RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02256
BRANCH OF SERVICE:  Army	
DATE OF PLACED ON TDRL:  20000601 	DATE REMOVED FROM TDRL:  20020405

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Dental Specialist, medically separated from the Temporary Disability Retirement List (TDRL) for “fibromyalgia,” “bilateral knee pain,” rated at 10% each, with a combined disability rating of 20%.  “Ehlers-danos syndrome [EDS] type III” and “scoliosis of T6-T11” were determined to have existed prior to service (EPTS) and were not rated.

CI CONTENTION:  “Please consider all conditions.”  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 – 20000313/20011231	VARD - 20031014	
Condition	Code	Rating	Condition	Code	Rating
Proximate	
		TDRL
Placement	TDRL Removal			TDRL Placement	TDRL
Removal	
Fibromyalgia	5025	20%	10%	No VA Placement	
Bilateral Knee Pain	5099- 5003	10%	10%	S/P Arthroscopy R Knee	5257	20%	20%	
				Patellar Chondromalacia Right Knee 	5257	20%	20%	
				S/P Arthroscopy L Knee	5257	20%	20%	
EDS Type III	5099- 5002	EPTS	EPTS	EDS	6399-6350	60%	60%	
Scoliosis	5099- 5003	EPTS	EPTS	Thoracic Scoliosis 	5290-5293	10%	10%	
Bilateral Shoulder Crepitus and Pain	Not Unfitting	No VA Placement	
Bilateral Carpal Tunnel Syndrome		Bilateral CTS	8515	20%	20%	
Situational Depression		Depression	9400	50%	50%	
Mitral Prolapse Valve		Heart Condition	7000	0%	0%	
GERD		GERD	7346	NSC	NSC	
COMBINED RATING:  30% → 20%	COMBIEND RATING OF ALL VA CONDITIONS:  90%	

ANALYSIS SUMMARY.  

The CI was evaluated for multiple conditions with overlapping symptoms.  Accordingly, a single history is presented initially with subsequent discussion of the separate conditions individually.  Review of the record shows that the CI reported a lifelong history of joint hypermobility and hyper-extendibility of his skin.  He had easy bruising and was advised against contact sports due to the risk of joint dislocation.  EDS (a disease of abnormal collagen, leading to laxity of joint ligaments) was not diagnosed until after enlistment though.  In basic training, he sustained an injury to the right knee during hand-to-hand combat training.  This lead to surgical repair of a torn anterior cruciate ligament (ACL) and a partial medial and lateral meniscectomy in 1994, the latter for a medial meniscal tear (MMT) and a lateral meniscal tear (LMT).  He underwent reconstruction of the ACL repair in 1996 and was noted to have hypermobile joints.  This was also noted incidentally in a dermatological appointment in July 1997 and the CI was referred to rheumatology where the diagnosis of EDS was made in November 1997.  He was determined to be non-deployable and an evaluation for possible reclassification was begun.  

The initial rheumatology narrative summary (NARSUM) was undated (likely 21 January 1998 based on a clinical note), but prepared for a presumptive MEB implying that the CI had not yet met a Medical Retention Board (MMRB) for possible training in a different Military Occupational Specialty.  It noted the lifelong history of hypermobility issues and the repair of the right knee ACL with subsequent revision.  The examination showed both hypermobility of the joints and hyper-extendibility of the skin.  An echocardiogram showed mitral valve prolapse (MVP) which required the use of antibiotics prior to certain medical procedures but otherwise had no duty impairment.  The CI was also noted to have a history of bleeding of the conjunctiva (soft tissue lining the outside of the eye) consistent with the EDS diagnosis.  The CI had an MMRB on 2 June 1998 and was referred for Medical Evaluation Board (MEB).  

