RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	     CASE:  PD-2014-03887
BRANCH OF SERVICE:  NAVY                                                                  SEPARATION DATE:  20011106

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Mess Attendant Specialist, medically separated for “fibromyalgia, syndrome” with a disability rating of 10%. 

CI CONTENTION:   The CI requested consideration of 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 20011002	VARD - 20020125	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Fibromyalgia Syndrome	5025	10%	Fibromyalgia 	5025 	40%	20011001	
Chronic Pelvic Pain	Related to Diagnosis 1	No VA Placement	
Chronic Headaches	Related to Diagnosis 1	Migraine Headaches	8100	30%	20011001	
Degenerative Disk Disease (DDD)	Related to Diagnosis 1	Cervical DJD	5290	30%	20011001	
Possible History of Meniere Disease	Cat III	Meniere’s Disease…	6204	10%	20011001	
History of Uterine Fibroids	Cat III	Uterine Fibroids	7613	0%	20011001	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDTIONS:  80%	

ANALYSIS SUMMARY:  

Fibromyalgia Syndrome with Related Chronic Pelvic Pain, Chronic Headaches, and DDD.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI had problems with headaches as a teenager, but did not have recorded problems with these for the first few years after accession in 1993.  The first record in evidence for headaches was a primary care note in February 1997 in which she was thought to have “stress headaches” and treated with aspirin and recommended to get adequate sleep.  She was next seen in January 2000 when she reported a one year history of neck pain without antecedent trauma and was thought to have a strain.  The CI was then evaluated for multiple, but overlapping conditions of headaches, neck pain, pelvic pain, and finally fibromyalgia syndrome (FMS).  These are discussed separately below.  

	Chronic Pelvic Pain.  The records show that the CI was evaluated several times for pelvic pain in 2001, beginning in June.  She reported daily pain which lasted from 10–120 minutes.  Her evaluation was remarkable for fibroids of the uterus; no etiology for the pain was found although it was thought to be related to either the fibroids or to the underlying FMS.  The record does not show significant duty impairment from a pelvic condition.  The evidence does not support a finding that the pelvic pain was separately unfitting at separation.  

	Headaches.  Following the initial presentation in 1997, the next record specifically for headaches was an emergency room (ER) note dated 12 October 2000.  The CI was treated with injections for nausea and vomiting and placed on quarters for 24 hours.  Over the next year, the CI had multiple appointments for evaluation of the headache condition but no further acute visits for treatment.  The MEB NARSUM noted that the CI had multiple muscular aches and pains, especially in her neck.  It was not clear if the headaches were a separate diagnosis or related to the FMS.  The non-medical assessment dated 30 July 2001 recorded that she stood watch but did not have additional duties.  It also noted that the CI complained of chronic headaches and that “she is overall dissatisfied with Naval service.”  Lost duty time from the headaches was not documented.  The MEB examination (recorded on DD Form 2807 Report of Medical History and DD Form 2808 Report of Medical Examination) the same day noted that the headaches were thought to be related to the FMS.  At the VA Compensation and Pension (C&P) evaluation, performed on 1 October 2001, 1 month before separation, the CI reported that she had headaches once a week and that these lasted 1-2 days.  She needed to take time off from work about 50% of the time.  The Board did not find evidence in the record to corroborate this statement.  It found no evidence of prostrating attacks in the STRs other than the above ER note dated 12 October 2000, over 1 year prior to separation.  A CT and MRI of the head were both normal.  The evidence does not support the addition of the headaches as a separately unfitting condition.  The Board noted that even if the headaches were determined to be unfitting, no more than a 0% rating could be assigned as there was no evidence of prostrating headaches in the year prior to separation other than the history provided by the CI to the VA.  

	Degenerative Disc Disease (Neck pain).  One month after the initial presentation, the CI reported the onset of neck discomfort as over a year previous.  Her examination was remarkable for tenderness, but a normal neurological examination and full range of motion (ROM).  An MRI on 16 March 2000 showed multilevel DDD without neural compromise.  The next day, she was noted to have limitation of motion from pain at the extremes of motion.  In neurology on 21 April 2000, she was noted to have an unremarkable neurological examination and a trial of injections was recommended.  This was done in the pain clinic on 10 July 2000 with some improvement; the ROM and neurological examination were normal.  On 18 January 2001, the CI was noted to have reduced ROM of the neck secondary to guarding of the cervical muscles.  In rheumatology on 23 January 2001, the CI was noted to have 14 positive (of 18) trigger points and a diagnosis of FMS was made.  She continued the injections with temporary relief of her pain.  She was evaluated in neurosurgery on 8 June 2001, 5 months prior to separation, and noted to have a supple neck and normal sensation and reflexes.  The motor examination was reduced to 4/5 bilaterally.  The neck pain was noted to be of “unknown etiology.”  The MEB NARSUM only noted that her neck was supple.  The VA C&P examination noted a normal neurological examination and that motion was pain free.  Tenderness, spasm, and weakness were not present; however, the ROM was limited in all planes.  In rheumatology on 16 September 2002, the ROM was noted to be decreased without further specification.  Tender points were noted.  One year after separation on 19 November 2002, the CI was noted to have full ROM with minimal pain and a normal neurological examination.  The Board considered the evidence and determined that it supports a finding of the neck DDD being separately unfitting.  The PEB subsumed the neck under the FMS condition.  The VA rated it at 30%, coded 5290 (limitation of motion of the cervical spine at the severe level of impairment).  The Board noted that this is an older code and no longer used.  However, the Board must utilize the VASRD in effect at the time of separation.  The Board considered the rating.  The limitation in flexion cited by the VA examiner is an outlier from the other examinations most of which documented a normal ROM.  Painful motion was a common finding.  The Board observed that this could provide a separate 10% rating IAW VASRD §4.59 (painful motion).  However, the neck pain would then be severed from the fibromyalgia and a 20% rating for the fibromyalgia would not be supported (see discussion below).  The Board recommends that it remain not separately unfitting.  

