RECORD OF PROCEEDINGS 
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXX		BRANCH OF SERVICE: NAVY
CASE NUMBER:  PD0900262		BOARD DATE: 20100317
SEPARATION DATE: 20081218
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SUMMARY OF CASE:  This covered individual (CI) was an Aviation Ordnanceman Second Class medically separated from the Navy in 2008 after approximately 11.5 years of service.  The medical basis for the separation was Fibromyalgia.  After an injury to his back in the fall of 2007, the CI continued to have back pain and he also later developed more widespread pain, weakness due to pain, and sleep disturbance.  He underwent a medical board and an initial informal Physical Evaluation board (PEB) determined he was fit for duty in March of 2008.  He was evaluated by rheumatology initially in May 2008.  At that time he did not meet the diagnostic criteria for fibromyalgia but the rheumatologist diagnosed chronic pain syndrome and recommended continuing treatment for chronic pain syndrome with central nervous system sensitization or neuropathic pain process.  The CI requested a reconsideration and in late May 2008 (after the rheumatology evaluation), the CI was again found to be fit for duty.  The CI had also submitted a letter from his flight surgeon that stated he was unable to perform his required duties.  He continued to receive care from his flight surgeon and underwent a second evaluation by rheumatology in July 2008 after stopping all of his medications for 2.5 weeks.  At that time he met the criteria for the diagnosis of fibromyalgia.  A psychiatric evaluation on 20080730 revealed no psychiatric diagnosis.  A formal PEB in August 2008 determined the CI was unfit for continued Naval service and he was separated.  His condition of fibromyalgia was rated at 20% using the Veterans Affairs Schedule for Ratings Disabilities (VASRD) and applicable Navy and Department of Defense regulations.
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CI CONTENTION:  The CI states: “The rating of 20% is episodic, but present more than one-third of the time.  The 40% rating states that it is constant, or nearly so, and refractory to therapy.  I have constant pain and fibromyalgia symptoms, the medication may reduce the American College of Rheumatology (ACR) tender points from 18/18 to 10/18-12/18.”
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RATING COMPARISON:

Service PEB	VA (2 Mo. Pre- Separation)	
Unfitting Conditions	Code	Rating	Date	Condition	Code	Rating	Exam	Effective	
Fibromyalgia	5025	20%	20080805	Fibromyalgia and Chronic Pain Syndrome 	5025	10%	20081007	20081219	
Myofascial pain syndrome	CAT II
Conditions that contribute to the unfitting condition(s)						
	In original NARSUM	Lumbar Sprain, Claimed as Lumbar Spondylosis 	5237	10%	20081007	20081219	
	Not in DES	Left Thumb Sprain, Claimed as Left Thumb Dislocation	5228-5024	10%	20081007	20081219	
	Not in DES	Allergic Rhinitis, also Claimed as Seasonal Allergies	6522	0%	20081007	20081219	
	Not in DES	Gastroesophageal Reflux Disease 	7399-7346	0%	20081007	20081219	
	Multiple surgeries for this mentioned in Rheumatology Addendum may 2008	Residual Scar, Status Post Pilonidal Cyst Removal,
Claimed as Recurrent Pilonidal Cyst 	7802	0%	20081007	20081219	
	Not in DES	Dyshidrotic Eczema, Claimed also as Bilateral Hand Dermatitis 	7806	0%	20081007	20081219	
				(4) other conditions	NSC				
TOTAL Combined:  20%	TOTAL Combined (Includes Non-PEB Conditions):    
30%  from 20081219
                                                                   	
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ANALYSIS SUMMARY:

FIBROMYALGIA:

Two Rheumatology addenda were done concerning this condition, one in May and one in July 2008.  In May he did not meet the diagnostic criteria for fibromyalgia because he only had 8 out of 18 possible trigger points.  American College of Rheumatology diagnostic criteria require 11/18 trigger points which must be bilateral and above and below the waist.  However, he did have trigger points on both sides of his body, above and below the waist, and axial pain (not just peripheral pain).  In the progress note dated 1 May 2008, the rheumatologist stated his fatigue, chronic back pain, non-restorative sleep pattern, and muscle skeletal pain suggests fibrositis but he didn’t meet the ACR criteria for fibromyalgia because he did not have 11/18 trigger points positive.  He complained of muscle weakness attributed to pain.  He was also currently on Lyrica, and Non-Steroidal Anti-Inflammatory Drug (NSAID), a muscle relaxer and had an active prescription for Tylenol with codeine and these may have masked some of his pain.  The Lyrica in particular did decrease his pain.

