RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXX	      CASE:  PD-2013-01722
BRANCH OF SERVICE:  aRMY                                                                   SEPARATION DATE:  20040526

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E6, Human Resources Specialist, medically separated for “myofascial pain syndrome” and “bilateral knee pain,” rated 20% and 0%, respectively, with a combined disability rating of 20%.   

CI CONTENTION:  She was given higher ratings for her conditions by the VA.  Her complete submission is at Exhibit A. 

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44.  It is limited to those conditions determined by the Physical Evaluation Board (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 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 PEB - 20040202	VARD - 20040430  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Myofascial Pain Syndrome 	5025	20%	Myofascial Pain Syndrome with Fibromyalgia	5099-5025	20%	20040217	
			Post-Operative Residuals, Left Acromioclavicular Joint Arthrosis	5201-5019	10%		
Bilateral Knee Pain	5099-5003	0%	Left Retropatellar Pain Syndrome	5260-5024	10%		
			Post-Operative Residuals, Degenerative Changes, Right Retropatellar Pain Syndrome	5260-5010	10%		
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Myofascial Pain Syndrome.  The service treatment records (STR) documented the initial diagnosis and treatment of fibromyalgia by a flight surgeon in June 2002, and subsequent treatment with narcotics in July 2002.  She was referred to and attended a fibromyalgia seminar in conjunction with rheumatology in August 2002.  At an occupational therapy visit in September 2002, the CI reported pain at rest, during activity, and at night; and inability to independently perform all activities of daily living, work, and household chores.  

Despite treatment, the CI’s conditions could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for a Medical Evaluation Board (MEB).  The MEB forwarded “left shoulder pain-rotator cuff tear, acromioclavicular joint arthrosis, s/p surgery and fibromyalgia” for PEB adjudication.

At the MEB NARSUM examination on 11 August 2003, she reported taking Tylenol three times a day.  At a rheumatology consultation in September 2003 (8 months before separation), the CI reported a history of multiple medications for her chronic pain, that were “sub optimally effective.”  The symptoms had not changed since the last evaluation in August 2002.  She had not been taking medications during the post-partum period, since April 2003; but listed taking Tylenol as needed.  She was working and “functioning pretty well,” despite inability to run, carry a backpack, or perform pushups.  She also endorsed constipation, sleep disturbance, morning fatigue, and headaches.  The examiner documented “multiple” trigger points (anterior chest, left posterior shoulder, bilateral elbows, hips, distal thighs, and sacroiliac regions) and reiterated the diagnosis of myofascial pain syndrome.  He further opined that the CI was “limited in regards to the physical requirements of the military and activities of daily living.”  No medications were prescribed.  

At the 17 February 2004 VA Compensation and Pension (C&P) evaluation, performed 3 months prior to separation, the CI reported “constant pain” and taking narcotics (frequency not addressed).  The CI reported the ability to walk for 15 minutes, perform the activities of daily living, and sustain heavy physical activities without immediate distress.  She reported a low energy level for the previous several months resulting in the inability to perform her military duties.  The examiner documented tender points (anterior chest, left posterior shoulder, bilateral elbows, and hips) with a normal gait, strength, and neurologic examination; and endorsed the diagnosis of fibromyalgia.  

The Board directed attention to the rating recommendation based on the above evidence.  The PEB subsumed the left shoulder and neck within the fibromyalgia diagnosis and rated 20%.  In contrast, the VA separated the shoulder rating from the fibromyalgia and rated the fibromyalgia 20%, citing “episodic symptoms… that are present more than one-third of the time.”  The VA separately rated the left shoulder condition 10% and the neck was not separately rated.  The Board first considered if the fibromyalgia, having been de-coupled from the combined PEB adjudication, remained itself unfitting as established above.  The condition was implicated in the MEB NARSUM and in the rheumatology addendum where it was stated that the CI was “limited in regards to the physical requirements of the military.”  Fibromyalgia was considered to fail retention standards by the MEB and was adjudicated as unfitting by the PEB.  It was not specifically implicated in the commander’s statement; however, it was stated that “her pain and multiple profiles prevent her from accomplishing her mission.”  Members agreed that the functional limitations in evidence justified the conclusion that the condition was integral to the CI’s inability to perform her duties; and, accordingly a separate rating is recommended.  

