RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00671
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20040502

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Medical Laboratory Specialist, medically separated for “fibromyalgia with migraine headaches” with a disability rating of 20%.  

CI CONTENTION:  “Please review all conditions.”  The complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The panel’s scope of review is defined in DoDI 6040.44.  It is limited to review of disability ratings assigned 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 or non-compensable.  Any conditions outside the panel’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 panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The panel’s assessment of the PEB rating determination 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(s) at the time of separation.  The panel 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 panel 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 - 20040203	VARD - 20041126	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Fibromyalgia with Migraine Headaches and 18/18 tender points	5025	20%	Fibromyalgia also claimed as Painful Shoulders, Back, Hips, Knees, Feet	5025	10%	20040909	
			Migraine Headaches	8100	30%		
Plantar Fasciitis	Not Unfitting	Bilateral Pes Planus with Bilateral Plantar Fasciitis	5276	0%		
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Fibromyalgia (FM) with Migraines Headaches (HAs).  The PEB combined the FM and migraine HAs conditions under a single disability rating, coded 5025 (fibromyalgia) and rated 20%.  The panel noted that the 5025 code specifies “With widespread musculoskeletal pain and tender points, with or without associated…headache…" and that this approach does not necessarily compromise the VASRD §4.7 directive to choose the higher of two valid ratings.  The panel’s initial charge in this case was therefore directed at determining if combining conditions under a single rating was justified in lieu of separate ratings.  When considering a separate rating for each condition, the panel considers each bundled condition to be reasonably justified as separately unfitting unless a preponderance of evidence indicates the condition would not cause the member to be referred into the DES or be found unfit because of physical disability.  When the panel recommends separate fitness recommendations in this circumstance, its recommendations may not produce a lower combined rating than that of the PEB.  The evidence for each of the FM and migraine HAs conditions is presented separately, with attendant recommendations regarding separate unfitness, and separate rating if indicated. 

FM. According to the service treatment record (STR), the Medical Evaluation Board (MEB) narrative summary (NARSUM), and the MEB rheumatology addendum, the CI’s FM condition began in approximately November 2002 without specific injury or trauma.  The CI was treated for chronic neck, shoulder, elbow, back, hip, knee and ankle pain, and muscle tension HAs.  She reported morning stiffness of less than one hour and pain exacerbated by activity.  Occasionally she had flare-ups associated with muscle spasms.  Imaging studies of the spine and multiple joints were all normal.  Though a rheumatology evaluation found no evidence of a systemic inflammatory disease the CI was eventually diagnosed with FM by the MEB rheumatologist.  She was treated with antidepressant medications for chronic pain and daily exercise/physical therapy showed some improvement, but not a complete resolution of her symptoms.  

The 15 January 2003 permanent profile, 14 months before separation, listed FM and myofascial pain syndrome.  Walking was approved for an alternate physical fitness test.  The 6 November 2003 commander’s statement, 6 months before separation, implicated migraine HAs, lower back pain and shin pain.  The commander indicated that the CI’s “ailments” had caused her to miss a “minimal amount of work” and had “minimally prevented her from fulfilling her duties at work.”  The MEB NARSUM noted the CI’s diagnoses of FM, migraine HAs, and plantar fasciitis and recommended the case be forwarded to the PEB for adjudication and the MEB forwarded FM and migraine HAs to the PEB as medically unacceptable. 

The 29 July 2003 MEB NARSUM examination, 10 months prior to separation, noted complaints of multiple muscle and joint pains.  Physical examination showed full range of motion (ROM) of all joints, extremities and the spine.  There was tenderness of bilateral upper thoracic and paravertebral muscles, suprascapular regions, right hip, bilateral anterior tibiae, and plantar surface of the feet.  

At the 17 December 2003 MEB rheumatology examination, 5 months before separation, the CI’s medications for FM had been changed to an anticonvulsant type medication (gabitril) for chronic pain.  The examiner noted that currently the CI had “mild symptoms, but with occasional severe flares.”  Physical examination noted no evidence of synovitis.  There was good ROM of all joints.  There were 18/18 American College of Rheumatology tender points for FM diagnosis.  Neurological examination was normal.  The rheumatologist concluded that despite maximal medical therapy, the CI was still “fairly symptomatic.”  Addition of tramadol (opioid pain medication) twice daily was recommended.

At the 9 September 2004 VA Compensation and Pension (C&P) evaluation, 4 months after separation, the CI reported shoulder area pain and foot pain.  She reported taking breaks during work to do exercises and stretches, especially for shoulder area pain.  She remained on the same medications (gabitril and tramadol) noted at the MEB rheumatology examination.  Physical examination showed a normal gait.  The neck was supple and non-tender; the abdomen was soft and non-tender.  There was full ROM of the cervical and thoracic spine without pain and full ROM of the shoulders, elbows, wrists, hip, knee and ankle with no additional limitation of motion of any joint with repetitive motion.  There was a “slight tenderness” of the left anterior tibia compared to the right but no swelling.  The plantar surface of the feet with decreased arches showed tenderness.  There was “mild discomfort of the right scapular area, and “no evidence of significant pain of the trigger points otherwise.”  Neurological examination was normal.  Imaging studies (X-rays) of both feet, both shoulders and the lumbar spine were normal.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the FM with migraine HAs condition 20%, coded 5025 (fibromyalgia), citing 18/18 tender points.  The VA rated the FM condition 10%, coded 5025 (fibromyalgia), based on the C&P examination 4 months after separation, citing FM symptoms that require continuous medication for control.  The panel first considered if the FM condition, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The FM condition was permanently profiled, implicated in the commander’s statement, and judged to fail retention standards.  The panel concluded there was not a preponderance of evidence in the service records which overcame the panel’s presumption that the bundled FM condition was reasonably considered separately unfitting.  The panel then considered its rating recommendation for the unfitting FM condition at the time of separation.

