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AF | PDBR | CY2013 | PD-2013-02284
Original file (PD-2013-02284.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXXXX       CASE: PD-2013-02284
BRANCH OF SERVICE: Army          BOARD DATE: 20150618
SEPARATION DATE: 20040720


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Aircraft Power Plant Repairer) medically separated for fibromyalgia. The 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 P3U3L3 profile and referred for a Medical Evaluation Board (MEB). The “fibromyalgia” and “cervical spine DDD (degenerative disk disease)” conditions were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. The MEB also identified and forwarded five other conditions (shin splints, RPPS [retropatellar pain syndrome], shoulder impingement, low back pain and hemorrhoids) as meeting retention standards, for PEB adjudication. The Informal PEB combined the two conditions adjudicated as “fibromyalgia” as unfitting, rated 20% with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD). The remaining conditions were determined to be not unfitting and therefore not rated. The CI made no appeals and was medically separated.


CI CONTENTION: “At the time I was permanently separated from military service by reason of disability, I was not otherwise eligible for retirement from my military service”.


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 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 :

IPEB – Dated 20040326
 VA* - (~1 Mo. Pre-Separation)
Condition
 Code Rating Condition Code Rating Exam
Fibromyalgia (includes Cervical DDD) 5025 20% Fibromyalgia 5025 20% 20040614
Cervical Spine Degenerative Disc Disease 5243 20% 20040614
Other MEB/PEB Conditions x 5 (Not In Scope)
 Other x 11
RATING: 20%
 RATING: 60%
* Derived from VA Rating Decision (VA RD ) dated 200 50113 (most proximate to date of separation ( DOS ) ) .
ANALYSIS SUMMARY: The Army PEB combined fibromyalgia (FM) and cervical DDD, into a single unfitting condition. These bundled unfitting conditions were coded 5025 and rated at 20%. The PEB acknowledged that the condition of DDD had a role in the CI’s neck pain; however, opined that the condition of fibromyalgia also contributed to his neck pain and therefore, could not be separately rated due to 4.14. In contrast, the VA rated the FM and cervical DDD separately. The Board evaluated whether or not it was appropriate for the FM and cervical DDD conditions to be “bundled” together. If the Board judges that two or more conditions are reasonably justified as separately unfitting, then each separate condition must be rated IAW the VASRD §4.71a.

Fibromyalgia. The CI underwent an evaluation with physical medicine/rehab in November 2002 and was diagnosed with polyarthralgias after reporting neck, back, and lower extremity pain. In addition to the consultation with physical medicine, he was evaluated by chiropractor, neurology, and hematology to rule out specific pathology. Hematology noted that the CI had “classic” fibromyalgia syndrome. Rheumatology consult in November 2003 confirmed the diagnosis of fibromyalgia after a thorough evaluation for autoimmune disease was negative. The CI’s symptoms included arthralgia (joint pain) in multiple joints, the neck, back, knees, shoulder, left hip; fatigue, headaches and poor sleep. Some form of each condition was present since 1998 after a motor vehicle accident; (i.e., neck pain, upper back pain, shin splints and knee pain). Magnetic resonance imaging (MRI) of the cervical spine in 2003 demonstrated right sided disc protrusion and associated neural foraminal stenosis at C6-7 with mild DDD. Lumbar spine and bilateral knee radiographs were normal. There were mild degenerative changes of the thoracic spine at T6 and T7. He was treated off and on with Tylenol and non-steroidal anti-inflammatory (NSAID) medications with limited benefit. The CI reported that he felt fatigued after taking Naprosyn and developed a rash after taking Celebrex and Vioxx. In July 2003, all of his medications were discontinued due to concern over his renal function (he had a nephrectomy [surgical removal of a kidney]). In November 2003, the rheumatologist indicated the CI should avoid NSAIDs. He reported some relief with stretching and Percocet was “not too helpful.” Chiropractor treatment provided no relief. The CI reported interrupted sleep pattern that had not improved with medications. He had tried Elavil but could not tolerate it. He was thought to have had a sleep disorder and was sent to ENT (ear, nose and throat) for evaluation for possible sleep apnea; ENT found enlarged tonsils which were surgically removed in January 1999 (tonsillectomy). He continued to report sleep disturbance and was later prescribed Trazodone, but reported limited benefit.

At the MEB/narrative summary (NARSUM), 4 March 2004, dated approximately 4 months before separation, the CI reported continued symptoms of pain in the upper back and neck, low back pain, and pain in the legs, as well as radiating pain from the neck into the right upper extremity. He only took medication for sleep, and noted that his sleep was not restful; he had frequent headaches, and chronic fatigue. He indicated he could walk a half a block at his own pace but at times needed to use a cane. The examiner did not perform a physical examination on the day of the NARSUM; however, referenced an October 2003 examination (9 months before separation) that showed “widespread tender points including over the trapezius, rhomboids, lumber muscles, lateral epicondyles, medial femoral condyles, and upper sternocostal cartilages.” There were additional findings of diffuse tenderness in the knees and left hip. The diagnoses of fibromyalgia, “severe enough to prevent successful performance of duty” and cervical spine: degenerative disk disease, “unresponsive to conservative treatment and necessitating significant limitation of physical activity” were documented. The frequency of symptoms was not recorded.