A general narrative summary (NARSUM), dated 15 July 1998, noted both the EDS as well as ACL instability of the right knee.  On 1 October 1998, an MEB determined the CI did not meet retention standards for the EDS or right knee instability and arthritis.  The MVP did meet retention standards.  The right knee was determined to be unfitting in the PEB dated 29 January 1999 and the EDS was adjudicated as an EPTS condition.  The PEB was returned for further evaluation by the Formal PEB on 12 February 1999.  The CI was evaluated by a different rheumatologist in a second NARSUM.  He was noted to have developed additional symptoms of diffuse musculo-skeletal pain, sleep disturbance and non-restorative sleep, headaches, fatigue, and abnormal sensations over the previous year.  A diagnosis of fibromyalgia syndrome (FMS) was made.  Additional diagnoses included the right knee internal derangement as well as bilateral carpal tunnel syndrome (CTS), gastro-esophageal reflux disease (GERD), depression, and seasonal allergic rhinitis.  Hypermobility was noted and the FMS trigger points were 4+.  An orthopedic addendum to the NARSUM noted ongoing instability of the right knee as well as a history of an elbow infection on the left, decreased motion of the right elbow, neck pain, and hypermobility.  This was then updated to include bilateral shoulder pain and crepitus (a grinding sensation or sound in the joint on movement) thought to be from the EDS with early wear and tear.  He also was noted to have an asymptomatic abnormal curvature (scoliosis) of the spine.  Another general NARSUM was based off of an examination dated 22 September 1999.  It noted that the ACL repair of the right knee was impaired by the EDS.  He was also noted to have had arthroscopy of the left knee and chondromalacia patella (CMP), a disease of the cartilage of the kneecap, was diagnosed.  He was given these diagnoses: EDS Type III, instability of the right knee (written as left, a typo), left knee CMP, bilateral shoulder crepitus and pain, scoliosis, bilateral CTS, FMS, and depression.  

The MEB dated 13 December 1999 listed all of the above eight conditions as well as situational depression GERD without comment of whether or not any or all of these met or failed retention standards.  The PEB dated 13 March 2000 determined that the FMS condition was unfitting and rated it 20%, coded 5025 (FMS), for symptoms present over 1/3 of the time.  The bilateral knee pain was rated 10% and coded analogous to degenerative arthritis (5099-5003).  The EDS Type III and scoliosis conditions were both determined to be EPTS and non-ratable.  The remaining conditions were determined to be not unfitting and not ratable.  The CI was placed on the TDRL on 31 May 2000.  

The VA Compensation and Pension (C&P) general examination was performed on 9 August 2000, 2 months after TDRL palcement.  The specific findings are discussed under the appropriate diagnosis.  

The TDRL evaluation was apparently accomplished by the VA on 2 October 2001.  He was evaluated for 3 conditions (bilateral knee osteoarthritis, EDS Type III, and FMS) as addressed below under each condition.  The TDRL PEB convened on 31 December 2001 and recommended separation.  The CI was rated at 10% for FMS, coded 10%, a reduction from the 20% at TDRL placement, and the knees were continued at 10%, coded 5099-5003.  The EDS Type III and scoliosis conditions remained EPTS.  The CI appealed this decision to the US Army Physical Disability Agency (USAPDA) which upheld the PEB adjudication.  The CI was removed from TDRL and permanently separated on 5 April 2002.  

