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AF | PDBR | CY2014 | PD-2014-00207
Original file (PD-2014-00207.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXXXX       CASE: PD-2014-00207
BRANCH OF SERVICE: AIR FORCE     BOARD DATE: 20150716
SEPARATION DATE: 20070306


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (Power Production Craftsman) medically separated for fibromyalgia-like syndrome and limited motion of right wrist. The right wrist conditions could not be adequately rehabilitated to meet the physical requirements of his Air Force Specialty (AFS). He was issued a temporary P4, U4 profile and referred for a Medical Evaluation Board (MEB). The “fibromyalgia” and “wrist pain,” were forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123. No other condition was submitted by the MEB. The Informal PEB adjudicated “pain syndrome consisting of fibromyalgia-like syndrome and right wrist pain” and “limited range of motion right wrist, status-post scapholunate ligament repair and capsulodesis” as Category I unfitting conditions, rated 20% and 0%, c iting application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) and Department of Defense (DoD) guidelines. The CI made no appeals and was medically separated.


CI CONTENTION: He contends DoDI 1332.39 should not have been used. His 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 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.

The Board acknowledges the CI’s contention that “item 10c” (presumably a reference to his disability not being a result of armed conflict, per the PEB Form 356) was marked inaccurately. The Board does not have the jurisdiction to offer remedy in reference to decisions of this nature. That authority resides with the Board for the Correction of Military Records.


 RATING COMPARISON :

IPEB – Dated 20070124
 VA* - (~5 Mos. Post-Separation)
Condition
 Code Rating Condition Code Rating Exam
Fibromyalgia-Like Syndrome Including Right Wrist Pain 5025 20% Fibromyalgia-Like Pain Syndrome 5099-5025 20% 20070816
Limited Range of Motion (ROM), Right Wrist 5215 0% Status Post Scapholunate Ligament Repa ir a nd Capsulodesis, Partial Fusion Right Wrist 5215 Deferred
Other MEB/PEB Conditions x 0 (Not In Scope)
 Other x 6
RATING: 20%
 RATING: 40%
* Derived from VA Rating Decision (VA RD ) dated 200 80408 (most proximate to date of separation ( DOS ) ) .


ANALYSIS SUMMARY:

Pain Syndrome Condition. The CI was evaluated by a rheumatologist in May 2006 (10 months prior to separation) for a several month history of severe, persistent pain throughout his neck, back and posterior legs. There was associated numbness and tingling in the arms; and fatigue, sleep difficulty and depression. His hands and feet were very sensitive to pressure, touch, and pain. It was noted that no interventions to date, which included physical therapy (PT) and medications, were helpful. Examination was remarkable for 18/18 positive fibromyalgia tender points. The rheumatologist opined that the diffuse pain condition was most likely due to fibromyalgia, and recommended exercise and medication to improve sleep, and treatment of depression.

At follow-up with primary care on 3 August 2006 (7 months prior to separation), the CI reported “sleeping a little better than before, but doesn’t feel rested when he gets up.” On 6 October 2006 (5 months prior to separation), the insomnia was reportedly “not getting much better.” The CI’s request for a stronger dose of narcotic pain medication was declined by the provider because “it doesn’t sound like he always needs it.” He was instructed to take two pills if he was “having a bad day.”

The narrative summary (NARSUM) on 7 November 2006 (4 months prior to separation) reported symptoms of fatigue and diffuse pain from “the base of the skull all the way down to his toes.” Bilateral wrist pain was also noted. It was stated that he was tried on multiple medications, “most of which did not benefit him at all.” However, it was also noted that he was “currently on pain medications to try and cope with his pain, but these sometimes are inadequate.” Examination showed diffuse tenderness of the cervical, thoracic and lumbar spine areas.

A psychiatric NARSUM reported that symptoms of worry, irritability and insomnia were more prominent during the work week and improved when away from work. An initial trial of a medication for sleep in June 2006 had been “partially effective.” The examiner also noted that alteration in the medication regimen beginning in September 2006 resulted in overall improvement in pain and sleep, although full resolution was not achieved. Mood and anxiety symptoms reportedly resolved. The psychiatrist rendered diagnoses of pain disorder and sleep disorder, both associated with fibromyalgia; and adjustment disorder (resolved).