The Board next considered the evidence for rating.  There was evidence of treatment prior to separation with multiple medications that was interrupted by a period of post-partum breastfeeding.  There was subjective documentation of symptoms that had evolved from September 2003 to February 2004 to cause an inability to perform her duties and were of such severity to necessitate the resumption of the use of narcotic medications by the time of the February 2004 VA C&P examination prior to separation and addition of the condition to the MEB process.  Prior to separation, there was no specific documentation of precipitating factors and frequency of exacerbations and medication usage.  However, there was documentation of medication trials that were sub-optimally effective (rheumatology consultation); and documentation prior to separation  of “constant pain,” several active trigger points, and the use of narcotics (VA C&P) that resulted in the inability to perform her military duties and therefore referral into the DES.  This evidence supported a 20% rating based on the criteria that the fibromyalgia symptoms 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.”  There was scant evidence in support of a higher rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 20% for the myofascial pain condition.  

Left Shoulder Pain-Rotator Cuff Tear and Acromioclavicular Joint Arthrosis, Status Post Surgery.  Radiographic imaging (MRI) in December 2001 documented a partial tear of the rotator cuff, and acromioclavicular (AC) joint degeneration.  Arthroscopy (sub-acromial decompression and rotator cuff debridement) was performed in March 2002.  At a physical medicine visit in September 2003 (8 months prior to separation), the CI reported persistent pain; the sensation of subluxation and looseness; and posterior shoulder stiffness.  The examiner documented no muscular atrophy, and no scapular winging (weakness).  There was decreased strength (4+/5) of flexion, extension, and rotation due to pain.  The examiner diagnosed “chronic left shoulder pain from rotator cuff syndrome and AC joint arthritis and post traumatic myofascial pain (not resolved with surgery).”  

At the MEB NARSUM examination on 11 September 2003 (10 months prior to separation), the CI reported 10/10 pain, inability to sleep on the left side due to pain, reduced range of motion (ROM), and difficulty entering and exiting vehicles.  It was aggravated by driving, overhead work, cold weather and exercise.  The examiner documented flexion of 150 degrees and abduction of 135 degrees (normal 180 each) after three repetitions.  In the MEB addendum dated 22 September 2003, the examiner documented abduction of 180 degrees with pain, and evidence of mechanical impingement of the rotator cuff with no evidence of tear.  The examiner diagnosed “left shoulder pain, status post-surgery.”  

At an orthopedic visit in January 2004 (4 months prior to separation), the examiner documented a left shoulder flexion of 170 degrees and abduction of 140 degrees.  There was tenderness and impingement of the left AC joint.  The examiner diagnosed “AC degenerative joint disease (DJD) with shoulder pain.”  

At the 17 February 2004 VA C&P evaluation, performed 3 months prior to separation, the CI reported continuous pain, inability to sleep on the left side, and aggravation by driving, overhead work, and exercise.  Flexion was to 128 degrees and abduction was to 115 after five repetitions with documentation of painful motion (9/10).  

The Board directed attention to the rating recommendation based on the above evidence.  The PEB rated the “left shoulder region” together with the myofascial pain syndrome at 20% coded 5025 (fibromyalgia).  The VA separately rated 10% for the “postoperative residuals, left acromioclavicular joint arthrosis” analogously coded 5201-5019 (arm, limitation of motion; bursitis), citing evidence of painful and limited motion based on the 17 February 2004 VA C&P examination.  

The Board then considered if the left shoulder condition, having been de-coupled from the combined PEB adjudication, remained unfitting as established above.  In this case, the “shoulder” was profiled.  The condition was implicated by both NARSUM examiners.  The commander’s statement was nonspecific regarding limitations related to the left shoulder and stated that the CI was able to perform all of the duties in a garrison environment; however, “her pain and multiple profiles prevent her from accomplishing her mission.”  The condition was referred for adjudication by the MEB as “left shoulder pain-rotator cuff tear” and “acromioclavicular joint arthrosis.”  The “left shoulder region” was bundled with the myofascial pain syndrome and adjudicated as unfitting by the PEB.  After due deliberation and considering all of the evidence, the Board concluded that the pathology and subsequent residuals in evidence justified the left shoulder condition as separately unfitting and accordingly a separate rating is recommended.  The VASRD §4.71a (code 5201, arm limitation of motion) threshold for a rating for ROM impairment is “at shoulder level” (90 degrees from the side), and the ROM in evidence demonstrated motion above this level.  However, Board members agreed that a 10% rating was justified with application of VASRD §4.59 (painful motion), coded 5201-5003 (arm, limitation of motion; arthritis, degenerative).  There was no malunion or recurrent dislocation of the humerus and no dislocation or nonunion of the clavicle or scapula to justify a higher rating under the 5202 (humerus, other impairment of) or 5203 (clavicle or scapula, impairment of) codes.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the left shoulder condition.  

