RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW NAME: XXXXXXXXXXXXXXXXXX BRANCH OF SERVICE: ARMY CASE NUMBER: PD1201662 SEPARATION DATE: 20061222 BOARD DATE: 20130312 SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SPC/E-4 (14T10/Patriot System Repairer) medically separated for chronic musculoskeletal pain. The CI injured her left hamstring in August 2003 and subsequently experienced left knee pain. She also developed multiple areas of myofascial pain that was treated with physical therapy (PT), non-operative pain management strategies and mental health counseling. She 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 L4 profile and referred for a Medical Evaluation Board (MEB). Abnormal non-physiologic gait with antalgic-like component and chronic pain syndrome were forwarded to the Informal Physical Evaluation Board (IPEB) as medically unacceptable IAW AR 40-501. Psychological factors affecting a general medical condition (meralgia paresthetica) and dysthymic disorder conditions, identified in the rating chart below, were identified and forwarded by the MEB as medically acceptable. The IPEB combined the two medically unacceptable conditions into one condition designated as chronic musculoskeletal pain and adjudicated it with specified application of the US Army Physical Disability Agency (USAPDA) pain policy and rated at 0%. The remaining conditions were determined to be not unfitting. The CI appealed to the Formal PEB (FPEB), which affirmed the IPEB findings, and she was medically separated with a 0% disability rating. CI CONTENTION: “My condition was grouped into a catch-all and rated 0% despite being medically distinct and debilitating. The VASRD, not then [sic] (continued) this is a chronic condition that in my present state can only be maintained, rather then [sic] meaningfully improved, with intensive and ongoing physical therapy. Shortly after being discharged I was diagnosed with fibromyalgia and RSD/CRPS. The attached memorandum explains why I feel my PEB was flawed and needs to be reevaluated. The VA and SSA have declared me disabled at 60% full respectively.” The CI attached a two-page statement (to the USAPDA) to her application that was reviewed by the Board and considered in its recommendations. 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 contended psychological factors affecting a general medical condition-meralgia paresthetica and dysthymic disorder are considered by the Board only with regard to rating the unfitting conditions and are otherwise outside the scope of the Board. The unfitting abnormal non- physiologic gait with antalgic-like component and chronic musculoskeletal pain condition meets the criteria prescribed in DoDI 6040.44 for Board purview and is accordingly addressed below. Any condition 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 20060830 VA (5 Mos. Post-Separation) – Effective Date 20061223 Condition Code Rating Condition Code Rating Exam Abnormal Non-Physiologic Gait with Antalgic-Like Component 5099-5003 0% Fibromyalgia 5025 40% 20070522 Chronic Musculoskeletal Pain Psychological Factors Affecting a General Medical Condition-Meralgia Paresthetica Not Unfitting Dysthymic Disorder Not Unfitting Dysthymic Disorder 9433 30% 20070514 No Additional MEB/PEB Entries 0% x1 / Not Service-Connected x2 20070522 Combined: 0% Combined: 60% ANALYSIS SUMMARY: The Board acknowledges the sentiment expressed in the CI’s application regarding the significant impairment with which her service-incurred condition continues to burden her. The Board wishes to clarify that it is subject to the same laws for service disability entitlements as those under which the Disability Evaluation System (DES) operates. The DES has neither the role nor the authority to compensate members for anticipated future severity or potential complications of conditions resulting in medical separation. That role and authority is granted by Congress to the Department of Veterans Affairs (DVA), operating under a different set of laws (Title 38, United States Code). The Board evaluates DVA evidence proximal to separation in arriving at its recommendations, but its authority resides in evaluating the fairness of DES fitness decisions and rating determinations for disability at the time of separation. 