loss of sensation and occasional weakness in the 
right upper extremity. PE revealed normal gait and normal spinal curvature. No muscle spasm 
was noted. There was mild tenderness to palpation of the cervical and mid-thoracic regions. 
Cervical ROM testing showed flexion of 50 degrees, extension 60 degrees, lateral bending 30 
degrees (left & right), and rotation 80 degrees (left & right). All motions produced mild 
discomfort in the cervical spine. Neurological exam was normal. The ROM evaluations which 
the Board weighed in arriving at its rating recommendation, are summarized in the chart below. 

 

 

 

 

 

 

 


Cervical ROM 

MEB ~ 5 mos. Pre-Sep 

(20030227) 

VA C&P ~ 2 mos. Pre-Sep 

(20030602) 

Flexion 

45° 

50° 

Extension 

(not noted) 

60° 

Right Lat. Flexion 

(not noted) 

30° 

Left Lat. Flexion 

(not noted) 

30° 

Right Rotation 

60° 

80° 

Left Rotation 

60° 

80° 



 

The Board carefully reviewed all evidentiary information available, and directs attention to its 
rating recommendation based on the above evidence. The PEB and the VA chose different 
coding and rating options for the chronic neck pain condition. The PEB coded it 5299-5295 
(analogous to lumbosacral strain) and rated it 10% for characteristic pain on motion. The VA 
used diagnostic code 5290 (limitation of cervical motion) and rated it 20% (moderate). The 
Veterans’ Administration Schedule for Rating Disabilities (VASRD) coding and rating standards 
for the spine, which were in effect at the time of the CI’s separation, were changed in 
September 2003. The older standards were based on the rater’s opinion regarding degree of 
severity, whereas current standards specify certain rating thresholds, with measured degrees of 
ROM impairment. IAW DoDI 6040.44, the Board must use the VASRD coding and rating 
standards which were in effect at the time of the CI’s separation from service. 

 

The June 2003 C&P exam was done just seven weeks prior to separation, and therefore carries 
significant probative value. At that exam, the CI had limited lateral flexion to the right and to 
the left. Based on the evidence in the treatment record, the Board unanimously agreed that 
the VASRD code which most closely aligns with limited cervical motion is 5290 (Spine, limitation 
of cervical motion). The Board also determined that the CI’s chronic neck pain condition was 
best described as “slight.” There was insufficient evidence in the treatment record to support 
classifying the chronic neck pain condition as “moderate” or “severe.” IAW VASRD §4.71a, the 
Board unanimously recommends a rating of 10% for the chronic neck pain condition. The 
Board tried to find a path to a higher rating using other codes which could be applied to the 
chronic neck pain condition. The other VASRD codes that were considered did not result in a 
higher rating, since the treatment record did not show evidence of a significantly disabling neck 
abnormality which would justify a rating higher than 10%. 

 

The Board also considered the matter of cervical radiculopathy. As noted above, The June 2003 
VA C&P exam was the exam most proximal to separation. On that evaluation, neurological 
exam was essentially normal. The CI’s radiculopathy symptoms were purely subjective. After 
reviewing all of the information in the treatment record, there was insufficient objective 
evidence of a clinically significant neuropathy that interfered with satisfactory performance of 
military duties. Therefore, the radiculopathy condition was not unfitting at the time of 
separation from service. After due deliberation, considering all of the evidence and mindful of 
VASRD §4.3 (reasonable doubt), the Board unanimously recommends a disability rating of 10% 
for the chronic neck pain condition. It is appropriately coded 5290, and IAW VASRD §4.71a, 
meets criteria for the 10% rating level. 

 

Other PEB Conditions. Back pain, headaches, bilateral knee pain, bilateral ankle pain, hearing 
loss, and aortic insuffiency were all adjudicated by the PEB as not unfitting and therefore not 
ratable. The Board’s main charge with regard to these conditions is to assess the fairness of the 
PEB’s fitness determination. 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. These other 
conditions were not profiled, implicated in the commander’s statement, or judged to fail 
retention standards. All were reviewed by the action officer and considered by the Board. 
There was no performance based evidence from the record that any of 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 any of these other conditions. 
Therefore, no additional disability ratings are 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. In the matter of the 
chronic neck pain condition and IAW VASRD §4.71a, the Board unanimously recommends a 
disability rating of 10% for the chronic neck pain condition. In the matter of the back pain, 
headaches, knee pain, ankle pain, hearing loss, and aortic insuffiency; the Board unanimously 
recommends no change in the PEB adjudication 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, effective as of the date of his prior medical separation: 

 

UNFITTING CONDITION 

VASRD CODE 

RATING 

Chronic neck pain, and slightly reduced range of motion 

5290 

10% 

COMBINED 

10% 



 

 

 

The following documentary evidence was considered: 

 

Exhibit A. DD Form 294, dated 20130105, 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 xxxxxxxxxxxxxxxxxxxxxxxx, AR20130011069 (PD201300015) 

 

 

1. 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 to modify the individual’s disability description without modification of the 
combined rating or recharacterization of the individual’s separation. This decision is final. 

 

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. 

 

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 xxxxxxxxxxxxxxxxxxxxxxx 

 Deputy Assistant Secretary 

 (Army Review Boards)