RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX		CASE:  PD-2014-03509
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20020718

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E6, Voice Interceptor/ Transcriber, medically separated for “fibromyalgia with low back pain” and “chronic pain temporomandibular joint (TMJ), left wrist, right ankle, and left shoulder,” rated 10% and 10% respectively, with a combined disability rating of 20%.

CI CONTENTION:  The CI requests the Board 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 based upon a 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 - Dated 20020409	VARD - 20030519	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Fibromyalgia with Low Back Pain	5025	10%	Fibromyalgia	5025	20%	20021205	
			Lumbar Strain	5295	0%	20021205	
Chronic Pain TMJ, Left Wrist, Right Ankle, Left Shoulder	5099-5003	10%	TMJ Dysfunction	9905	10%	20021206	
			S/P Arthroscopic Surgery Left Wrist	5215	10%	20021205	
			S/P Right Ankle Inversion Sprain	5271	10%	20021205	
			Left Shoulder Impingement Syndrome	5203	10%	20021205	
Obstructive Sleep Apnea	Not Unfitting	Sleep Apnea	6847	50%	20021205	
Cognitive Disorder	Not Unfitting	Cognitive Disorder	9310	30%	20021205	
Migraine Headaches	Not Unfitting	Migraines	8100	30%	20021205	
History of Irritable Bowel Syndrome	Not Unfitting	No VA Placement	
Hypertension	Not Unfitting	Hypertension	7101	10%	20021205	
COMBINED RATING:  20%	COMBINED RATING FOR ALL VA CONDITIONS:  90%	

ANALYSIS SUMMARY:

Fibromyalgia Condition.  According to service treatment records (STR) and the Medical Evaluation Board narrative summary (NARSUM) the CI was hospitalized for possible Gulf War Syndrome in 1994 and diagnosed with fibromyalgia in 1998.  Fibromyalgia is characterized by widespread musculoskeletal pain and tender points, with or without associated fatigue, sleep disturbance, stiffness, paresthesias (abnormal sensation, tingling, burning, prickling), headache, irritable bowel symptoms, depression, anxiety, or Raynaud’s-like symptoms (recurrent finger and toe vasospasm in response to cold or stress).  The 30 January 2002 MEB addendum by rheumatology documented “The patient was diagnosed with fibromyalgia syndrome in 1998 by Rheumatology at Wilford Hall Medical Center (WHMC) with manifestations of polyarthralgia, TMJ, headache, fatigue and irritable bowel syndrome.  The patient was also diagnosed with obstructive sleep apnea [OSA] which was contributing to his poor sleep.”  He underwent surgery (uvulopalatopharyngoplasty [UPPP] resection of uvula, tonsils, soft palate, and lateral pharyngeal tissue) in an attempt to correct the OSA and subsequently was started on CPAP.  The CI reported improved sleep and less fatigue.  He endorsed mild to moderate fatigue and morning stiffness lasting approximately 2 hours.  The CI complained of moderate constant pain involving the neck, back, shoulders, elbows, knees, and ankles with minimal to mild swelling of the knees and ankles.  Symptoms significantly impacted upon his ability to perform activities of daily living (ADLs) to include dressing, grooming, bathing, cleaning, meal preparation, some work duties, and getting and in and out of beds and cars.  Pain was improved with medication (Diclofenac) and resolved with rest.  The joint examination revealed all joints were without synovitis (synovial membrane inflammation) and normal range of motion (ROM) except for decreased shoulder (L greater than R) active ROM.  The musculoskeletal examination was “notable for greater than 11/18 American College of Rheumatology tender points located above and below the waist and occurring symmetrically on both sides of the body.”  The diagnosis listed fibromyalgia syndrome.  In the 5 December 2002 VA Compensation and Pension (C&P) examination, 5 months after separation, the CI complained of multiple joint pains, back pain, neck pain, jaw pain, TMJ syndrome, headache, sleep disturbance, stiffness, and anxiety.  He reported symptoms were present more than 2/3 of the year and were precipitated by drastic change in temperature, emotional stress, and overexertion.  Symptoms impacted upon his ability to perform ADLs to include normal activities, dressing, and exercise.  The CI stated his fibromyalgia required continuous treatment and it caused him to lose approximately 2 hours a day from work.  Pain was improved with medications (Diclofenac, Midrin, Amitriptyline, and Flexeril).  The musculoskeletal examination documented “multiple tender points, starting at the cervical spine through the trapezius down entire length of the spine to the SI joints, the hips, the upper arms, the forearms, elbows, wrists, hips, thighs and knees.”  The diagnosis listed active fibromyalgia.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under the 5025 code (fibromyalgia) citing relatively well controlled with medication.  The VA assigned a 20% rating under the 5025 code (fibromyalgia) based on the VA C&P examination 5 months after separation, citing 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 episodic, with exacerbations often precipitated by environmental or emotional stress or by overexertion, and that are present more than 1/3 of the time.  The VA C&P examination findings of multiple tender points, multiple joint pains, back pain, neck pain, jaw pain, TMJ syndrome, headache, sleep disturbance, stiffness, anxiety, symptoms precipitated by change in temperature, emotional stress, and overexertion symptoms, symptoms present more than 2/3 of the year, and symptoms requiring continuous treatment were consistent with the 20% rating under 5025.  The higher 40% rating would require symptoms that are constant, or nearly so, and refractory to therapy.  The record does not support that the core symptoms were constant, or nearly so, and refractory to therapy.  The Board agreed the evidence was consistent with the 20% 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 fibromyalgia condition, coded 5025.  