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. The DVA, however, is empowered to compensate service-connected conditions and to periodically re-evaluate said conditions for the purpose of adjusting the Veteran’s disability rating should the degree of impairment vary over time. Chronic Musculoskeletal Pain: The narrative summary (NARSUM) prepared 11 months prior to separation noted that the CI suffered an injury to her left hamstring, then developed left knee pain knee during her initial training. She had a constant, dull 6/10 non-radiating left knee pain treated with temporary profiles, crutches, long leg cast and physical therapy (PT) after cast removal for most of a 16 month period. She passed an alternate physical fitness test (walk) and completed advanced individual training (AIT). At her next duty station, when the same knee symptoms returned, she was placed back on crutches, prescribed a knee brace and began pool therapy. She was evaluated by orthopedics where no specific diagnosis was given and after a bone scan revealed activity in the left knee, she was referred to rheumatology where a presumptive diagnosis of fibromyalgia was made. In addition to the above, she complained of an 18-month history of diffuse aches and pains most prominent at the shoulders and hips (groins and greater trochanter areas) and that cold and rain increased her symptoms. Her sleep was poor and restless with constant search of a comfortable position and she woke up tired and stayed tired all day. She was off medications at the time due to pregnancy. She was sent for a gait evaluation and subsequently was seen regularly at PT and behavioral health. Physical examination revealed a blunted affect, guarded en-block movements and ambulation with full left knee brace and crutches and aided by husband. The CI’s stance and gait were evaluated with and without the knee brace. The changes in her stance were all reversible when asked to put full weight on both legs. Her gait was abnormal with and without the brace. There were numerous trigger points of her right and left side and upper and lower body. (This was not confirmed after review of the file.) No laboratory or radiographic data was available. Present condition and prognosis was that the CI's condition was disabling and her prognosis for unhindered return to the duties of an active duty Soldier was poor. Functionally speaking, she was hampered by insufficient coping skills to allow her to become fully independent. Her diagnoses were abnormal non-physiologic gait with antalgic-like component and chronic pain syndrome (with abnormal illness behavior) with trigger and tender points suggestive of tension myalgia. At the MEB exam accomplished 10 months prior to separation, the CI reported pain in knee, hips, shoulder, back and chest that had impaired the use of her appendages. Her left knee swelled, cracked, locked popped and had a grinding sensation. She used a knee brace from May 2004 to October 2005 and crutches since January 2004. She had a stress fracture in left tibial plateau and stress reaction in hips. The MEB physical exam revealed tenderness to palpation of the left knee, both hips and lumbar area. At the VA Compensation and Pension (C&P) exam performed 5 months after separation, the CI reported a history similar to the one above with the following significant additions. Many diagnoses were proposed: Lyme disease, malingering with psychosomatic illness and fibromyalgia. The CI reported having flare-ups when she could not walk at all that occurred once or twice a week, lasted for four to five hours and were usually triggered by the weather or increased activity. She would require help bathing, dressing and toileting on “bad days.” She did no exercise and she rarely drove because of the overall pain. The physical exam was significant for the fact that the CI arrived for her exam on crutches, with a severely antalgic gait. It took her three times the normal walking time to make her way down the hall to the exam room. She had difficulty standing on the scales without using her crutches. She needed help undoing the button on her pants. She had difficulty getting on the exam table and had to use crutches to boost herself up onto the table. She was obviously in pain, straining and grimacing with even simple tasks. Her appendicular skeleton, spine and associated musculature revealed no strength deficits and normal range-of-motion (ROM) was found at all joints, with the following exceptions: she had exquisite tenderness with the lightest palpation of her left leg, especially the knee, and of the back. She could barely stand to be touched and flinched and tried to avoid examination for fear of causing pain. There were no incapacitating episodes noted within 12 months of the exam. Review of the service treatment records revealed the following significant item. The CI was evaluated by rheumatology and physical medicine specialist on multiple occasions with an evaluation performed nine months prior to separation. All evaluations concluded that the CI did not meet the American College of Rheumatology (ACR) criteria for fibromyalgia. The Board directs attention to its rating recommendation based on the above evidence. The FPEB adjudicated the CI’s medically unacceptable MEB conditions as chronic musculoskeletal pain and rated it 0% disabling for minimal and frequent pain specifically citing the USADPA pain policy. The MEB condition abnormal non-physiologic gait with antalgic-like component is not diagnosis, but is a description of the functional result of one or more conditions. The VA applied