RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2013-02564
BRANCH OF SERVICE:  AIR FORCE 	BOARD DATE:  20141223
SEPARATION DATE:  20050927

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an activated reservist E-5 (Supply Management) medically separated for fibromyalgia.  The condition could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty (MOS) or satisfy physical fitness standards.  She was issued a U4 profile and referred for a Medical Evaluation Board (MEB).  The condition, characterized as “,” was the only condition forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The informal PEB adjudicated chronic left shoulder pain as unfitting, rated 10%, citing criteria of the Veteran’s Affairs Schedule for Rating Disabilities (VASRD).  The PEB further adjudicated “possible fibromyalgia, existed prior to service (EPTS) without service aggravation” as a Category II condition.  The CI appealed to the Formal PEB (FPEB), which changed the chronic left shoulder pain condition to fibromyalgia, rated at 20%, stating that it was EPTS, but was aggravated during military service.  The CI was then medically separated.

CI CONTENTION:  The CI makes no contentions but states that she meets the eligibility criteria for review by the PDBR.  Her complete submission is at Exhibit A.

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 when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting.  Any conditions outside the Board’s defined scope of review and any contention not requested in this application may remain eligible for future consideration by the Board for Correction of Military/Naval Records.  Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards to the unfitting medical condition at the time of separation.  The Board has neither the role nor the authority to compensate for post-separation progression or complications of service-connected conditions.  That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws.  The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation. 

RATING COMPARISON:

Service FPEB – Dated 20050824 | VA - (6 Mos. Post-Separation)
Condition | Code | Rating | Condition | Code | Rating | Exam
Fibromyalgia (L shoulder pain per MEB/IPEB) | 5025 | 20% | Fibromyalgia, to Include L/Shoulder Bursitis and Groin Pain | 5019-5025 | 20% | 20060322
Other x 0 (Not in Scope) | Mood and Adjustment Disorder with Depression a/w Fibromyalgia | 9435 | 30% | 20060126
| (Cervical) Mild Anterior Compression  with Paresthesia L Upper Arm | 5237-8510 | 20% | 20060322
| L Knee, Mild Degenerative Changes | 5010 | 10% | 20060322
| R Knee, Mild Degenerative Changes | 5010 | 10% | 20060322
| Other x 1 | 20060322
Combined:  20% | Combined:  70%
Derived from VA Rating Decision (VARD) dated 20061114 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:  Fibromyalgia (fibrositis, primary fibromyalgia syndrome) rating criteria include "widespread musculoskeletal pain and tender points, with or without associated fatigue, sleep disturbance, stiffness, paresthesias, headache, irritable bowel symptoms, depression, anxiety, or Raynaud’s-like symptoms."  Therefore, the CI’s other symptoms potentially related to fibromyalgia are discussed below with attention to the ratable criteria of episodes of exacerbations, symptom severity and response to therapy.

Fibromyalgia Condition.  The CI injured her left shoulder and chest in 2003.  Conservative therapy including electrical stimulator did not resolve her left shoulder tendonitis pain or left arm numbness and tingling.  Imaging of the cervical spine (MRI and X-rays for referred neck/arm symptoms) was normal.  Specialty evaluations led to rheumatologist-diagnosed fibromyalgia and sero-negative inflammatory arthritis.  The narrative summary, 5 months prior to separation, documented symptoms of chronic left shoulder pain, diffuse arthralgias (joint pains), myalgias (muscle pains), insomnia and fatigue secondary to pain.  The exam indicated “Decreased range of motion of left shoulder is noted.  No active synovitis noted.”  The exam was otherwise normal.  Medications included Elavil at night and a daily non-steroidal anti-inflammatory medication.  