On 27 December 2006 (2 months prior to separation) the CI reported that the generalized pain was still present, “and about the same for the most part.” He was currently having more back pain. However, at a primary care clinic follow-up one month later, the CI reported being pain free at that time.

At the VA Compensation and Pension (C&P) exam on 16 August 2007 (5 months after separation), the CI reported “back pain when he moves his spine.” Pain was usually 3/10 in severity but could sometimes be 7/10. Current response to medication therapy was considered to be “fair.” Fatigue, malaise, sleep impairment and depression were denied. At the psychiatric C&P exam on 2 November 2007, the CI reported that his depression was mainly related to the fibromyalgia illness, and that taking medication and talking to a psychiatrist while in the Service was helpful. He currently enjoyed fishing, shooting at the rifle range, hunting and camping. Since separation from service, his sleep had improved.

The Board directed attention to its rating recommendation based on the above evidence. In accordance with (IAW) VASRD code 5025, fibromyalgia includes “widespread musculoskeletal pain with tender points,” with or without symptoms such as fatigue, paresthesias, sleep disturbance, depression and anxiety, all of which were noted in the record. The PEB and the VA assigned a 20% rating for fibromyalgia under the 5025 code (analogously by the VA), and rated a right wrist condition separately (see below). The Board next considered if the higher 40% rating was justified. Under the 5025 code, a 20% rating is appropriate when symptoms are episodic, with exacerbations often precipitated by environmental or emotional stress or by overexertion, but are present more than 1/3 of the time. A 40% rating, the maximum rating available under this code, is warranted when fibromyalgia is constant, or nearly so, and refractory to therapy. Although some primary care notes and the NARSUM described the failure of multiple medications to adequately treat symptoms, the NARSUM also reported that current pain medications were “sometimes” inadequate (i.e. by implication therefore often helpful). The psychiatric NARSUM noted a history of fluctuating mood symptoms and sleep difficulty that displayed some beneficial response to medication. Not only did the psychiatrist report that the mood symptom component of fibromyalgia resolved, but a primary care note two months prior to separation reported the absence of pain. Evidence from the VA exams noted fluctuating pain that was usually mild (3/10); an acknowledgment that there was a positive response to medications; the absence of fatigue, depression or sleep impairment; and a history of psychiatric symptoms that responded to treatment while in service. Board members concluded therefore that the “constant, or nearly so” and “refractory to therapy” stipulations of the 40% rating were not met; and agreed that the condition most closely approximated the 20% rating at the time of separation. 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 pain syndrome condition.

Right Wrist Limited Range of Motion Condition. In August 2005 the right-handed CI had right wrist surgery for repair of a scapholunate ligament tear causing chronic pain. Because of progressive wrist pain and instability, in August 2006 (7 months prior to separation) a second surgery was performed. Post-operative PT led to improved but restricted range-of-motion (ROM), and variable reports of pain.

The NARSUM examiner noted a complaint of right wrist pain and stiffness, but also reported bilateral wrist pain. The right wrist pain was described as “a little better” but he experienced very limited ROM. He was not able to perform his duty functions because of pain and lack of mobility. Per the CI’s report, further PT was not likely to result in additional improvement. Examination showed a well-healed surgical scar but was silent regarding tenderness or painful motion, and did not compare findings with the left wrist.

At PT follow-up on 1 December 2006, the CI indicated wrist stiffness and 3/10 pain that was improved from before surgery, and the he was “fine with the results.” The examiner opined that the CI would likely have permanent loss of some wrist motion, but that he should be “quite functional.” At a primary care clinic visit on 29 January 2007 the CI reported he was currently pain free.
At the VA C&P exam 5 months after separation, the CI reported right wrist pain, numbness and tingling after use of the wrist or after bending it. The psychiatric C&P evaluation reported that the CI was a full-time student and full-time computer programmer who enjoyed fishing, shooting at the rifle range, hunting and camping.

The ROM evaluations in evidence, which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.