After a 2.5 week drug holiday, the CI was evaluated by the same rheumatologist in July 2008.  At that time he had the same general complaints but now had 18/18 positive trigger points and he therefore now met all the criteria for diagnosis of fibromyalgia.  He most likely had fibromyalgia all along but was medicated prior to his first visit to the rheumatologist.

At the July 2008 evaluation objective signs of pain include elevated blood pressure (BP) 145/94 (was 126/85 at April 2008 visit and this lower BP is c/w most other measurements).  CI also had abnormal gait and stance due to pain and while in no acute distress, he did appear uncomfortable to the rheumatologist.  He also had a severe headaches, poor sleep, and non-restorative sleep pattern. Pain was rated 8.5/10.  He also had paresthesias.

The formal PEB rationale documented the CI’s command noticed daily pain and fatigue/sedation.  A couch was placed in his office to facilitate his ability to change position by lying down.  He was also allowed to sleep during duty hours and he was not allowed to drive government vehicles. The formal PEB determined fibromyalgia was unfitting and applied a 20% rating for symptoms that were present more than one-third of the time.

At VA exam in October 2008 (2 mo prior to separation) he had been on meds since rheumatology visit in July 2008 but still had 14/18 positive trigger points and bilateral pain above and below the waist, axial and in extremities.  He also required an assistive device for ambulation. VA rated 10% for requires continuous medication to control and said he did not have symptoms that were episodic, with exacerbations often precipitated by environmental or emotional stress or by overexertion, but that are present more than one-third of the time. However, Compensation and Pension (C&P) exam said he had constant pain and when he has flares, he is unable to move.  His medication helps (is controlling) but the disease is still active, not in remission, and he still has constant pain.  The C&P did not specify how frequently the flares occur.  However, it does not appear that the CI’s symptoms were controlled with medication as he still had constant severe pain along with fatigue, headaches, sleep disturbance, stiffness, and paresthesias.

Back pain

CI had mechanical low back pain that persisted after an injury to his back.  He was in his usual state of health until an accident with a piece of flight equipment, approximately two years prior to his medical evaluation board (MEB).  The equipment fell over (200 pounds and chest high).  He attempted to prevent it from falling over, but it ‘bent him over 90 degrees backwards and fell on him’.  There was no loss of consciousness.  Immediately afterwards, he had bilateral leg numbness, urinary incontinence without fecal incontinence, and was unable to walk temporarily.  He subsequently has been complaining of severe lower back pain with numbness that radiates down his legs.  Occasionally, this is associated with upper back pain and sharp, shooting pains down his legs.

The narrative summary (NARSUM) documents a normal Magnetic Resonance Imaging (MRI) of his lumbosacral spine and bone scan.  The patient has been evaluated by neurosurgery and noted not to be a surgical candidate.  The patient was also seen by the Pain Clinic and received two epidural steroid injections as well as medial branch blocks.  The patient reported that none of these procedures have helped.  The patient also received chiropractic care, with no significant improvement.  Physical Therapy included Aquatic Therapy as well as Back School.  The patient's medications included Naproxen, Mobic, Robaxin, and Zanaflex.  His pain is described as achy, crampy, midline, radiates down the bilateral legs to the soles of his feet, positive numbness, tingling, and weakness, and no bowel or bladder incontinence. The pain was rated as 2 out of 10.  The Navy evaluation did not measure range of motion (ROM) but did report pain with motion. VA ROM documented flexion limited to 70 degrees. There were no signs of radiculopathy on either exam.

