RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00137
BRANCH OF SERVICE:  	ARMY SEPARATION:  20070206

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Field Recruiter, medically separated from the Temporary Disability Retired List (TDRL) for “fibromyalgia,” with a disability rating of 0%.

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 based on 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 – 20041101/20050214	VARD - 20051125	
Condition	Code	Rating	Condition	Code	Rating
Proximate	
		TDRL
Placement	TDRL Removal			TDRL
Placement	TDRL
Removal	
Fibromyalgia…, Pelvic Pain, Low Back Pain, Depression…	5025	40%	0%	FMS with Pelvic Pain	5025	10%	10%	
				Chronic Back Strain…	5243	0%	0%	
				Major Depression	9434	30%	30%	
Mild OSA	Not Unfitting 	OSA	6847	0%	0%	
COMBINED RATING:  40% → 0%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

Fibromyalgia (FMS). The record shows that the CI was referred to the PEB by the Medical Evaluation Board (MEB) for pelvic pain, chronic low back pain (LBP), major depression, fibromyalgia (FMS), and mild obstructive sleep apnea (OSA).  The OSA met retention standards.  The PEB then combined the four medically unacceptable conditions into a single unfitting condition, FMS, and placed the CI on TDRL at 40%.  Due to the overlapping symptoms and histories, a single narrative is presented for all these conditions.  The conditions are then addressed individually to determine if any were separately unfitting and ratable at separation.  

According to service treatment records and the MEB narrative summary (NARSUM), the CI re-entered active duty on 28 May 2002 after two prior periods of service. Although the CI had a history of LBP in her prior enlistments and of depression dating to her adolescence, during the third and final enlistment she was initially evaluated for pelvic and abdominal pain.  An ultrasound of the pelvis and abdomen on 13 January 2003 was normal.  She then underwent a diagnostic laparoscopy on 24 February 2003 which was suspicious of endometriosis (implants of uterine tissue outside of the uterus).  She began medical treatment (Lupron) which was not effective.  It was noted that she strongly desired a hysterectomy which she was counseled against having.  She also began treatment for depressive symptoms in July.  In September it was noted that her pelvic pain had not responded to conservative management and a hysterectomy was accomplished on 22 September 2003 with a finding that there was “no obvious evidence of endometriosis.”  The examination was otherwise normal with the exception of some adhesions on the right (in the area where the appendix had previously been removed).  Following surgery, she continued to have pain which was aggravated by activity and by certain foods.  She was noted to be on an anti-depressant (it is not clear which clinic initiated this treatment).  

She was evaluated in gastroenterology on 9 December 2003 and thought to have possible irritable bowel syndrome (IBS).  She was noted to be in no acute distress and to have a normal abdominal examination other than mild diffuse tenderness and obesity.  She had no back complaints at this examination.  X-rays of the back on 12 December 2003 were normal.  During this period she had continued her mental health individual and group therapy.  An MRI of the lumbar spine on 8 January 2004 was also normal.  She had a colonoscopy on 9 January 2004 which only showed a few hemorrhoids and polyps; these were not associated with her pain and she was begun on a dietary regimen for IBS.  On 4 February 2004, she presented to mental health as a walk-in appointment and reported suicidal ideation with a plan.  She was transferred to a local hospital for an involuntary admission (Baker Act).  These records are not in evidence.  Five days later on 9 February 2004, she was again seen in mental health and reported a better mood, but occupational problems.  The CI was then evaluated by a rheumatologist on 23 February 2004; a diagnosis of possible FMS was made and treatment was begun.  On 2 March 2004, X-rays of the sacro-iliac joints (SIJ), the joints between the pelvis and lower spine, were normal.  The CI noted symptoms of urinary incontinence though formal testing on 7 May 2004 was normal.  Electrodiagnostic testing performed 6 July 2004 for a history of right greater than left pain and tingling radiating down the legs was normal.  She was evaluated for possible reclassification on 23 July 2004, but her evaluation was determined to be incomplete.  The CI was again seen in gynecology on 12 August 2004. The chronic pain was not thought to be gynecological in origin and FMS was considered as an explanation.  

The CI continued to be seen in mental health, but held an S1 profile in the clinic visits.  A 1 November 2004 mental health addendum to the MEB NARSUM was based on a 5 October 2004 examination.  It noted that the CI first sought treatment in mental health on 8 May 2003 after a physician requested her to do so.  At the May 2003 visit, she reported a miscarriage a few months earlier (there are no records of this in evidence) and feeling depressed for one year.  She reported a suicide attempt at age 15.  She was thought to have major depression which did not meet medical retention standards.  An S3 profile was recommended.  