Fibromyalgia.  As noted above, FMS was mentioned in the undated rheumatology NARSUM prior to the second MEB.  A rheumatology note dated 20 April 1999, also prior to the second MEB (13 December 1999), documented that the FMS was typical and severe despite treatment; however, a follow-up visit 4 days later with the same rheumatologist listed five diagnoses, but did not mention FMS.  The general NARSUM, dated 22 September 1999, noted that the CI had 4+ tender points (probably referring back to the undated rheumatology addendum) and that the FMS exacerbated the symptoms from his other conditions.  An email to the MEB from this same rheumatologist, dated 15 February 2000, noted that the FMS and EDS III were separate diagnoses and EDS was an EPTS condition and generally non-compensable.  The FMS condition was rated 20% and coded 5025 (FMS).  The VA neurology C&P dated 27 July 2000, 2 months after separation, attributed his joint pains to the EDS and did not list FMS as a diagnosis.  The VA joint C&P, dated 9 August 2000, was accomplished by an allergist.  It noted a history of muscle aches and trigger points, but did not comment on these in the examination.  Treatment was not addressed.  The diagnosis of FMS was listed under the impression section.  A general C&P, also dated 9 August 2000, was accomplished in the orthopedic clinic, addressed the EDS condition and the musculoskeletal complaints, but was silent for the FMS condition.  A VA primary care note dated 2 October 2001 listed multiple diagnoses, but was silent for the FMS condition.  The TDRL evaluation was accomplished the same day by the VA (see PEB correspondence as addressed above).  It noted that the CI was in constant pain from the FMS condition and treated it with Tylenol, but the frequency was not recorded.  The CI took 4 Tylenol a day (presumably 325 mg, the most common sized tablet) for the knee pain.  It was noted that he had at least 11 trigger points on “either side of the body.”  It was also recorded that the pain was above and below the waist.  It was also noted that he had been on anti-depressants in the past.  The medical officer observed that the maximum daily dosage of Tylenol for an adult is 4000 mg/day.  The TDRL removal PEB was dated 31 December 2001.  It noted sub-optimal Tylenol dosage for control (of the FMS) and 11/18 trigger points documented on the examination.  The code 5025 was retained, but the rating reduced to 10%.  The CI was permanently separated and removed from TDRL effective 5 April 2002.  A VA rheumatology note dated 30 January 2003 recorded that FMS had been a diagnosis in the past medical history, but it was not listed as a working diagnosis.  

The Board directed its attention to its rating recommendation based on the above evidence.  The VA, in the 5 March 2002 rating decision, subsumed the FMS symptoms under the EDS diagnosis which was rated at 60% under the code for lupus erythematosus (6399-6350).  It retained the rating and code in the 14 October 2003 rating decision.  The PEB rated the CI at 20% for FMS, coded 5025 (FMS) at TDRL placement and 10% at TDRL removal.  The Board considered the evidence.  It noted that the MEB rheumatologist clearly indicated that the EDS Type III and FMS are two distinct conditions and that the former is a genetic condition.  As discussed below, there was evidence in the record which also shows symptoms dating back to childhood and well before accession.  The rating criteria for a 40% level of impairment, under the code 5025, require that the condition be refractory to treatment.  The record supports the observation of the PEB (TDRL removal) that the treatment had been suboptimal.  This does not support a finding that the condition was refractory to treatment.  A route to a rating higher than 20% at TDRL placement was not found.  The Board then considered the rating at TDRL removal.  The TDRL removal NARSUM, done by the VA 3 months prior to separation, indicated that the symptoms were constant; however, a VA primary care note 6 months prior to TDRL removal and a rheumatology note 10 months after TDRL removal were both silent as to current symptoms from the condition and neither listed it as a current diagnosis.  The evidence does not support a rating higher than the 10% adjudicated by the PEB at TDRL removal.  After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the FMS condition at TDRL placement or removal.  

Bilateral Knee Pain.  The record shows that the CI underwent ACL reconstruction and meniscal repair in 1994 with a second surgery in 1996 as documented above.  A third surgery was done on 23 February 1999.  The initial (undated) orthopedic NARSUM recorded right knee ligamentous laxity (instability) and pain with compression of the kneecap.  The range of motion (ROM) was not recorded.  He also had surgery of the left knee, on 19 May 1999, while in the MEB process and continued rehabilitation.  An orthopedic note, dated 6 July 1999, 11 months prior to TDRL placement, documented full ROM (FROM) without laxity.  Painful motion was not recorded, but pain with compression of the kneecap was present.  The NARSUM was dated 22 September noted right knee pain and instability.  The left knee was noted to have FROM without an effusion.  A follow-up orthopedic examination on 18 October 1999, 7 months prior to TDRL placement, showed no change in the examination of the left knee.  An update to the NARSUM, also undated, noted that the CI used a brace for the right knee, but had FROM.  It also recorded that the CI was recovering from the left knee surgery.  The VA C&P dated 9 August 2000, 4 months after TDRL entry, recorded a history of chronic left and right knee pain with right instability.  On the right, he was noted to have lateral instability and limited flexion due to pain.   