Veterans Affairs Schedule for Rating Disabilities (VASRD) code 5025, fibromyalgia, and rated it 40% based on the presence of widespread musculoskeletal pain and tender points with symptoms that were constant and refractory to therapy. Prior to separation, two specialists specifically documented that the CI did not meet ACR criteria for fibromyalgia with only seven of 18 painful points present and with the most recent evaluation being nine months prior to separation. The FPEB DA 199 specifically stated, “The soldier does not have fibromyalgia.” The VARD written 7 months after separation noted 11 of 18 tender trigger points and this most likely represented post-separation worsening of the CI’s condition. A coding and rating scheme that would account for the majority of the CI’s pre-separation complaints utilizes VASRD code 6354, chronic fatigue syndrome (CFS). It is noteworthy that data contained in both the core DES file and the C&P exam support the use of CFS for rating this CI’s disability. Analogous ratings are allowed IAW §4.20 when an unlisted condition is encountered it will be permissible to rate under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. The CI manifested 5 of 6 required and 10 possible VASRD criteria for the diagnosis of CFS IAW §4.88a. Service treatment records (STR) document that she manifested generalized muscle aches or weakness, fatigue after exercise, migratory joint pains, neuropsychological symptoms and sleep disturbance. Manifesting six of the ten criteria fully meets the VASRD standard for the diagnosis of CFS; therefore, the CI’s disability picture is closely analogous to the VASRD criteria for CFS. Rating CFS is based on the consistency of the fatigue, the impact on daily activity or the duration of incapacitation if present. The CI’s symptoms were nearly constant and restricted her daily activities by less than 25 percent of the pre-illness level as evidenced by her ability to achieve “outstanding results” while performing as orderly room clerk for her unit. She experienced no periods of incapacitation within the 12-month period prior to the C&P exam. This meets the 20% disability level. The next higher 40% disability level requires restriction in routine daily activities to 50 to 75 percent of the pre-illness level, or symptoms that wax and wane with periods of incapacitation of at least four but less than 6 weeks total duration per year. The Board also considered an alternative rating scheme for this condition that identified the left knee pain and left hip pain as separately unfitting with each joint rated 10% for painful motion IAW §4.59 as both joints had non-compensable ROM measurements. Each of these joints had documented injuries as the cause of their impairment. However, using this alternative rating scheme would not account for the additional painful areas encompassed by the PEB’s combined adjudication. These painful areas, left shoulder, back, right hip and right knee pain, were documented in the STR and after review and extensive deliberation; Board consensus was that none were separately unfitting. Additionally, these painful areas did not have any underlying pathologic process or injury as the basis for the joint pain other than that caused by the CFS. Application of this alternative coding and rating scheme would similarly result in a combined 20% disability rating that confers no benefit to the CI and does not accurately reflect the CI’s total disability picture. 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 chronic musculoskeletal pain condition coded analogously to CFS. 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 abnormal non-physiologic gait with antalgic-like component and chronic musculoskeletal pain left shoulder, hip and back was operant in this case and the condition was adjudicated independently of that policy by the Board. In the matter of the chronic musculoskeletal pain condition, the Board unanimously recommends a disability rating of 20%, coded analogously as 6399-6354 IAW VASRD §4.88a. 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 her prior medical separation: UNFITTING CONDITION VASRD CODE RATING Chronic Musculoskeletal Pain 6399-6354 20% COMBINED 20% The following documentary evidence was considered: Exhibit A. DD Form 294, dated 20120917, w/atchs Exhibit B. Service Treatment Record Exhibit C. Department of Veterans’ Affairs Treatment Record xxxxxxxxxxxxxxxxxxxxxxx, DAF Acting Director Physical Disability Board of Review SFMR-RB MEMORANDUM FOR Commander, US Army Physical Disability Agency (TAPD-ZB / xxxxxxxxxxxxxx), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557 SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for xxxxxxxxxxxxxxxxxxxxxxxxxxx, AR20130006853 (PD201201662) 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 rating to 20% without 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 xxxxxxxxxxxxxxxxxxxxx Deputy Assistant Secretary (Army Review Boards)