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AF | PDBR | CY2014 | PD-2014-00766
Original file (PD-2014-00766.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXX    CASE: PD-2014-00766
BRANCH OF SERVICE: Army  BOARD DATE: 20150205
SEPARATION DATE: 20050220


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-6 (Shower/Laundry Specialist) medically separated for fibromyalgia (FM). The condition could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty or satisfy physical fitness standards. The alternate walk fitness test was authorized. She was issued a permanent U3/L3 profile and referred for a Medical Evaluation Board (MEB). The FM condition was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. The MEB also identified and forwarded one other osteoarthritis condition as medically unacceptable for PEB adjudication. The Informal PEB adjudicated “myalgias and a clinical diagnosis of fibromyalgia” as unfitting, rated 20%. The remaining condition was not mentioned by the IPEB . The CI made no appeals and was medically separated.


CI CONTENTION: “I have myalgias and a clinical diagnosis of fibromyalgia. l continue to have 12/18 tender points that are still present. I strongly feel I should have been medically retired due to my disability I incurred during my military career.”


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 IPEB – Dated 20041209
 VA - (2 Mos. Post-Separation)
Condition
 Code Rating Condition Code Rating Exam
Myalgias and Clinical Diagnosis of Fibromyalgia 5025 20% Fibromyalgia 5025 0%* 20050505
Other x 0 (Not In Scope)
 Other x 13
Combined: 20%
 Combined: 40%
Derived from VA Rating Decision (VA RD ) dated 200 51213 ( most proximate to date of separation [ DOS ] ).
*The VA rated several joints as degenerative arthritis separately instead of a single rating for fibromyalgia.

ANALYSIS SUMMARY:

Fibromyalgia Condition. According to service treatment records (STR) and the MEB narrative summary (NARSUM) the CI had a several-year history of musculoskeletal pain including back, neck, hips and shoulders. The CI presented to clinic in March 2002 complaining of diffuse swelling in the hands, shoulders, hips, and knees, as well as frequent headaches. In November 2003, she developed diffuse arthralgias (joint pains) and cold weather sensitivity. X-rays, bone scanning, and laboratory results were normal. She was given several profiles and medications without significant benefit. Due to persisting and increasing symptoms the CI was referred for MEB in April 2004. The commander’s statement on 22 April 2004 stated that the CI could not perform physically demanding soldier duties (such as lifting 100 pounds and wearing and/or carrying combat gear), but did not note whether she was working or could work in other venues. At the MEB examination on 11 May 2004, 10 months prior to separation, the CI complained of painful bilateral shoulders (which popped all the time), constant back pain, foot pain, tender “knots” on both of the knees, and “very painful joints (all over).” On examination, she had decreased range-of-motion (ROM) of the lumbosacral spine secondary to tenderness, but no other documented musculoskeletal abnormalities. The permanent physical profile on 3 June 2004 listed “Joint pain due to arthritis” as the involved diagnosis, with multiple restrictions including no jumping, squatting, or standing over 15 minutes. At the MEB NARSUM examination on 8 July 2004, 7 months prior to separation, the CI stated that she could not run, do push-ups or sit-ups, or wear a 40-pound rucksack. On examination she had full range-of-motion (ROM) and strength in the joints of the upper and lower extremities. She had decreased ROM in the lumbosacral spine secondary to pain, with normal gait and station. The MEB concluded with diagnoses of fibromyalgia and osteoarthritis. Orthopedic evaluation on 19 July 2004, noted a history of right hip pain since 1999 and pain in her hands, shoulders, hips, and knees that had been previously attributed to osteoarthritis (degenerative joint disease). On examination she had full ROM of the hips and knees, with positive patellar grind of both knees. X-rays (spine, hips, knees, hands), were noted to be normal (no evidence for osteoarthritis or other abnormalities). The orthopedist diagnosed bilateral patellofemoral pain syndrome (pain of the patellas, or kneecaps) but stated, “No finding of OA” (no evidence for osteoarthritis). Rheumatology evaluation in August 2004 confirmed a diagnosis of FM based on the presence of characteristic tender points and absence of arthritis, inflammatory arthritis or other abnormalities; and the CI was prescribed medication. An internal medicine assessment on 22 November 2004 (4 months prior to separation), summarized the results of the rheumatology evaluation and noted that the CI reported that her arthralgias were worsened with any changes in the weather, that her current pain was 8/10, and that “She was told that the arthritis is primarily in the hips and shoulders.” On examination the CI was in no acute distress and had 14/18 positive tender points. The internist noted she had not been taking the medication prescribed for the FM and recommended the CI take the medication on a regular basis. At the VA Compensation and Pension exam on 5 May 2005, 3 months after separation, the CI reported she was evaluated for diagnoses of FM (diagnosed in 2000, was “having pain all over”); back and neck spasms (secondary to falling off a cattle truck on an unspecified date); leg spasms (once a week, since 1992), degenerative joint disease (diagnosed in 2000, was told that all of her joints had this, manifesting primarily as pain in both hips and both knees); and osteoarthritis (since 2000, with positive X-rays of the hips/ shoulders/knees, with sharp pain and popping of the shoulders). The CI reported that she had fatigue problems sleeping at night due to pain; and she took sleeping pills about 3 days a week however not taking the medication was recommended by the rheumatologist and internist for FM. She indicated that that any little thing would trigger her pain, including just walking. The pain was usually severe, it occurred at least 4 days a week, and it affected her daily activities as she was constantly hurting. The examiner stated, “She has missed a couple of days and just began work a month ago.” On examination the CI had rigid movement of the thoracolumbar spine and bent her knees to stand upright, had four positive tender points (lateral hips and lateral shoulders) and no other abnormalities of the muscles. She had decreased ROM of several joints (thoracolumbar spine, hips, and knees) with crepitation (grating) of the left knee with movement. A bone scan on 26 May 2005 was reported to show increased activity of the left knee that could be due to degenerative arthritis.