Right Wrist ROM
 (Degrees)
 PT ~ 4 Mo s . Pre-Sep MEB ~ 4 Mo s . Pre-Sep VA C&P ~ 5 Mo s . Post -Sep
Dorsiflexion (70 Normal)
 30 30 30 (32)
Palmar Flexion (80)
 20 (18) 10 55 (53)
Comment
 ROM limited by pain and partial fusion surgery
§4.71a Rating
 0% 0% (PEB 0%) 0% (VA 10%)

The Board directed attention to its rating recommendation based on the above evidence. The PEB subsumed pain from the right wrist under the fibromyalgia rating (described above), and rated limitation of wrist motion at 0% under a 5215 code. The VA’s decision noted that non-compensable limitation of motion was present, but cited “limited motion and evidence of flare-ups of pain with slight weakness” as a rationale for a 10% rating. The Board agreed that limitation of wrist motion was insufficient to warrant a compensable rating, but devoted ample attention to the possible application of VASRD §4.40 (functional loss) or §4.59 (painful motion) as alternate routes to a 10% rating. The Board majority concluded that right wrist pain was properly subsumed under the fibromyalgia rating, and that to assign an additional 10% rating on the basis of §4.40 or §4.59 constitutes pyramiding in this case. In this regard the degree of significant functional loss or painful motion was debated in the context of the CI’s expressed satisfaction with the surgical outcome at the December 2006 PT follow-up; his participation in activities such as fishing, hunting, shooting and camping; and his post-separation full-time occupational and educational activities. 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 right wrist limited range of motion 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. As discussed above, PEB reliance on DoD guidelines (possibly including DoDI 1332.39) for rating fibromyalgia and right wrist limitation of motion was operant in this case and the conditions were adjudicated independently of that instruction by this Board. In the matter of the pain syndrome consisting of fibromyalgia-like syndrome and right wrist pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication. In the matter of the limited ROM right wrist condition and IAW VASRD §4.71a, the Board, by a majority vote, recommends no change in the PEB adjudication. The single voter for dissent submitted the appended minority opinion. 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 20131230, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans Affairs Treatment Record




XXXXXXXXXXXXXXXXXXXX
President
Physical Disability Board of Review


 Minority Opinion:
Based on VASRD §4.3 (Reasonable doubt), the minority finds the CI’s right wrist limitation of motion condition at the time of separation supports a 10% rating versus the majority vote 0% recommendation.

As documented in the primary text above, “In August 2005 the right-handed CI had right wrist surgery for repair of a scapholunate ligament tear causing chronic pain. Because of progressive wrist pain and instability, in August 2006 (7 months prior to separation) a second surgery was performed. Post-operative PT [physical therapy] led to improved but restricted range-of-motion (ROM), and variable reports of pain.”

The minority finds that the CI’s post-surgery limited ROM was separate and distinct from the fibromyalgia condition and does not constitute VASRD §4.14 (Pyramiding). The PEB also came to this separate and distinct conclusion finding the right wrist condition separately unfitting and rated 0%. This conclusion is corroborated by: a U4 temporary profile that identified [right] wrist pain with no lifting > 15 pounds or pushups; in the MEB NARSUM Prognosis and Recommendation (November 2005) the examiner opined, “…he [CI] is not able to perform his current duty functions because of this pain and lack of mobility. It is unlikely that this will change….”; and the MEB forwarded wrist pain [right] as not meeting retention standards.

The minority concedes the CI reported less pain at a PT exam (December 2005). However, the examiner opined, “He [CI] will have mod loss in the right wrist for life, based on his current status, he should be quite functional however. The examiner did not provide individual right wrist ROMs, but stated the “[right] wrist of motion was abnormal mod loss all planes, stiff,….” The minority concludes this ROM exam did not comply with VARSD §4.46 (Accurate measurement), but document the CI with continued right wrist pain and limited motion.

The VA also determined the right wrist condition separate and distinct from the fibromyalgia condition and granted a 10% rating effective at the time of separation.

Based on the above corroborating evidence and VASRD §4.3 (Reasonable doubt), the majority vote recommends a 10% rating for the right wrist limitation of motion condition analogously coded 5215 (Wrist, limitation of motion of) IAW VASRD §4.40 (Functional loss) or §4.59 (Painful motion).

RECOMMENDATION: The Board minority, therefore, 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 her prior medical separation:

CONDITION
 VASRD CODE RATING
Fibromyalgia 5025 20%
Right Wrist Limitation of Motion 5299-5215 10%
RATING
 30%


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

Dear XXXXXXXXXXXXXXXXXXXX :

 Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2014-00207 .
         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,






XXXXXXXXXXXXXXXXXXXX
Director
Air Force Review Boards Agency
Attachment:
Record of Proceedings

cc:
SAF/MRBR

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