Neck Condition.  The Board first considered if the neck condition, having been de-coupled from the combined PEB adjudication, remained itself unfitting as established above.  In this case, the “neck” was profiled.  The condition was implicated by the NARSUM examiner (as “pain in the …upper back as well as reduced range of motion”).  The commander’s statement was nonspecific regarding limitations related to the neck, and stated that the CI was able to perform all of the duties in a garrison environment; however, “her pain and multiple profiles prevent her from accomplishing her mission.”  The neck condition was not referred for adjudication by the MEB; however, the “neck” was subsumed under the diagnosis of myofascial pain syndrome and adjudicated as unfitting by the PEB.  Board members additionally agreed that by subsuming the neck condition under the fibromyalgia condition, the PEB appropriately avoided the considerable risk of pyramiding; that is, the evaluation of the same disability (pain) under various diagnoses, which is prohibited under VASRD.  After due deliberation, and considering all of the evidence, the Board concluded that the neck was appropriately subsumed with the unfitting fibromyalgia and accordingly a separate disability rating is not recommended.  

Bilateral Knee Pain.  The PEB combined the right and left knee conditions under a single Service disability rating, coded analogously to 5003.  Although VASRD §4.71a permits combined ratings of two or more joints under 5003, it allows separate ratings for separately compensable joints.  IAW DoDI 6040.44 if the PEB combined adjudication is not compliant with the 5003 combined rating criteria, each condition subsumed under the single disability rating must be reasonably justified as separately unfitting in order to remain eligible for rating.  The Board’s initial charge in this case was directed at determining if the PEB’s combined adjudication was justified in lieu of separate ratings.  The evidence for each condition is presented separately along with separately unfitting recommendations.  If Board members determine by performance based fitness criteria that the condition is reasonable justified as separately unfitting and is separately ratable; IAW VASRD §4.7 (higher of two evaluations), separate ratings are recommended.  IAW DoDI 6040.44 the combined rating for the conditions determined to be separately unfitting and ratable may not be lower than the single disability rating from the PEB.  

Right Knee Pain.  The STR documented a traumatic injury during a unit basketball game in 1992.  The CI was diagnosed with recurrent right patellar dislocation, had knee arthroscopy in 1993, patellar reconstruction, lateral release, and meniscal repair in 1994, and a second surgery for subluxation in 1994.  

Despite treatment, the right knee condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for an MEB.  The MEB forwarded “right recurrent patellar dislocations” for PEB adjudication.  

The MEB NARSUM examination on 11 August 2003 (9 months prior to separation) the CI reported continued right patellar dislocations that spontaneously relocate.  She reported manual relocation of the right patellae approximately 1-2 times per week.  She had right knee pain at rest (5/10) that increased to 8-9/10 pain with dislocations.  She reported pain and stiffness with prolonged walking, sitting, stair climbing, mounting vehicles, and heavy lifting.  Right knee ROM was 0-120 degrees (normal 0-140) after repetition.  In an MEB addendum dated 22 September 2003, the examiner documented patellar grind and apprehension (sensation of dislocation with pressure) and no evidence of laxity, or meniscal or ligamentous damage.  The examiner diagnosed right knee pain with patellar retinaculum tightening.  At a physical medicine visit in September 2003, the examiner documented an antalgic gait, crepitus, tenderness of the medial joint line and patella, and normal strength and reflexes, and no muscular atrophy of the thighs.  The examiner diagnosed right knee subluxations with pain not resolved after surgery.  

At an orthopedic visit in January 2004 (4 months prior to separation), the examiner documented a ROM of 0-120 degrees, medial patellar tenderness and crepitus, and no effusion; and diagnosed patellar instability.  

At the 17 February 2004 VA C&P evaluation, performed 3 months prior to separation, the CI reported the ability to walk for 15 minutes, but inability to walk or run more than that.  The examiner documented a non-antalgic gait, a ROM of 0-119 degrees after repetition with no pain.  There was no evidence of laxity, or meniscal or ligamentous damage.  Two separate radiographs from December 2003 reportedly documented “very mild osteoarthritis,” and “mild degenerative changes” of the medial knee.  

Left Knee Pain.  The MEB NARSUM documented a diagnosis left patellar bursitis in 1997, with subsequent development of patellar dislocations.  Despite treatment, the left knee condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for an MEB.  The MEB forwarded “left recurrent patellar dislocations” for PEB adjudication.  

The MEB NARSUM examination on 11 August 2003 (9 months prior to separation), the CI reported continued left patellar dislocations with manual relocation of the left knee 1-2 times per month.  She reported that her left knee was much less painful than the right.  She reported pain and stiffness with prolonged walking, sitting, stair climbing, mounting vehicles, and heavy lifting.  Left knee ROM was 0-100 after repetition.  In an MEB addendum dated 22 September 2003 (8 months prior to separation), the examiner documented patellar grind and apprehension and no evidence of laxity, or meniscal or ligamentous damage.  The examiner diagnosed left knee retropatellar pain syndrome.  At a physical medicine visit in September 2003, the examiner documented an antalgic gait, tenderness of the left patellae, normal strength and reflexes, and no muscular atrophy of the thighs.  The examiner diagnosed left knee subluxations with pain.  At an orthopedic visit in January 2004 (4 months prior to separation), the examiner documented left patellar tenderness and crepitus, however ROM was not documented.  The examiner diagnosed left patellar instability.  