Temporomandibular Joint (TMJ) Condition.  According to the STR and MEB NARSUM, the CI’s TMJ condition began after he slipped and fell on the snow while carrying a heavy projectile in 1984 which resulted in bilateral clicking and popping.  He was treated conservatively with nonsteroidal anti-inflammatories (NSAIDs).  At an 8 June 2001 MEB addendum by otolaryngology, 1 month before separation, the CI noted a history of bilateral clicking and popping since 1986.  He reported two episodes when he had “frozen joints.”  The CI modified his diet to increase softer foods since 1988.  He worked as a linguist and noted increasing pain after prolonged daily headphone use with associated headaches.  The CI reported multiple conservative strategies for the temporomandibular disorder and reported “good success” with the current Voltaren.  The physical examination revealed bilateral crepitus (grating sensation or sound) at the TMJs.  The oropharynx examination revealed surgical (UPPP) changes.  The oral cavity opened to 30 mm.  The addendum documented the CI was “having good success with current regimen of Voltaren 75 mg po bid to tid; using heat packs prn.”  The examiner documented “Recommend continued medical therapy, no surgical procedures are indicated at this time.”  The diagnosis listed bilateral temporomandibular disorder.  The 6 December 2002 dental C&P examination, 5 months after separation, oral examination revealed a normal mandible, maxilla, ramus, and palate.  The temporomandibular articulation revealed the mid-line was within normal limits.  The inter-incisal opening was 36 mm.  Both the right and the left lateral excursions were 1 mm.  The diagnosis listed TMJ dysfunction.  The examiner documented “Recommend a forward repositioning splint followed by orthodontics and possible orthognathic surgery.”  

The Board directed attention to its rating recommendation based on the above evidence.  As previously elaborated, the Board must first consider whether the TMJ condition remains separately unfitting, having been de-coupled from a combined PEB adjudication.  The PEB assigned a 10% rating under an analogous 5003 code citing chronic TMJ pain and rated as slight/frequent pain IAW USAPDA pain policy.  The VA assigned a 10% rating under the 9905 code (temporomandibular articulation, limited motion of) based on the dental VA C&P examination citing mid-line was within normal limits, inter-incisal opening was 36 mm, and bilateral lateral excursions were 1 mm.  The Board concluded that the evidence did not provide sufficient grounds for recommending a separate TMJ disability rating in this case, and that a combined conditions rating of 10%, coded 5099-5003, is a good analogy to both the pathology and disability.  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 TMJ condition.  

