RECORD OF PROCEEDINGS 

PHYSICAL DISABILITY BOARD OF REVIEW 

 

NAME: XXXXXXXXXXXXXXXXXXXXX BRANCH OF SERVICE: ARMY 

CASE NUMBER: PD1201211 SEPARATION DATE: 20030303 

BOARD DATE: 20130315 

 

 

SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this 
covered individual (CI) was an active duty SPC/E-4 (11B/Infantry) medically separated for 
fibromyalgia (FMA), incorporating a bilateral knee condition. He developed knee pain in 1998; 
and, over time developed pain in multiple joints, along with fatigue and other constitutional 
symptoms. He was subsequently diagnosed with FMA, but carried a separate diagnosis of 
retropatellar pain syndrome (RPPS) involving both knees. The multiple joint pains and 
associated symptoms did not respond adequately to treatment to permit continued 
performance within his Military Occupational Specialty (MOS). He was issued permanent P3 
and L3 profiles, and referred for a Medical Evaluation Board (MEB). FMA and “bilateral knees: 
RPPS” were forwarded to the Informal Physical Evaluation Board (IPEB) as separate medically 
unacceptable conditions IAW AR 40-50. The MEB also identified and forwarded a hay fever 
condition, judged to meet retention standards. The IPEB adjudicated the FMA and knee 
diagnoses as a single unfitting condition, rated 20%, citing specific criteria of the Veterans 
Affairs Schedule for Rating Disabilities (VASRD). In its rationale for subsuming the knee 
condition, the PEB’s DA Form 199 stated, “Retropatellar pain syndrome is included in this rating 
in that it cannot be separately rated (pyramiding).” The hay fever condition was determined to 
be not unfitting. The CI withdrew an initial request for a Formal PEB (FPEB), and was medically 
separated with a 20% disability rating. 

 

 

CI CONTENTION: “I have Fibromyalgia and RPPS. The PEB decided I was unfit to continue in the 
military with a disability rating of 20%. Code 5025 of the VASRD states: ... [proceeds with the 
code and 20%/40% rating descriptions]. These problems are absolutely constant and have 
been so for the last 12 years. The last year or so I was in the army, my NCOIC's did not require 
me to report to sick call every day because they understood the conditions ... [elaborates the 
futility of constantly seeking medical treatment for FMA while in service]. The PEB told me that 
the last year medical records indicated that it was a part time problem. I can see how it may 
have looked this way at the time but it is still and has always been constant. The pain and 
fatigue are absolutely exacerbated with too much physical activity but are always present. I 
received a 40% disability rating from the Department of Veterans Affairs the day after I was 
released from the Army.” 

 

 

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. The rating for the unfitting FMA condition is 
addressed below. The bilateral knee condition was separately identified by the PEB, although 
subsumed in the FMA rating; and, is thus within the DoDI 6040.44 defined purview of the 
Board. 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 respective 
Board for Correction of Military Records. 

 

 


RATING COMPARISON: 

 

Service IPEB – Dated 20021126 

VA (2 Wks. Pre-Separation) 

Condition 

Code 

Rating 

Condition 

Code 

Rating 

Exam 

Fibromyalgia 

(Subsuming Bilateral Knee RPPS) 

5025 

20% 

Fibromyalgia 

5025 

40% 

20030221 

RPPS, Right Knee 

5099-5260 

0% 

20030221 

RPPS, Left Knee 

5099-5260 

0% 

20030221 

Hay Fever 

Not Unfitting 

No VA Entry 

20030221 

Combined: 20% 

Combined: 40% 



Derived from VA Rating Decision (VARD) dated 20030407 (most proximate to date of separation [DOS]). 

 

 

ANALYSIS SUMMARY: In order to provide the appropriate recommendations in this case, the 
Board must first determine whether the bilateral knee condition merits separate rating; since, 
the rating recommendation for FMA must consider whether or not the knee disability is 
incorporated. The members thus turned first to the knee condition(s) to make the following 
determinations: whether the PEB’s consolidated rating was justified IAW VASRD §4.14 
(Avoidance of pyramiding); if not, whether the knee condition was separately unfitting (vs. a 
component of unfitness due to overall effect); and, if so, what rating (or separate ratings) was 
fairly recommended. The evidence and analysis for these determinations follow. 