A sleep study dated 30 November 2004 showed mild sleep apnea.  This was successfully treated surgically on 4 February 2005.  A rheumatology note dated 14 January 2005 recorded the diagnosis of FMS as well as depression and anxiety.  The MEB NARSUM was dated 14 February 2005, 3 months prior to TDRL placement.  She reported ongoing intermittent LBP since her hysterectomy (the Board noted that the LBP actually dated to the 1990s and was recorded on a separation physical in 1999).  She also reported ongoing pelvic pain and reported that her rheumatologist had attributed it to her FMS.  On examination, she was noted to be in no acute distress.  The abdomen was tender in both lower quadrants, but otherwise benign.  The lower back was tender diffusely and the range of motion decreased.  The neurological examination was normal other than an abnormal gait secondary to pain.  Pelvic pain, chronic LBP, FMS, and mild OSA were listed.  Depression was not addressed.  The rheumatology note dated 15 February 2005 noted that the CI had FMS with a history of Raynaud’s Syndrome (a circulatory disturbance in the extremities when exposed to cold; it is seen in different rheumatologic diseases).  Mild arthritis (not specified) had been seen on a bone scan.  She had not responded well to treatment.  The CI was seen again in gastroenterology on 22 February 2005 and noted to have the diagnoses of IBS and FMS.  She did not report significant LBP or joint pain.  On examination, she was in no acute distress and had diffuse mild tenderness on the abdominal examination (unchanged from 15 months previously).  There were no clinical visits for LBP in the final 9 months on active duty.  

More than a year prior to TDRL placement there were two S2 profiles (DA Form 3349) in evidence (15 and 22 Jan 2004).  An S3 was noted in the November 2004 MEB NARSUM addendum, prepared 6 months prior to TDRL placement and again in the profile (DA Form 3349) dated 6 April 2005. However, in the final 18 April 2005 mental health clinic entry, the last one documented prior to separation and less than one month prior to TDRL placement, she was issued an S1 profile.  The Board could not explain the discrepancy between the final clinical entry (S1) and the final DA Form 3349 (S3), but did note that the clinician who prepared the NARSUM was not a mental health provider.  The Board also noted that the MEB NARSUM addendum had been prepared 6 months prior to TDRL placement; in fact, the MEB had been completed 2 weeks earlier (on 21 March 2005) than the final S3 profile.  

During the 8 August 2005 VA General Compensation and Pension (C&P) examination, performed 3 months after TDRL placement, the CI reported bilateral hip bursitis, LBP, FMS with pelvic pain, and mild OSA.  She reported that the OSA condition was improved after surgery and that she was not being treated for it.  On examination, she was noted to be alert, talkative, and in no apparent distress.  She was obese.  She walked without a limp or signs of pain.  The abdominal examination showed tenderness; however, this was not apparent when the CI was distracted.  Muscle atrophy and wasting were absent.  The examination of the hips was unremarkable.  Examination of the back showed mild tenderness and some discomfort with some motion, but with full ROM.  The neurological examination was normal.  An X-ray of the back showed some degenerative changes at L5S1 (spondylosis, a condition associated with “wear and tear”).  X-rays of the SIJs were normal.  A bone scan was unremarkable.  A trigger point examination (for FMS) was unreliable as she had multiple positive trigger points including controls (which should be negative) and had diffuse tenderness which is not characteristic of FMS.  A sleep study was normal as well.  A mental health C&P was done the same day.  It noted that she had been a high achiever in high school.  However, a later C&P dated 29 July 2008 recorded that she had performed below average in high school.  She reported two hospitalizations for psychiatric reasons (one is in evidence).  She reported little interest in activities other than caring for her children.  She endorsed a depressed mood, chronic fatigue, sleep dysfunction, and low self-esteem.  The initial onset of symptoms was recorded as 1992 (elsewhere, she reports depression since at least adolescence with a suicide attempt at age 15).  On examination, her affect was blunted and mood depressed.  She was easily distracted and had mildly impaired recent and immediate memory, but otherwise had an unremarkable examination.  The depression was significantly elevated, suggesting exaggeration or a personality disorder.  A significant depression could still be present as well though.  She was unemployed, but noted multiple reasons.  These included chronic pain, emotional distress, child care responsibilities, and lack of appropriate employment opportunities.  She was thought to have recurrent major depressive disorder (MDD).  