Left Wrist Condition.  According to the STR and MEB NARSUM, the CI’s left wrist condition began during training in 1998.  The 5 November 2001 NARSUM, 8 months before separation, documented that the left-hand dominant CI sustained a left shoulder and left wrist injury during a training exercise carrying a litter with a 100 pound mannequin while crawling.  He felt and heard a pop from the left shoulder and wrist, and had immediate onset of pain.  He sustained a left wrist triangular fibrocartilage complex (TFCC) tear and underwent left wrist arthroscopy in April 1998.  Postoperatively, the CI achieved 85% wrist strength with an occasional popping sensation after rehabilitation.  He complained of intermittent pain with gripping, leading to a loss of strength.  Pain was exacerbated by pushups and prolonged typing.  The examiner referred to the previous physical examination (SF 88/93) for general examination findings.  The left wrist examination revealed dorsal midline tenderness with no edema (excess tissue fluid swelling), erythema (redness), or crepitus.  Pain-free active ROM was extension of 50 (70 normal) and flexion of 50 (80 norma) degrees with full supination and pronation.  Strength (5/5), sensation (light touch), and pulses were normal.  A left wrist X-ray was unremarkable.  The diagnosis listed moderate left wrist pain.  The VA C&P examination recounted the history and interventions.  The CI complained of limited left wrist flexibility, painful movement, and loss of strength.  The left wrist examination revealed slight swelling with marked crepitus and a feeling of subluxation (incomplete or partial dislocation) with ROM.  Left wrist pain-limited active ROM was dorsiflexion of 50 (70 normal), palmar flexion of 50 (60 normal), radial deviation of 10 (20 normal), and ulnar deviation of 40 (45 normal) degrees. 

The Board directed attention to its rating recommendation based on the above evidence.  As previously elaborated, the Board must next consider whether the left wrist condition remains separately unfitting, having been de-coupled from a combined PEB adjudication.  The PEB assigned a 10% rating under an analogous 5003 code citing chronic left wrist pain and rated as slight/frequent pain IAW USAPDA pain policy.  The VA assigned a 10% rating under the 5215 code (wrist, limitation of motion of) based on the VA C&P examination citing limited flexibility, painful movement, loss of strength, swelling, and ROM.  The Board concluded that the evidence did not provide sufficient grounds for recommending a separate left wrist disability rating in this case, and that a combined conditions rating of 10%, coded 5099-5003, is a good analogy to both the pathology and disability.  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 left wrist condition.  

Right Ankle Condition.  According to the STR and MEB NARSUM, the CI’s right ankle condition began during training in 1999.  The NARSUM documented that the CI complained of a 2 year history of right ankle pain following a sprain in a motor vehicle accident (MVA).  There had been no significant improvement with NSAIDs.  Pain was exacerbated by running and tolerable with current medications.  The right ankle examination revealed no tenderness, edema, erythema, or crepitus.  Pain-free active ROM was dorsiflexion of 5 (20 normal) and plantar flexion of 40 (45 normal) degrees.  Strength (5/5), sensation (light touch), and pulses were normal.  Left ankle X-rays showed mild degenerative changes of the medial and lateral malleoli.  Left ankle magnetic resonance imaging (MRI) showed a small osteochondritis dissecans ([OCD] fragment of cartilage and bone separating from joint surface) lesion on the talar dome a mild tendonopathy of the peroneal tendons.  The diagnosis listed right talar dome OCD lesion.  The VA C&P examination recounted the history and interventions.  The CI complained of chronic right ankle pain, weakness, stiffness, swelling, fatigue, and limited ROM.  The right ankle revealed a normal appearance.  Right ankle active ROM was dorsiflexion of 15 (20 normal) and plantar flexion of 25 (45 normal) degrees.  The ROM was limited by stiffness and discomfort, but not fatigue, weakness, lack of endurance, or incoordination.  

The Board directed attention to its rating recommendation based on the above evidence.  As previously elaborated, the Board must next consider whether the right ankle condition remains separately unfitting, having been de-coupled from a combined PEB adjudication.  The PEB assigned a 10% rating under an analogous 5003 code citing chronic right ankle pain and rated as slight/frequent pain IAW USAPDA pain policy.  The VA assigned a 10% rating under the 5271 code (ankle, limitation of motion of) based on the VA C&P examination citing normal appearance, pain, weakness, stiffness, swelling, fatigue, and ROM.  The Board concluded that the evidence did not provide sufficient grounds for recommending a separate right ankle disability rating in this case, and that a combined conditions rating of 10%, coded 5099-5003, is a good analogy to both the pathology and disability.  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 right ankle condition.  

