RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02141
BRANCH OF SERVICE:  Army 	Date of SEPARATION:  20040521

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reserve, E5, Motor Transport Operator, medically separated for “fibromyalgia syndrome” and “chronic pelvic pain due to endometriosis,” rated 10% and Existed Prior to Service (EPTS), respectively, with  a combined disability rating of 10%.  

CI CONTENTION:  “Please consider all conditions.” 

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 -  20040419	VARD - 20040728	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Fibromyalgia	5025	10%	Fibromyalgia 	5025	20%	STR	
Pelvic Pain due to Endometriosis	7629	EPTS	Endometriosis 	7629	30%		
Thyroid Disorder 	Not Unfitting	Hypothyroidism	7903	10%		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY: 

Fibromyalgia.  In April 2003, while deployed overseas, this CI had pain in her back, chest, neck, and left arm.  In January 2004, after returning to the US, she was seen by Rheumatology.  She reported morning stiffness in her neck, shoulders, arms, and legs.  She said there was loosening as the day progressed.  She stated that muscle aches kept her awake at night.  On physical examination (PE), there were myofascial tender points on cervical spine, elbows, knees, and ankles.  The CI was diagnosed with fibromyalgia.  The examining rheumatologist recommended medications, restorative sleep, and a graded exercise program.  However, in spite of all treatment efforts, the symptoms persisted and an MEB was initiated.  The MEB PE was performed on 3 February 2004.  The CI reported that she had daily pain which was 5/10 (moderate).  The pain was in her shoulders, hips, back, and thighs.  Her pain was worse whenever she overworked, or worked for greater than 6-8 hours per day.  On PE, she appeared to be fatigued.  There was generalized tenderness of the abdomen, but no masses, guarding, or rebound.  PE of the legs revealed bilateral weakness of the legs, because she was unable to do deep knee bend.  There was no muscle atrophy, and no problem with heel-to-toe walk.  Neurologic exam was normal.  As noted above, the CI was found unfit for service and was medically separated.  The PEB chose VASRD diagnostic code 5025 (Fibromyalgia), and rated it 10%.  In a VA Rating Decision (VARD) dated 28 July 2004, the VA also used code 5025, but they assigned a disability rating of 20%.  The VARD rating was based on evidence in the service treatment record (STR).  No musculoskeletal Compensation and Pension (C&P) exam was done at that time.   

The Board directed attention to its rating recommendation based on the above evidence.  In VASRD §4.71a, fibromyalgia is described as widespread musculoskeletal pain and tender points with or without fatigue, sleep disturbance, stiffness, paresthesias, headache, irritable bowel symptoms, depression, anxiety, or Raynaud’s-like symptoms.  A 10% rating applies when the symptoms require continuous medication for control.  A 20% rating applies when the symptoms are episodic, and are present more than one third of the time.  A 40% rating applies when symptoms are constant (or nearly so), and are refractory to treatment.  A critical component of the Board’s deliberation, to reach a fair and accurate recommendation in this case, was to determine whether the CI’s fibromyalgia symptoms were “constant, or nearly so, and refractory to therapy,” or “episodic, with exacerbations often precipitated by environmental or emotional stress or by overexertion, but that are present more than one-third of the time,” or “requiring continuous medication for control.”  

The Board determined that, based on the evidence, it was more likely than not that at separation the fibromyalgia symptoms required continuous medication for control.  There was insufficient evidence in the record to justify a conclusion that the symptoms were present more than one-third of the time.  There was also insufficient evidence in the record to justify a conclusion that the symptoms were constant, or nearly so, and refractory to therapy.  After due deliberation, considering all of the evidence, and mindful of VASRD §4.3 (Reasonable doubt), the Board found insufficient cause to recommend a change in the PEB adjudication of the unfitting fibromyalgia condition.  It is appropriately coded 5025, and IAW VASRD §4.71a, meets criteria for the 10% rating level.  

Endometriosis.  This CI has a history of chronic pelvic pain.  In June 2000, she had laparoscopy and was diagnosed with endometriosis.  In October 2003, while deployed overseas, she experienced a worsening of symptoms.  After returning to the US, she was seen by a Gynecologist.  Pelvic ultrasound revealed a small uterine fibroid, but was otherwise negative.  She was treated with Lupron, an injectable medication that is often used to treat endometriosis.  The April 2004 PEB adjudicated the endometriosis as “existed prior to service (EPTS).”  On DA Form 199, the PEB wrote: “There is compelling evidence to support a finding that the current condition existed prior to service (EPTS) and was not permanently aggravated beyond natural progression by such service.”

The Board directed attention to its rating recommendation based on the above evidence. Service aggravation is defined as the permanent worsening of a pre-Service medical condition over and above the natural progression of the condition, caused by trauma or the nature of Military Service.  The presumption that a disease is aggravated in the line of duty may only be overcome by competent medical evidence establishing by a preponderance of evidence that the disease was clearly not aggravated while serving on active duty or authorized training.  Such medical evidence must be based upon well-established medical principles, not personal medical opinion alone.  After due deliberation, considering all of the evidence, the Board recommended a disability rating of 10% for the endometriosis condition.  The condition had existed prior to service (EPTS), but was permanently aggravated beyond natural progression by military service.  

Thyroid Disorder.  In February 2004, the CI was diagnosed with hypothyroidism.  This condition was adjudicated by the PEB as not unfitting.  The Board’s main charge with respect to this condition is to assess the appropriateness of the PEB’s adjudication.  The Board’s threshold for countering a fitness determination is higher than the VASRD §4.3 (reasonable doubt) standard used for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard. This condition was thoroughly reviewed by the action officer and considered by the Board.  The thyroid disorder was not judged to fail retention standards, nor was it specifically profiled.  The Board determined that there was insufficient evidence in the record that the thyroid disorder significantly interfered with satisfactory performance of military duties.  After due deliberation, and in consideration of the preponderance of the evidence, the Board found insufficient cause to recommend a change in the PEB adjudication of the thyroid disorder.  Therefore, no additional disability rating is recommended.    

BOARD FINDINGS:  In the matter of the fibromyalgia condition, and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the endometriosis condition, the Board by majority recommends a disability rating of 10%, coded 7629, IAW VASRD §4.116.  The single voter for dissent did not elect to submit a minority opinion.  In the matter of the thyroid disorder, the Board unanimously recommends no change from the PEB determination.  There were no other conditions within the Board’s scope of review for consideration.  The Board, therefore, recommends that the CI’s prior determination be modified as follows, effective as of the date of her prior medical separation:  

CONDITION	VASRD CODE	RATING	
Fibromyalgia syndrome	5025	10%	
Chronic pelvic pain, due to endometriosis 	7629	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140507, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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 XXXXXXXXXXXXXXXXXXXXX AR20160007115 (PD201402141)

1. I have reviewed the enclosed Department of Defense Physical Disability Board of
Review (000 PDBR) recommendation and record of proceedings pertaining to the
subject individual. Under the authority of Title 10, United States Code, section 1554a,
accept the Board's recommendation to modify the individual's disability rating to 20%
without re-characterization of the individual's separation. This decision is final.

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.

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:

CF:
( ) DoD PDBR
( ) DVA