At VA Compensation and Pension (C&P) exam performed on 14 June 2004, approximately 3 weeks before separation, the examiner documented that the CI was able to sit, stand, walk and do all of the daily activities; however, in cold weather or during a stress type of activity “he gets fibromyalgia diffuse.” The CI noted he was still working at his own pace and that his condition of fibromyalgia “interferes with his job sometimes.” He was working only 4 hours a day in a desk job. The CI noted his neck pain had not interfered with his work, and stated that any flare-ups he had which were 4-5 a month, took about a day to resolve, but he was still able to work during the flare-ups. Running aggravated his bilateral shin splints, but otherwise they presented no problem. He continued to have pain behind the patella, and was able to walk 1/2 to 1-mile, and could walk up one flight of stairs, most times. He took medication for his headaches that were occurring twice a week. There was no documented medication use for fibromyalgia symptoms. On physical examination, gait was recorded as normal. Tenderness was noted on palpation in the midback paraspinal areas. Right shoulder showed signs of bursitis, with ROM flexion of 180 degrees, abduction of 180 degrees and external/internal rotation of 85 degrees. Left shoulder ROM measurements were normal. Musculoskeletal examination of the upper and lower extremities documented absence of neurological findings, including no evidence of radiculopathy, and normal muscle strength.

The Board directed attention to its rating recommendation based on the above evidence. Both the PEB and VA rated the fibromyalgia condition at 20% under the code 5025. A rating of 20% requires widespread pain and tender points with associated symptoms to be episodic and present more than one third of the time. The criteria for a higher rating of 40% required evidence that symptoms were constant or nearly constant and were refractory to treatment. The Board agreed that neither the NARSUM nor the C&P evaluation documented a history consistent with a 40 % disability rating. Although the NARSUM did not document the frequency of his pain symptoms, 4 months before separation, the C&P examination 3 weeks before separation specifically noted symptoms were “episodic,” supporting the 20% rating. There was no evidence in the record at hand to support the higher rating of 40%. 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 determination for the fibromyalgia condition. The Board was unable to ascertain a pathway for higher rating under any applicable VASRD code.

The Board next considered the condition of DDD of the cervical spine. This CI’s history of neck pain began after a motor vehicle accident in late July 1998. MRI of the cervical spine on 22 August 2000 demonstrated “very early degenerative disc disease at C6-7.” Treatment entries focusing on a single complaint of neck pain was absent in the available service treatment record. The commander’s performance statement dated 6 November 2003 acknowledged that the CI had suffered neck and upper back injuries and stated that he “had recovered after eight months of physical therapy.” It was specifically noted that his diagnosis of fibromyalgia had limited his ability to perform his duties. The CI was unable to lift anything over 20 pounds, fire an M-16, walk or stand for prolonged periods of time, and could not perform his duties as an aircraft engine repairer. However, the NARSUM examiner opined that both the cervical spine condition and fibromyalgia failed to meet retention standard, and the MEB forwarded the conditions as not meeting retention standards. The condition identified on his profile was “multiple joints pain: neck, upper back, Low back pain and knee.” The VA C&P examination, 3 weeks before separation documented “no definite profiles” for the cervical spine condition, and noted that the CI reported he had “flare-ups” four to five times a month but was still able to continue to work. He was advised to work at his own pace and to modify neck positions while seated at a desk. The VASRD defines widespread pain within the context of fibromyalgia as “pain in both the left and right sides of the body, that is both above and below the waist, and that affects both the axial skeleton (cervical spine, anterior chest, thoracic spine or low back and the extremities). Based on the evidence cited above, and the fact that the neck condition was not separately profiled or specifically implicated by the commander’s performance statement as significantly interfering with duty performance, and the absence of evidence of isolated neck pain treatment independent of other recorded pain complaints, Board members concluded there was not a preponderance of evidence to support a separate unfitting cervical spine condition. After due deliberation, the Board agreed that the evidence supports a conclusion, that the cervical spine condition and the FM syndrome are reasonably justified as not being separately unfitting. The Board opined that the cervical spine condition recorded in the MEB was an integral, comorbid component of the fibromyalgia condition and could not be rated as single unfitting condition IAW VASRD §4.14 (avoidance of pyramiding).


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 PEB adjudication. There were no other conditions within the Board’s scope of review for consideration.


RECOMMENDATION: The Board, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination.


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20131004, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans Affairs Treatment Record


XXXXXXXXXXXXXXXXXXXX
President
Physical Disability Board of Review



SAMR-RB                                                                         


MEMORANDUM FOR Commander, US Army Physical Disability Agency
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557


 SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXXXXX , AR20150012444 (PD201302284)

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                                                  XXXXXXXXXXXXXXXXXXXX
                                                      Deputy Assistant Secretary of the Army
                                                      (Review Boards)
                                                     
CF:
( ) DoD PDBR
( ) DVA




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