 

Bilateral Knee Condition. Bilateral knee pain emerged as the initial sole symptom in this case, 
dating to an assignment to Korea in 1998. There are no entries in the available service 
treatment record (STR) until a bilateral knee X-ray report (normal findings) of November 2000, 
without an attendant treatment note. The narrative summary (NARSUM) conveys the CI’s 
history that he was treated with an anti-inflammatory and temporarily profiled at this juncture. 
The earliest STR entry for knee pain is from July 2001; and, notes “bilateral knee pain with 
activity for past 3 years.” Physical findings at that juncture were tenderness and “mild 
swelling,” with no instability or other abnormality. There are five STR entries between then and 
separation addressing knee pain as an isolated complaint; with a diagnosis of bilateral RPPS by 
an orthopedic consultant in September 2001, and a final entry in August 2002 (7 months prior 
to separation) noting a suspected “meniscal injury.” Neither the NARSUM, nor the orthopedic 
addendum, clarified the functional limitations of the knee condition apart from the general 
limitations due to FMA. The commander’s statement noted knee, wrist, elbow, and shoulder 
pain, along with FMA; and, no breakdown of limitations by condition was elaborated. The final 
permanent profile specified FMA and “knee pain” for the P3/L3 restrictions. Regarding physical 
findings, the NARSUM and addendum noted bilateral knee tenderness; but, there was no 
effusion, no signs of cartilage impingement, and no ligamental laxity to stress maneuvers in all 
planes. At the VA Compensation and Pension (C&P) evaluation on the eve of separation, the CI 
reported knee stiffness and pain exacerbated by jogging and negotiating stairs. The VA exam 
noted crepitus and tenderness, without signs of cartilage impingement or ligamental laxity. 
None of the exams (NARSUM, orthopedic addendum, VA C&P) specified painful motion. Range-
of-motion (ROM) evidence was 138 degrees flexion (normal 140 degrees) bilaterally for the 
NARSUM; “full” bilaterally in the addendum; and, “normal” bilaterally in the C&P exam. 
Extension was normal (0°) by all examiners. 

 

Based on the above evidence, the Board first considered if the bilateral knee condition was 
appropriately combined with the FMA disability rating by the PEB, under the rationale that this 
would violate VASRD §4.14 (Avoidance of pyramiding). The relevant provisions of §4.14 are, 
“The evaluation of the same disability under various diagnoses is to be avoided. Disability from 
injuries to the muscles, nerves, and joints of an extremity may overlap to a great extent ... and 
the evaluation of the same manifestation under different diagnoses are to be avoided.” The 
general rating description for FMA under 5025 specifies, “With widespread musculoskeletal 
pain and tender points, with or without ... [listing a host of non-orthopedic manifestations not 


relevant in this context].” The members agreed that wide spread musculoskeletal pain would 
encompass knee pain; and, that the knee pain from RRPS and FMA would logically constitute 
‘the same manifestation under different diagnoses. The PEB’s conclusion that separate knee 
rating would violate §4.14 was, therefore, not unreasonable. Members further agreed that, 
although there was distinct knee pathology that would probably be incompatible with an 
infantry MOS; the normal ROMs and lack of documented painful motion, especially given that 
the baseline pain cannot be extricated from the FMA rating, would leave no VASRD §4.71a basis 
for a compensable rating (as per the VA decision). After considerable deliberation, considering 
all of the evidence and mindful of VASRD §4.3 (Resolution of reasonable doubt), the Board 
determined that the PEB appropriately adhered to VASRD §4.14 in its consolidation of the 
bilateral knee condition under a single disability rating for FMA. 

 

Fibromyalgia Condition. The first entry in the STR for joint complaints other than the knees was 
in September 2001, when the CI received a temporary P4 profile for “osteoarthritis.” Clinical 
details are lacking, although multiple normal X-ray reports of various joints are in evidence. An 
entry in November 2001 (17 months prior to separation) noted wrist, hand and shoulder 
involvement in addition to the knees; making a diagnosis of “arthralgias, rule-out fibromyalgia,” 
and initiating treatment with amitryptyline. Over the following year there were three visits for 
routine follow-up and profile updates. An April 2002 entry noted that he was “sleeping well” 
and that his overall condition was “stable.” None of the STR entries characterize the symptoms 
as either constant or intermittent, although it is clear that they were correlated with more 
strenuous activities required of the MOS. A formal diagnosis of FMA was not made until a 
rheumatology consultation of October 2002 (5 months prior to separation). This documented 
“pain in a number of locations including his elbows, knees, arms, legs, neck, and upper and 
lower back.” It noted past treatment with various anti-inflammatories, none of which 
“afforded him much in the way of relief;” and, noted that the amitryptyline was helping with 
sleep “to a certain extent.” Diagnostic FMA tender points were documented by exam. There 
are no STR entries for FMA after this consult, other than the NARSUM prepared a month later. 
A relevant section of the NARSUM is excerpted below. 