Left Shoulder Condition.  According to the STR and MEB NARSUM, the CI’s left shoulder condition began during training in 1998.  The NARSUM documented that the CI sustained a left shoulder injury during a training exercise carrying a litter with a 100-pound mannequin while crawling.  He felt and heard a pop from the left shoulder and wrist, and had immediate onset of pain.  He sustained a left shoulder superior labral anterior to posterior (SLAP) tear and underwent left shoulder arthroscopy in October 1998.  Postoperatively, symptoms improved somewhat, but he still had intermittent left shoulder pain.  Pain was exacerbated by pushups.  The left shoulder examination revealed muscle tone that was symmetrical with the right with no tenderness or crepitus.  Active ROM was flexion of 170 (180 normal) and abduction of 180 (180 normal) degrees with pain at extreme of ROM.  Impingement tests (Hawkin’s, Neer’s) were positive, an instability test (sulcus sign) was positive, acromioclavicular (AC) joint tests (cross arm = positive, O’Brien’s = negative, Speed’s = negative) were mixed, and a rotator cuff strength test (lift-off) test was negative.  Strength (5/5) and sensation (light touch) were normal.  A left shoulder magnetic resonance arthrogram (MRA) showed mild tendonopathy (chronic localized tendon thickening) of the long head biceps tendon with no rotator cuff tear or SLAP lesion noted.  The diagnosis listed mild left shoulder impingement syndrome.  The VA C&P examination recounted the history and interventions.  The CI complained of painful left shoulder movement and paresthesias in the ulnar nerve distribution with running or aerobic exercises.  Left shoulder pain-limited active ROM was flexion of 160 (180 normal) abduction of 110 (180 normal) degrees.  The ROM was limited by pain, but not fatigue, weakness, lack of endurance, or incoordination.  

The Board directed attention to its rating recommendation based on the above evidence.  As previously elaborated, the Board must next consider whether the left shoulder condition remains separately unfitting, having been de-coupled from a combined PEB adjudication.  The PEB assigned a 10% rating under an analogous 5003 code citing chronic left shoulder pain and rated as slight/frequent pain IAW USAPDA pain policy.  The VA assigned a 10% rating under the 5203 code (clavicle or scapula, impairment of) based on the VA C&P examination citing painful movement, paresthesias in the ulnar nerve distribution, and ROM.  The Board concluded that the evidence did not provide sufficient grounds for recommending a separate left shoulder disability rating in this case, and that a combined conditions rating of 10%, coded 5099-5003, is a good analogy to both the pathology and disability.  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 left shoulder condition.  

Contended PEB Conditions.  OSA, cognitive disorder, migraine headaches, irritable bowel syndrome, and hypertension.  While the cognitive disorder was implicated by the commander’s statement (CI’s inability to concentrate), the OSA, migraine headaches, irritable bowel syndrome, and hypertension conditions were not.  The OSA, cognitive disorder, migraine headaches, irritable bowel syndrome, and hypertension conditions were not profiled 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 separation.  After due deliberation, and 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 OSA, cognitive disorder, migraine headaches, irritable bowel syndrome, and hypertension conditions and so no additional disability ratings are recommended.

BOARD FINDINGS:  In the matter of the fibromyalgia condition, the Board unanimously recommends a disability rating of 20%, coded 9905 IAW VASRD §4.71a.  In the matter of the chronic pain TMJ, left wrist, right ankle, left shoulder conditions and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended OSA, cognitive disorder, migraine headaches, irritable bowel syndrome, and hypertension 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; 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	
Fibromyalgia	5025	20%	
Chronic Pain TMJ, Left Wrist, Right Ankle, Left Shoulder 	5099-5003	10%	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150627, with attachments
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 
, AR20160017500 (PD201403509)

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 30% 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 30% 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.

Enclosure
					
CF: 
(  ) DoD PDBR
(  ) DVA