	Fibromyalgia.  The PEB adjudicated the FMS condition as the sole unfitting condition.  Review of the record shows that after an extensive evaluation for multiple symptoms, the diagnosis was made in rheumatology on 23 January 2001, 9 months prior to separation, based on the history and presence of 14/18 trigger points.  At a rheumatology follow-up on 20 February 2001, the laboratory evaluation was unremarkable other than a sedimentation rate which was elevated and an indicator of non-specific inflammation.  It is not typically elevated in FMS and the diagnosis was changed to “symptoms suggestive of fibromyalgia syndrome.”  The MEB NARSUM was dictated by the treating rheumatologist and dated 16 July 2001, 4 months prior to separation.  It noted the complaints of widespread muscle aches and pains as well as headaches and pelvic pain.  She had minimal benefit from medications and reported that she was limited in her duties.  The non-medical assessment noted that she stood watch, but complained of headaches and was moody at times and “must be treated with kid gloves.”  

The VA C&P examination was dated 1 October 2001, 1 month prior to separation.  It noted a 3 year history of widespread muscle aches and pains with non-restorative sleep.  She noted partial benefit from Motrin and also that her muscle aches were not as intense as previously documented.  On examination, 7/18 trigger points were positive.  She appeared to be in no distress.  

The Board considered the evidence.  The PEB and VA both coded the condition 5025 (fibromyalgia), but rated it 10% and 40%, respectively.  The VA noted that the examiner had documented that the CI had failed all treatment modalities and was limited in daily activities.  In fact, the C&P examiner also noted that the CI had benefit from Motrin and that her symptoms were decreased from earlier.  In addition, the number of positive trigger points had decreased from 14 to 7.  The Board considered the criteria for a 20% rating: “…episodic with exacerbation often precipitated by environmental or emotional stress or overexertion, but present more than one-third of the time” and the criteria for a 40% rating “…constant, or nearly so, and refractory to treatment.”  The Board noted that the symptoms were not refractory to treatment as the CI did report benefit from the Motrin.  It then considered if these were episodic and present over 1/3 of the time.  It noted that the headaches were present in adolescence and appeared to be, at least in part, separate from the FMS condition.  The pelvic pain condition was of uncertain etiology, but fibroids, a common cause of pelvic pain, were present.  The neck pain was also considered a Category II condition and contributed to the overall unfitting impairment.  The Board did note that at the VA C&P examination, the diagnostic criteria for FMS were no longer met though.  The Board considered the totality of evidence and found that the criteria for the 20% rating, when the fibromyalgia condition is considered with the Category II conditions, was met at separation.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommend the FMS condition be rated at 20%, coded 5025.  

Contended PEB Conditions:  Possible History of Meniere Disease and History of Uterine Fibroids.  The Board’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  The diagnosis of Meniere disease was not definitive and the last visit for the condition was 10 months prior to separation.  Formal testing was suggestive of symptom exaggeration.  The Board also noted that the onset of symptoms was during an ear infection complicated by a perforated ear drum.  There was no evidence of significant hearing loss in either ear as is typically seen in Meniere Disease.  Finally, review of post-separation office visits do not show that this was continued as an active diagnosis.  The Board did not find evidence that the fibroid condition resulted in lost duty time.  There was no performance-based evidence from the record that either of the conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for either of the contended conditions and so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the FMS condition, the Board unanimously recommends a disability rating of 20%, coded 5025 IAW VASRD §4.71a.  In the matter of the contended chronic pelvic pain and headache conditions, the Board unanimously agrees that it cannot recommend either as separately unfitting for an additional disability rating.  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 the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Fibromyalgia Syndrome	5025	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140521, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR DIRECTOR, SECRETARY OF THE NAVY COUNCIL OF REVIEW
               BOARDS 

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS
 
Ref:   (a) DoDI 6040.44
       (b) CORB ltr dtd 22 Sep 16

      In accordance with reference (a), I have reviewed the cases forwarded by reference (b), and, for the reasons provided in their forwarding memorandums, approve the recommendations of the PDBR that the following individual’s records not be corrected to reflect a change in either characterization of separation or in the disability rating previously assigned by the Department of the Navy’s Physical Evaluation Board:

		- former USN
		- former USN
		- former USN
		- former USN
		- former USN
		- former USN
		- former USN
		- former USN
		- former USN
		- former USN