His current status is that he is unable to walk more than two miles without increased pain and 
cannot sit at his computer for more than one hour without increased pain. He rides his bicycle 
15 to 20 minutes at a time three times a week for fitness. He has pain with push-ups and sit-ups, 
with kneeling, squatting and crawling and has poor sleep. These symptoms continue despite 
treatment with medications. 

The NARSUM physical exam noted various symmetric tender points of trunk and extremity 
muscle groups. Normal lumbar spine ROM measurements were provided. At the C&P 
evaluation on the eve of separation, the CI reported continued pain “involving primarily the 
elbows, wrists, and knees.” He complained of fatigue and sleep disturbance; and, the examiner 
noted prior improvement with amitryptyline, but added “he now reports that sleep is not 
good.” A relevant section of the pre-separation VA C&P evaluation is excerpted below. 

The patient reports that he has an increase in his symptoms about each week. He will have 
significant increase in his symptoms with stiffness, soreness, pain and poor sleep and will have to 
take one to two days off each week. The patient reports that he tries to exercise by riding a 
bicycle outside for about 20 minutes two to three days a week. He is unable to run or jog or do 
much other type of exercise since it increases his symptoms. 

 

The Board directs attention to its rating recommendation based on the above evidence. The 
PEB’s DA Form 199 paraphrased the 20% rating criteria under 5025; i.e., 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 40% criteria, which 
the VA determined were met, are for symptoms “that are constant, or nearly so, and refractory 
to therapy.” Although a presumption may be drawn from the evidence that there was a 
constant baseline of symptoms; the Service evidence depicts pain cycles mediated by activities, 


and the VA evidence depicts weekly flares. It is also noted that there was a longstanding period 
of improvement with treatment until the final evaluations; and, the Board must always weigh 
the probative value of subjective evidence in the context of evaluations directed at disability 
compensation. The Board’s rating recommendation must further consider the overall 
functional disability in evidence, and the clinical acuity reflected in treatment records. 
Members agreed that, although there were intermittent exacerbations and flare-ups of 
symptoms, they were most reasonably characterized as constant; especially considering that 
the subsumed knee pain was most likely continuous. It was further agreed that whether the 
nocturnal symptoms responded favorably to treatment on a temporary or sustained basis, it is 
clear that the baseline daily pain symptoms were most reasonably characterized as refractory. 
After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (Resolution of 
reasonable doubt), the Board recommends a disability rating of 40% for the FMA 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 discussed bilateral knee condition, the Board unanimously 
agreed that a separate disability rating is incompatible with VASRD §4.14. In the matter of the 
FMA condition, the Board unanimously recommends a disability rating of 40%, coded 5025, 
IAW VASRD §4.71a. 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 his prior medical separation: 

 

UNFITTING CONDITION 

VASRD CODE 

RATING 

 Fibromyalgia (Including Bilateral Retropatellar Pain Syndrome) 

5025 

40% 

COMBINED 

40% 



 

 

The following documentary evidence was considered: 

 

Exhibit A. DD Form 294, dated 20120716, w/atchs 

Exhibit B. Service Treatment Record 

Exhibit C. Department of Veterans’ Affairs Treatment Record 

 

 

 

 

 XXXXXXXXXXXXXXXXXXXXXXXX, DAF 

 Acting Director 

 Physical Disability Board of Review 


SFMR-RB 


 

 

MEMORANDUM FOR Commander, US Army Physical Disability Agency 

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

 

 

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation 

for xxxxxxxxxxxxxxxxxxxxxx, AR20130007836 (PD201201211) 

 

 

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 40% 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 
40% 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 xxxxxxxxxxxxxxxxxxxxxxxxx 

 Deputy Assistant Secretary 

 (Army Review Boards)