The TDRL evaluation, done by the VA on 2 October 2001, 5 months prior to TDRL removal, noted ongoing pain in both knees and that the CI took 4 Tylenol a day without adequate relief (as noted above, this is well below the maximal daily dosage).  He used a brace on the right.  On examination, he had a limp favoring the right.  He was noted to have FROM although flexion was recorded as 130 degrees (normal 140).  Signs of instability were noted on the right.  Some laxity was present on the left, but was attributed to the overall ligamentous laxity (consistent with the EDS diagnosis).  The CI had an orthopedic evaluation on 28 January 2003, 10 months after TDRL removal.  The ROM was not commented upon, but the knees were both noted to be stable and the motor function was normal.  Tenderness above and below the joint lines was present bilaterally.  The goniometric ROM evaluations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.

Knee ROM
(Degrees)	VA C&P ~4 Mo. Post TDRL Placement	C&P ~5 Mo. Pre-TDRL Removal	
	Left	Right	Left	Right	
Flexion (140 Normal)	130	90	130	130	
Extension (0 Normal)	0	0	0	0	
Comment	Right knee limited by pain.  Marked lateral instability.  Right limp with a brace.  Hx of right MMT and LMT	Limp on the right.  Instability on the right.  Painful motion not documented	
§4.71a Rating	0%	20%	0%	10%	

The Board first considered if each knee was separately unfitting.  Both knees had surgery and both symptomatic.  While the right knee was much more impairing than the left, the evidence supports a finding that each was unfitting at TDRL placement.  

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral knee condition at 10%, coded 5099-5003 (analogous to degenerative arthritis) at both TDRL placement and removal.  The VA rated the right knee at 20%, coded 5257 for patellar chondromalacia of the right knee and 0% for the history of arthroscopy of the left knee.  The VA also listed the right knee at 20%, also coded 5257, for status post arthroscopy of the right knee.  This is thought to be in error as there was only a single diagnosis listed at the initial summary of the VARD and only one entry in the discussion.  No change was made on the subsequent VARD dated 5 March 2003.  While the left knee had surgery, painful motion was not documented at either TDRL placement or removal.  Neither was instability nor signs of meniscal irritation.  The Board found no route to a rating higher than 0% for the left knee at TDRL placement or removal.  The Board then considered the right knee.  At TDRL placement, painful motion was documented along with limited motion supporting a 10% rating under the code 5260 (limitation of flexion) or code 5259 (removal of a meniscal cartilage).  A separate 10% rating is also supported under code 5257 (recurrent subluxation or lateral instability at the slight level of impairment).  He used a brace and had a limp, but the record did not show giving way, subluxation, or dislocation.  At the TDRL removal examination, he continued to show signs of instability, but painful motion was not recorded and the ROM was noted to be normal albeit 10 degrees short of the VA normal value of 140 degrees.  A post-separation orthopedic examination showed no instability in either knee.  The evidence supports a 10% rating for instability, coded 5257, at TDRL removal, but only 0% for the 5260 or 5259 codes.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 0% for the left knee condition at TDRL placement and removal, coded 5299-5260.  The recommendation for the right knee is 20% at TDRL placement (10% each for codes 5257 and 5259) at TDRL placement and 10% at TDRL removal (coded 5257).  