The Board directed attention to its rating recommendation based on the above evidence.  On 30 March 2006, the CI was seen in physical medicine for back pain.  She was noted to be in no acute distress and to sit, stand, and walk without difficulty.  Lumbosacral (as opposed to thoracolumbar) motion was reduced and painful.  The neurological examination was normal.  The pain was thought to be multi-factorial including the FMS, spondylolysis, and a possible SIJ sprain.  Stretching and continuation of her current medications was recommended.  The final rheumatology evaluation in evidence was dated 22 January 2007 and accomplished as part of the TDRL review.  She reported diffuse daily pain in the neck, upper back, mid back, low back, chest, wrists, knees, and shins as well as fatigue.  She was able to do clerical work which she did at home.  On examination, she had tenderness over the back of the neck.  The joints showed normal, pain-free motion.  The neurological examination showed normal sensation, strength, and 2/4 reflexes (normal).  There was not a limp present.  Trigger points were not recorded.  The examiner recommended medical retirement as she was thought to be unlikely to regain function sufficient to return to active duty.  The TDRL removal examination was the next day on 23 January 2007.  She reported no improvement from TDRL placement.  She noted ongoing fatigue.  She denied taking prescription medications and used Aleve, an over-the-counter medication, 1-2 times a week.  Her pain was widely distributed throughout her body.  On examination, she was in no acute distress, but was tearful and obese.  Her examination was otherwise unremarkable and trigger points were not recorded.  She was permanently separated on 6 February 2007.  

The CI was seen in a VA mental health clinic on 7 February 2007.  At a biopsychosocial assessment, she reported periods of high energy followed by depression.  She was in constant pain.  A provisional diagnosis of bipolar disorder was added to the MDD diagnosis.  In mental health, the mental status examination was normal and she was noted to have MDD by history.  She was next seen on 27 June 2007 and reported depressive symptoms most of her life and a suicide attempt at age 15.  She had a total of three jobs since separation.  She was on medications with some benefit.  A follow-up on 7 August 2007 noted an essentially normal mental status examination although she endorsed ongoing symptoms.  

For the back, the CI was evaluated in primary care on 26 January 2007, 2 weeks prior to TDRL removal.  She noted ongoing pain.  On examination, the back showed normal curvature without tenderness or spasm.  However, it was also noted that there was tenderness to the lumbar spine in the same note.  The neurological examination was normal.  The abdominal examination was normal.  No trigger points were documented.  She had an X-ray on 20 June 2007 which showed slight indications of early degenerative disease.  In physical therapy on 16 July 2007, she reported LBP since the hysterectomy.  As noted above, the LBP condition had been recorded years prior to this though.  The ROM was within functional limits and the motor function was normal.  Tone was increased, but spasm was not recorded.  No comment was made on trigger points.  

The VA next conducted a general C&P examination on 29 July 2008, 18 months after TDRL removal and outside the normal 12-month window which is assigned high probative value.  She denied incapacitation the prior 12 months.  Her gait and neurological examination were normal.  Flexion was reduced to 80 degrees, but noted to be normal for her due to her FMS and morbid obesity.  She reported that she was unemployed, but that this was due to depression.  The mental health examination the same day recorded that she had quit because she was forgetful.  

The PEB rated the FMS condition at 0%, coded 5025.  It was the sole unfitting condition listed at TDRL removal.  The VA continued the 10% rating, assigned at TDRL placement, in the 11 September 2008 rating decision which cited the 29 July 2008 examination.  The VA examination after TDRL placement noted that the CI endorsed multiple trigger points, including controls which should have been negative.  No subsequent examination documented trigger points.  The CI was not on therapy other than occasional over-the-counter medications at TDRL placement.  A 40% rating requires that an individual be refractory to therapy.  A 20% rating is for the presence of widespread musculoskeletal pain (documented) and trigger points (not documented) over one-third of the time.  A 10% rating is for the presence of widespread musculoskeletal pain (documented) and trigger points (not documented) requiring continuous medications for control (medications were occasional).  The criteria for a compensable rating for FMS were not met at TDRL removal.  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 FMS condition at TDRL removal.  

Contended PEB Condition: OSA.  The Board’s main charge is to assess the fairness of the PEB’s determination that the contended condition was not unfitting.  The CI was noted to be asymptomatic after surgery.  It was included on the final profile, but this was problematic as discussed above.  The commander’s statement made no mention of the OSA condition.  It was judged to meet retention standards.  There was no performance-based evidence from the record that OSA 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 the OSA condition and so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the FMS condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication at TDRL removal.  In the matter of the contended OSA condition, the Board unanimously agrees that it cannot recommend it for additional disability rating.  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 20141117, 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 XXXXXXXXXXXXXXXXXXXXX, AR20170002969 (PD201500137)

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