At the 17 February 2004 VA C&P evaluation, performed 3 months prior to separation, the CI reported the ability to walk for 15 minutes, but inability to walk or run more than that.  The examiner documented a non-antalgic gait, a ROM of 0-120 degrees after repetition with no pain.  There was no evidence of laxity, or meniscal or ligamentous damage.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral knee pain condition 0% analogously coded 5099-5003 (degenerative arthritis), citing tenderness, patellar dislocations status post-surgery.   The VA rated the left knee condition as “post-operative residuals, degenerative changes, right retropatellar pain syndrome” at 10% analogously coded 5260-5010 (leg, limitation of flexion; traumatic arthritis), citing objective evidence of limited motion based on the February 2004 VA examination.  The VA also separately rated the left knee condition 10% using an analogous 5260-5024 code (leg, limitation of flexion; tenosynovitis), citing objective evidence of limited motion based on the February 2004 VA examination.  

The Board then considered if both knee conditions, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  In this case, “knee pain” was profiled.  Both knees were implicated by the NARSUM examiner.  Both right and left recurrent patellar dislocations were referred by the MEB and both knees were adjudicated as unfitting by the PEB.  The commander’s statement was nonspecific regarding limitations related to the knees.  Members agreed that the functional limitations in evidence justified separate unfitting determinations and separate ratings IAW VASRD §4.7 (higher of two evaluations).  

The Board next considered the evidence for rating the right knee.  There was radiographic evidence of osteoarthritis with degenerative changes of the knee, and evidence of recurrent patellar dislocations with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45) analogously coded 5260-5010 (leg, limitation of flexion; traumatic arthritis).  There was no evidence approaching a 10% rating or higher under the VASRD codes for limitation of motion (5260 or 5261).  There was no fracture, non-union, or malunion of the femur or tibia to support consideration under the respective codes for knee impairment related to long bone conditions (5255, 5262).  The examinations proximate to separation did not demonstrate the presence of ligamentous instability or laxity (5257), and there was no history of dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258).  After due deliberation, considering all of the evidence, the Board recommends a disability rating of 10% for the right knee condition, coded 5260-5010.  

The Board next considered the evidence for rating the left knee condition.  The CI was diagnosed with retropatellar pain syndrome, and there was evidence of recurrent patellar dislocations (painful motion), tenderness, and crepitus, with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45) analogously coded 5260-5024 (leg, limitation of flexion; tenosynovitis).  There was no limitation of flexion or extension that supported a rating under the VASRD diagnostic codes for limitation of motion (5260 or 5261).  There was no fracture, non-union, or malunion of the femur or tibia to support consideration under the respective codes for knee impairment related to long bone conditions (5255, 5262).  The examinations proximate to separation did not demonstrate the presence of ligamentous instability or laxity (5257), and there was no history of dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258).  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the left knee condition, coded 5260-5024.  

BOARD FINDINGS:  In the matter of the myofascial pain syndrome/ fibromyalgia condition, the Board unanimously recommends a disability rating of 20%, coded 5025 IAW VASRD §4.71a.  In the matter of the left shoulder condition, the Board unanimously agrees that it was unfitting and unanimously recommends a disability rating of 10%, coded 5201-5003 IAW VASRD §4.71a.  In the matter of the bilateral knee pain condition, the Board unanimously recommends that each joint be adjudicated as follows: an unfitting right knee condition coded 5260-5010 and rated 10%, and an unfitting left knee condition, coded 5260-5024 and rated 10%, both IAW VASRD §4.71a.  There were no other conditions within the Board’s scope of review for consideration.  The Board recommends that the CI’s prior determination be modified as follows; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective as of the date of her prior medical separation:  

CONDITION	VASRD CODE	RATING	
Myofascial Pain Syndrome	5025	20%	
Left Acromioclavicular Degenerative Joint Disease	5201-5003	10%	
Right Knee Retropatellar Pain and Osteoarthritis S/P Surgeries	5260-5010	10%	
Left Retropatellar Pain Syndrome	5260-5024	10%	
COMBINED 	40%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20130929, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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 XXXXXXXXXX, XXX-XX-XXXX, AR20160011330 (PD201301722)

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 re-characterize 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 decision:

	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:

			       
						      					
Enclosure
					
CF: 
(  ) DoD PDBR
(  ) DVA