If considered unfitting, this condition could be rated separately without pyramiding.  This is mechanical low back pain due to strain (VASRD 5237) and is not part of or related to fibromyalgia.  Fibromyalgia is a chronic pain syndrome with central nervous system sensitization or neuropathic pain process.  The CI had lumbar back pain and tenderness to palpation of his paraspinal muscles in the lumbar area.  This area is anatomically separated from both gluteal and greater trochanter trigger points of fibromyalgia.  However, even if neither of these pairs of trigger points was used to meet the minimum criteria for the diagnosis of fibromyalgia, the CI would still meet the diagnostic criteria as he had 18 out of 18 positive trigger points.  

The initial Navy Informal PEB and the reconsideration did not consider the condition of back pain as unfitting and recommended the CI return to duty.  The Formal PEB determined the CI was unfit for continued Naval service after the diagnosis of fibromyalgia was determined.

Other Conditions in Disability Evaluation System (DES) Packet
Residual Scar, Status Post Pilonidal Cyst Removal, Claimed as Recurrent Pilonidal Cyst:  No evidence this is unfitting. Not mentioned in commander’s letter. No duty restrictions secondary to this condition.

Conditions rated by the VA but not in DES:
Left Thumb Sprain, Allergic Rhinitis, Gastroesophageal Reflux Disease, and Dyshidrotic Eczema 
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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.  After careful consideration of all available information, the Board determined by simple majority that the CI’s condition is most appropriately rated at 20% for Fibromyalgia, 5025.  The single voter for dissent (who recommended adding an additional rating of 10% for Lumbar Strain, 5237) did not elect to submit a minority opinion.

The CI had constant pain which was partially alleviated with medication.  After stopping all medication, he had 18 positive trigger points in July 2008.  He restarted his medication after this evaluation.  At his VA evaluation three months later in October 2008 some improvement was documented and he had 14 positive trigger points. As medication did alleviate some of his pain, his symptoms are not considered refractory to therapy.

The Board determined by simple majority that the condition of lumbar strain is not unfitting.  The single voter for dissent did not elect to submit a minority opinion.  The Board unanimously determined that the condition of recurrent pilonidal cysts with scar is not unfitting.

The other diagnoses rated by the VA (Left Thumb Sprain, Allergic Rhinitis, Gastroesophageal Reflux Disease, and Dyshidrotic Eczema) were not mentioned in the Disability Evaluation System package and are therefore outside the scope of the Board. The CI retains the right to request his service Board of Correction for Naval   Records (BCNR) to consider adding these conditions as unfitting.
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RECOMMENDATION: The Board therefore recommends that there be no recharacterization of the CI’s disability and separation determination.

UNFITTING CONDITION	VASRD CODE	RATING	
Fibromyalgia	5025	20%	
COMBINED	20%	
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The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20090325, w/atchs.
Exhibit B.  Service Treatment Record.
Exhibit C.  Department of Veterans' Affairs Treatment Record.

 

DEPARTMENT OF THE NAVY 
SECRETARY OF THE NAVY COUNCIL OF REVIEW BOARDS
 720 KENNON STREET SE STE 309
 WASHINGTON NAVY YARD DC 20374·5023 
IN REPLY REFER TO 
1850 CORB:003 26 April 2010 
From: Director, Secretary of the Navy Council of Review Boards 
To: 

Subj: PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) 
Ref: (a) DoDI 6040.44 
(b) PDBR ltr of 19 MAR 10 
1. Pursuant to reference (a), the PDBR reviewed your case and forwarded its recommendation (reference (b)) to the Department of the Navy for appropriate action. 
2. On 23 April 2010, the Assistant Secretary of the Navy (Manpower & Reserve Affairs) took action in your case by accepting the recommendation of the PDBR that no change be made to the characterization of separation or disability rating assigned by the Department of the Navy's Physical Evaluation Board. 
3. The Secretary's decision represents final action in your case by the Department of the Navy and is not subject to appeal or further review by the Board for Correction of Naval Records. 

Copy to: PDBR