Ehlers-Danos Syndrome Type III.  The record shows the CI had a long history of hypermobility of the joints, hyper-elastic skin, and activity limitations prior to accession.  The EDS Type III condition is a genetic condition.  The PEB found that the EDS condition was EPTS.  The Board found no evidence to suggest that it was permanently service aggravated.  The Board noted that the VA rated the condition at 60%, but did not address either the genetic component or the pre-accession manifestations of the disease.  After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the EDS Type III condition.  

Scoliosis.  The PEB also found that the scoliosis was a congenital condition and not permanently service aggravated.  The medical officer observed that scoliosis can be an independent, congenital medical condition or associated with EDS.  The record did not show trauma to the spine or bony pathology to support a finding of an acquired scoliosis or of permanent service aggravation.  The medical officer did note that scoliosis can be progressive in individuals with EDS, but found no evidence of this in the records available for review.  After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the scoliosis condition.  

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that bilateral shoulders, bilateral CTS, situational depression, MVP, and GERD were not unfitting.  The Board’s threshold for countering fitness determinations requires a preponderance of evidence, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  The bilateral shoulders, bilateral CTS, situational depression, MVP, and GERD were not profiled or implicated in the commander’s statement and were not judged to fail retention standards.  All were reviewed and considered by the Board.  There was no performance based evidence from the record that any of these conditions significantly interfered with satisfactory duty performance at the time of separation.  After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the any of the contended conditions and so no additional disability ratings are 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 bilateral knee pain condition, the Board unanimously recommends a disability rating of 0%, coded 5299-5260 IAW VASRD §4.71a for the left knee at TDRL placement and removal.  For the right knee, IAW VASRD §4.71a, the Board unanimously recommends a disability rating of 10%, coded 5257 and 10% coded 5259 at TDRL placement and 10% coded 5257 and 0% coded 5259 at TDRL removal.  In the matter of the contended EDS Type III and scoliosis conditions, the Board unanimously recommends no change from the PEB determinations as EPTS.  In the matter of the contended bilateral shoulders, bilateral CTS, situational depression, MVP, and GERD conditions, the Board unanimously recommends no change from the PEB determinations as not unfitting.  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, effective as of the date of his prior medical separation:  

CONDITION	VASRD CODE	RATING	
		TDRL	PERMANENT	
Fibromyalgia	5025	20%	10%	
Right Knee Pain secondary to MMT and LMT repair	5259	10%	0%	
Right knee Instability	5257	10%	10%	
Left Knee Pain	5299-5260	0%	0%	
Ehlers-Danos Syndrome Type III	5099-5002	EPTS	EPTS	
Scoliosis	5099-5003	EPTS	EPTS	
COMBINED	40%	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140520, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20160010908, XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

I accept the recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) to constructively place you on the Temporary Disability Retired List (TDRL) at a combined disability rating of 40% rather than 30% for the period 31 May 2000 to 4 April 2002 and then following this period no recharacterization of your separation or modification of the permanent disability rating of 20%.  Enclosed is a copy of the Board's recommendation and record of proceedings for your information.

The correction will result in an adjustment to your pay providing you 50% retired pay from the original effective date of your placement on the TDRL and then no recharacterization of your separation or modification of the permanent disability rating of 20% following the TDRL period.

The accepted DoD PDBR recommendation has been forwarded to the Army Physical Disability Agency for required correction of records and then to the U.S. Defense Finance and Accounting Service to make the necessary adjustment to your pay and allowances.  These agencies will provide you with official notification by mail as soon as the directed corrections have been made.  Due to the large number of cases in process, please be advised that it may be several months before you receive notification that the corrections are completed and pay adjusted.  Inquiry concerning your correction of records should be addressed to the U.S. Army Physical Disability Agency, (AHRC-DO), XXXXXXXXXXXXXXXXXXX.

A copy of this decision has also been provided to the Department of Veterans Affairs.

Sincerely,

XXXXXXXXXXXXXXXXXXX
Deputy Assistant Secretary of the Army

Enclosure