RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	     CASE:  PD-2014-00792
BRANCH OF SERVICE:  ARMY		SEPARATION DATE:  20090407

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E7, Intelligence Analyst, medically separated for “fibromyalgia,” with a disability rating of 20%.    

CI CONTENTION:  Her fibromyalgia condition continues to worsen and negatively impact her daily activities.   The 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 - 20081215	VARD - 20090529  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Fibromyalgia	5025	20%	Fibromyalgia	5025	10%	20090218	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  70%	

ANALYSIS SUMMARY:  

Fibromyalgia Condition.  The record shows that the CI had a long history of musculo-skeletal pain with evaluations for ankle, knee, back, and neck pain.  She was treated with duty restrictions, medications, and physical therapy without resolution of her pain.  However, she continued to excel at her duty and did well on her physical fitness testing (low 270s in March 2008 and 293 in October 2006).  Due to chronic ankle and back pain, she was entered into the Medical Evaluation Board (MEB) process in June 2008.  During the MEB evaluations, she was referred to podiatry for possible ankle reconstruction due to her recurrent sprains.  The podiatrist was concerned about a possible chronic pain syndrome and referred the CI to rheumatology.  She was evaluated on 14 August 2008 and reported morning joint stiffness and a 7-year history of midline back pain.  Her examination was remarkable for spasm of the lumbosacral muscles and also for the presence of 12/18 trigger-points for fibromyalgia.  She was noted to meet all the criteria for the diagnosis of fibromyalgia and begun on medications.  At follow-up 2 weeks later, she reported trouble sleeping and her medications were changed.  On 12 September 2008, she reported some improvement; her medications were again changed to better treat a concomitant depression.  The narrative summary (NARSUM) was dated 24 October 2008, 5 months prior to separation and 2 months after initiation of treatment.  She reported continued discomfort and poor tolerance to her medications due to nausea and GI [gastrointestinal] upset.  She did not believe that she could meet her mental or physical duty requirements due to her fibromyalgia.  On examination, she had tenderness to palpation about the shoulder blades, but a listing of fibromyalgia trigger points was not recorded.  Sensation and motor function were normal.  The range-of-motion (ROM) of the neck, back, hips, knees, and ankles was normal or near normal in all planes.  She was diagnosed with fibromyalgia.  At the VA Compensation and Pension (C&P) examination performed on 18 February 2009, 6 weeks prior to separation, the CI reported pain of the back, left shoulder, bilateral wrists, hips, knees, ankles, and feet.  She took Tylenol for pain as the other medications which she had been prescribed caused GI distress.  On examination, she had a normal posture and gait.  Motor function was normal and 12/18 trigger points were positive.  She was diagnosed with fibromyalgia, but also flat feet (pes planus) and strain of the ankles, knees, hips, thoracolumbar spine, left shoulder, and wrists.  She was evaluated in primary care on 11 May 2009, 1 month after separation, and reported ongoing pain, but denied systemic symptoms such as weight loss, poor appetite, fever, or chills.  At a rheumatology follow-up on 9 June 2009, she reported ongoing pain and waking up from pain during the night.  Her medications were again modified.  She had also been told to drink tonic water for her muscle cramps and found it beneficial initially, but reported recurrent symptoms 2 weeks later.  At the rheumatology follow-up on 23 June 2009, she was begun on a different medication.  The VA conducted an additional C&P examination on 2 December 2009 (also noted as 14 November 2009, the day of a mental health evaluation.  It is not clear if there were two different C&P examinations for the joints within 3 weeks of each other or not; this was thought by the Board to be an administrative error).  The CI again reported diffuse pain.  Her gait was normal as was the strength.  The ROM remained normal or near normal for all which were measured.  

Ratable criteria for fibromyalgia include 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.  Of these, fatigue, sleep disturbance, depression, and anxiety were noted prior to separation.  The former two were attributed to the fibromyalgia and showed some benefit with treatment.  The latter two diagnoses, both mental health issues, were attributed to pre-service stressors and to military sexual trauma, although her depression was aggravated by the fibromyalgia.  Stiffness was also noted, but this was not generalized.  Rather, it was found in specific joints.  Also, there was radiographic evidence for degenerative joint disease.  

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB rated the fibromyalgia condition at 20%, coded 5025 (fibromyalgia) for episodic exacerbations present over 1/3 of the time.  The VA rated the fibromyalgia condition at 10%, also coded 5025.  It noted that generalized muscle weakness or wasting were not present.  Also, the VA service-connected and provided compensable ratings for the knees, hips, ankles, and lower back.  As noted in the decision to a subsequent appeal, the VA attributed some symptoms to these in order to support a higher combined rating.  The MEB and PEB though, did not consider any other musculoskeletal conditions besides flat feet (pes planus, which was non-compensable).  The latter was not contended by the CI and thus only fibromyalgia is in the scope of the Board.  The Board considered the description of the higher 40% rating “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 that are constant, or nearly so, and refractory to therapy.”  She was noted to have some symptoms, but did show a partial response to treatment.  A 40% rating was not supported by the evidence.  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 fibromyalgia condition.  

BOARD FINDINGS:  In the matter of the fibromyalgia 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.  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 20140218, 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, AR20160006027 (PD201400792)

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:

Enclosure

CF: 
(  ) DoD PDBR
(  ) DVA