Pain management clinic notes, 3 months prior to separation indicated daily use of an opioid medication (Darvocet) and a muscle relaxant.  MRI of the shoulder was reported as normal and history included the CI “describes some good days and bad days.  She continues to work eight hours per day at the Base. … Overall anesthetic modalities and medications do provide benefit to a certain extent allowing her to function with her usual daily activities of living and job duties.”  Left shoulder range of motion was “improved to about 130 degrees eliciting pulling sensation in the neck as well as on the right shoulder” [a prior note indicated 120 degrees “eliciting shoulder and neck pain” (normal 180 degrees; opposite side to 130 degrees)] and the diagnosis was “Myofascial pain syndrome versus fibromyalgia.”

The FPEB remarks indicated that “(the CI) suffers from episodic exacerbations of pain throughout her body although the pain is more severe in her neck and left upper extremity.  The member testified to having ‘good and bad days.’  She is able to work on a daily basis, ranging from 3 hours on a bad day and 7.5 hours on a good day.”

At the VA Compensation and Pension (C&P) exams performed 6 months after separation, the CI reported left arm numbness with flares four times a month, left shoulder pain with daily flares of pain to 7/10, left arm paresthesias (abnormal sensations), neck pain with spasms with flares two times a month, back pain, chest pain, bilateral knee pain, and groin and abdominal pain.  There were no incapacitating episodes and the CI lost no time from work.  Exams documented normal left arm, left shoulder, bilateral knee, and neck exams with full painless ranges of motion ROM.  Left shoulder X-rays was read as “no definite abnormality noted,” cervical X-rays documented mild compression and mild spondylosis, and knee x-rays documented mild degenerative changes.  The CI also underwent a VA C&P exam for Mental Disorders and was diagnosed with AXIS I “Mood disorder due to medical condition” with a Global Assessment of Functioning (GAF) in the moderate symptom range.  Exam documented symptoms of depression, sleep impairment, isolation and avoidance.  Mental status exam was otherwise normal.  The CI was working full-time with a history of losing her first post-separation job due to physical limitations.

The Board directed attention to its rating recommendation based on the above evidence.  Both the FPEB and VA rated the CI’s fibromyalgia and shoulder condition together using criteria of code 5025 (fibromyalgia), with the VA adding an analogous code of 5019 (bursitis) to indicate the left shoulder.  The Board first considered if the left shoulder, left arm/neck, bilateral knees, and/or mental disorder conditions could be separated from the fibromyalgia condition and separately rated.  Given that any condition that might be separately ratable would have to avoid pyramiding IAW VASRD $4.14, and more significantly meet the DoD threshold of being separately unfitting at the time of separation, the Board adjudged that in consideration of the preponderance of the evidence, there was no additionally ratable condition aside from the fibromyalgia condition.

The Board adjudged that the VA increase in combined ratings over 6 years remote from the date of separation was post-separation worsening and not indicative of the CI’s disability condition at the time of separation.  The Board next deliberated on the fibromyalgia rating level at the date of separation.  Discussions focused on the highest available 40% criteria (symptoms “that are constant, or nearly so, and refractory to therapy") versus the 20% criteria (symptoms that are “episodic, with exacerbations often precipitated by environmental or emotional stress or by overexertion, but that are present more than one-third of the time”).  The record indicated that proximate to separation the CI was responsive to therapy, and was able to work with good days and bad days (episodic) due to fibromyalgia symptoms.

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 fibromyalgia 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.  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 fibromyalgia condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the FPEB 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.

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20131202, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

			
		XXXXXXXXXXXXXXX
		President
		DoD Physical Disability Board of Review

SAF/MRB
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD 20762

Dear XXXXXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Title 10 U.S.C. § 1554a), PDBR Case Number PD-2013-02564.

	After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was appropriate.  Accordingly, the Board recommended no re-characterization or modification of your separation.

	I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding and their conclusion that re-characterization of your separation is not warranted.  Accordingly, I accept their recommendation that your application be denied.

Sincerely,

XXXXXXXXXXXXXXX
Director
Air Force Review Boards Agency

Attachment:
Record of Proceedings

PD-2013-02564