RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00678
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060928

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Human Resources Specialist, medically separated for “chronic widespread pain involving the spine, upper and lower extremities…diagnosed as fibromyalgia,” with a disability rating of 20%.  

CI CONTENTION:  The CI contends “I have chronic pain syndrome through my entire body.”  The CI’s 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 - 20060808	VARD - 20070515	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Widespread Pain Involving the Spine, Upper Extremities and Lower Extremities … Minimal Degenerative Arthritis Changes … Diagnosed as Fibromyalgia 	5025	20%	Chronic Fibromyalgia…	5025	40%	20060824	
			Right Knee, PFPS	5099-5010	10%		
			Left Knee, PFPS	5099-5010	10%		
			Right Elbow Epicondylitis	5099-5020	10%		
			Left Elbow Epicondylitis	5099-5020	10%		
			Left Foot Achilles Tendonitis	5024	10%		
			Right Forearm DJD	5024	10%		
			Pain Disorder a/w Psychological and General Medical Condition	9400	Deferred*	-	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  80%	
* VARD dated 20080118 changed rating for code 9440 to NSC (CI failed to report for exam).  

ANALYSIS SUMMARY:  

Chronic Widespread Pain Involving the Spine, Upper Extremities and Lower Extremities.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI had long standing generalized chronic pain syndrome which was constant and had multiple recurrent episodes throughout the years.  The CI had multiple joint pain diagnoses (neck, back, hips, elbows, wrists, ankles and knees) and was diagnosed with generalized chronic pain syndrome.  She was evaluated by rheumatology and additionally diagnosed with fibromyalgia, and also had co-morbid depression.  Despite treatment, the back 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 “generalized chronic pain syndrome” and “fibromyalgia” for PEB adjudication.  Co-morbid depression was an MEB condition that was determined to meet retention standards.  

At the MEB examination (recorded on DD Forms 2807 and 2808) dated April 2006, 6 months prior to separation, the CI reported bilateral shoulder pain, arthritis in joints, shoulder and lower extremity arthritis and numbness, constant migraine-like headache, pain and numbness in her upper arms.  The examiner indicated chronic pain syndrome, fibromyalgia and degenerative joint disease (DJD) combined, history of migraine headaches, and chronic pain syndrome and weakness.  Physical examination showed tender shoulders with pain-limited range of motion (ROM); tender ankles, knees bilaterally unable to abduct; tender cervical lumbar spine; and hip pain with motion.  

The MEB NARSUM examination dated April 2006 (6 months prior to separation) showed the CI appeared to be in general discomfort and had obvious ROM limitations in her extremities.  Cervical flexion and extension were severely limited to about 20 degrees (normal 45 degrees).  The thoracic spine had visible scoliosis (abnormal side curve) with tenderness and limited motion, and the lumbar spine was tender with limited motion.  Both elbows were tender with painful supination bilaterally and pain-limited elbow ROM.  Both shoulders were tender with abduction totally restricted – unable to elevate arms to 90 degrees (normal 180) and maintain them due to excruciating pain.  Bilateral wrists were painful with palpation and had positive Tinel’s sign (diagnosed as carpal tunnel syndrome).  Bilateral hips were tender with abduction limited to about 25 degrees (normal 45).  Both knees had suprapatellar pain with full ROM.  Both ankles were tender and had painful ROM.  Gait was normal and the muscles of both upper extremities were weak (3/5 - with normal 5/5).  X-rays showed degenerative changes in both hips and both ankles.  The examiner stated that the pain syndrome had failed to adequately respond to conventional therapy, and symptoms resulted in loss of numerous days from work.  

An MEB addendum in June 2006 (3 months prior to separation) reiterated the multiple joint symptoms and diagnosis of chronic pain syndrome as the primary diagnosis with an additional diagnosis of fibromyalgia.  Examination indicated the CI appeared to be hurting due to multiple joint pain.  Neurologic examination was consistent with multiple pain.  Extremities examination was consistent with pain doing passive ROM.  X-rays from May and June 2006 showed DJD of the right forearm and normal findings for the cervical spine and right wrist.  

At the VA Compensation and Pension (C&P) examination in August 2006, performed a month before separation, the CI reported complaints of recurrent headaches, insomnia, aches and pains in multiple joints including the cervical and thoracolumbar spine, upper and lower extremities and feet.  The examiner reported that these areas were the main trigger points for the fibromyalgia.  Physical examination showed a normal gait.  Both feet had pain and stiffness.  There was pain-limited, or painful, ROMs of the cervical spine, thoracolumbar spine, bilateral elbows, right forearm, and left ankle.  There was normal ROMs of the hips, knees and wrists.  Both knees were tender to palpation in the patellofemoral area, without laxity or instability.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 20% rating under the 5025 code (Fibromyalgia (fibrositis, primary fibromyalgia syndrome)), citing exacerbations that were precipitated by stress and over exertion and symptoms were present more than one third of the time.  The VA assigned a 40% rating using the 5025 code based on the VA C&P examination 1 month before separation, citing symptoms that were constant, or nearly so, and refractory to therapy (included cervical and thoracolumbar spine, chronic headaches, fatigue, and sleep disturbances).  The VA also separately rated each knee, each elbow, the left foot and the right forearm at 10% each (6 joints) as depicted in the rating comparison chart above, citing painful or limited motion or functional loss.  The ratings under 5025 are “With 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."  

The Board first considered if any joint condition rose to the level of being separately or combined as unfitting and ratable (as rated by the VA).  The presence of functional impairment with a direct impact on fitness is the key determinant in the Board’s decision to recommend any condition for rating as additionally unfitting.  While the CI may have suffered additional pain and limitations from the joint conditions, there was no evidence in this case that any specific joint disability existed to any degree that could be described as functionally impairing.  The Board therefore concluded that no separate joint disability rating was justified, however, the disability for all the joints would be appropriately considered for the rating under code 5025.  

The Board deliberated between the 40% criteria of symptoms “that are constant, or nearly so, and refractory to therapy" and the 20% criteria of symptoms "that are episodic, with exacerbations often precipitated by environmental or emotional stress or by overexertion, but that are present more than one-third of the time."  The record clearly documented that the CI's symptoms were refractory to therapy.  The record also indicated symptoms that were nearly constant with multiple treatment visits, lost work, and little indication of periods of being without some of the fibromyalgia symptoms noted under code 5025.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 40% for the chronic widespread pain condition, coded 5025.  

BOARD FINDINGS:  In the matter of the chronic widespread pain condition, the Board unanimously recommends a disability rating of 40%, coded 5025 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 the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic Widespread Pain Involving the Spine, Upper Extremities and Lower Extremities … Minimal Degenerative Arthritis Changes … Diagnosed as Fibromyalgia	5025	40%	
COMBINED	40%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20131223, 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 XXXXXXXXXXXXXXXXXX, AR20160013048 (PD201400678)

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 recharacterize 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 memorandum:

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