The Board directed attention to its rating recommendation based on the above evidence. The PEB found the unfitting condition to be “Myalgias and a clinical diagnosis of Fibromyalgia,” rated with code 5025 (fibromyalgia) at 20%. The MEB also forwarded the diagnosis of osteoarthritis, classified as “Medically Unacceptable,” but this was not addressed by the PEB because the diagnosis was not established after evaluation by orthopedic surgery and rheumatology. The VA rated the FM condition with code 5025 at 0%, noting that the CI also had degenerative arthritis affecting several joints (which were rated), and that the same criteria could not be used to grant a compensable evaluation for FM. FM is a common syndrome in which a person has long-term pain, spread throughout the body. The pain is most often linked to fatigue, sleep problems, headaches, depression, and anxiety. People with FM may also have tenderness in the joints, muscles, tendons, and other soft tissues. The VASRD rating guidance for FM, diagnostic code 5025, considers the impairment from 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, some of which were reported in the CI. Review of the STR did not identify any individual joint as requiring specific duty restrictions or being permanently unfitting (e.g., the NARSUM described her issue as “diffuse arthralgias and cold intolerance”). Thus, the pain and disability of joints, tendons, and muscles are more appropriately described and rated using the code for FM. The Board considered whether the CI’s pain and tender points were better characterized as “constant, or nearly so, and refractory to therapy” under code 5025, which would warrant a 40% rating. Although the commander noted that the CI was unable to perform physically demanding duties, he did not state that the CI was unable to perform other lighter, day-to-day duties. The physical profile did not restrict the CI from walking, biking, performing upper and lower body weight training, or standing up to 15 minutes. Similarly, the NARSUM did not describe any limitations with routine, non-military, physically-demanding activities. In the VA exam, the CI indicated that “any little thing” could trigger her pain, that the pain was severe, and that it occurred at least 4 days a week (not constant); also, she had begun work a month previously and had missed a couple of days. The Board noted that the CI did not have frequent office visits or medication adjustments and had not been taking the medication recommended by the rheumatologist. The Board concluded that there was not reasonable doubt in the CI’s favor supporting characterization of her FM symptoms as constant, or nearly so, and refractory to therapy. Therefore, 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 FM 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 FM 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 20140208, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans’ Affairs Treatment Record






XXXXXXXXXXXXXXX
President
                           DoD 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 XXXXXXXXXXXXXXX, AR20150010578 (PD201400766)


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

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