Following the MEB NARSUM examination, 10 months before separation, the CI’s FM medications were adjusted.  The commander’s statement, 6 months before separation, indicated the CI’s “ailments” minimally impacted her job performance and caused her to miss a minimal amount of work time.  At the time of the MEB rheumatology examination, 5 months before separation, the CI’s FM symptoms were described as mild, with occasional severe exacerbations on her new medications.  The rheumatologist added twice daily pain medication to the CI’s FM medication regime.  At the VA examination, 4 months after separation, the CI’s physical examination was minimally abnormal with slight tenderness of the anterior legs and right scapular areas (and tenderness of the plantar surfaces of the feet due to a separate plantar fasciitis diagnosis).  There was evidence of FM symptoms that required continuous medication for control to support a 10% rating under 5025, but after the last medication adjustments in record, there was no evidence that the FM symptoms were present more than one-third of the time with frequent exacerbations.  The panel therefore initially recommends a 10% rating for the FM condition at separation.  The panel may recommend a lower rating for an individual condition than the PEB, however, the panel may not recommend a lower combined rating than the PEB.  Therefore, the panel first reviewed the migraine HAs condition, which the PEB bundled with the FM condition, before determining a final rating recommendation for the FM condition.    

Migraine HAs.  According to the STR and MEB NARSUM the CI had a history of migraine HAs prior to 2002.  Severe HAs were associated with an aura, nausea, vomiting, and even passing out.  She was treated with triptans (medications for acute treatment of migraines).  A January 2003 orthopedic visit indicated that treatment of the CI’s FM with antidepressant medication and electrical stimulation had resulted in a decrease in the frequency of migraine HAs as well.  There were two clinic visits for treatment of acute migraine HAs in March and May 2003.  At the May 2003 visit, 12 months before separation, the CI was placed on quarters for 24 hours.  

The 15 January 2003 permanent profile, 14 months before separation, listed migraine HAs.  The 6 November 2003 commander’s statement, 6 months before separation, implicated migraine HAs, lower back pain and shin pain.  The commander indicated that the CI’s “ailments” had caused her to miss a “minimal amount of work” and had “minimally prevented her from fulfilling her duties at work.”  

During the 29 July 2003 MEB examination (recorded on DD Forms 2807-1 and 2808), 10 months prior to separation, the CI reported current medications included a triptan (Maxalt) for treatment of an acute migraine HA.  She reported there had been no episodes of syncope associated with the migraines HAs since her migraine medication was changed to Maxalt.  The 29 July 2003 MEB NARSUM examination, 10 months prior to separation, noted complaints of frequent HAs two to three times per month that caused the CI to miss work once every other month.  The physical examination did not address the migraine HAs condition. 
The 6 November 2003 commander’s statement, 6 months before separation, specifically cited that the CI had left work due to migraine HA three times in the previous 5 months.  At a 22 April 2004 clinic visit the CI reported a migraine HA and the note indicated a possible reaction to her current triptan medication (Zomig).  The CI was given a pain injection for the acute HA and she requested a prescription for Maxalt again.  

At the 9 September 2004 VA Compensation and Pension (C&P) evaluation, 4 months after separation, the CI reported being diagnosed with migraine HAs in approximately 2000 and experiencing them usually three to four times per month.  Her most recent migraine HA, 2 weeks earlier, was preceded by an aura and associated with nausea, vomiting, blurred vision, and dizziness; she missed 2 days of work.  Physical examination pertinent to migraine HAs was normal. The CI had a normal gait and no neurological abnormalities were noted. 

The panel first considered if the migraine HAs condition, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The migraine HAs condition was permanently profiled, implicated in the commander’s statement, and judged to fail retention standards.  Although the VASRD 5025 rating for FM rating may subsume HAs, in this case the CI had classic migraine HAs as well as frequent muscle tension-related HAs.  Panel members agreed the evidence reasonably justified that the functional limitations of the migraine HAs condition separately contributed to the CI’s inability to perform her military duties, and accordingly a separate disability rating is recommended.

Rating guidance under diagnostic code 8100 is based on the frequency of “prostrating attacks” over the “last several months.”  The VASRD does not further define prostrating attacks, however commonly accepted definitions include “utter physical exhaustion or helplessness” (Webster's New World Dictionary of American English), “complete physical or mental exhaustion” or “extreme exhaustion or powerlessness” (Dorland's Illustrated Medical Dictionary).  There were two encounters for HA care in the year before separation in record.  Of these, both were for acute migraine HAs and the evidence reflected one was prostrating.  At the VA examination, 4 months after separation, the CI indicated she had migraine HAs three to four times per month, but described only one recent prostrating HA.  Review of the record supports the conclusion that the CI experienced prostrating HAs occurring on average once every 2 months during the several months prior to separation.  The panel concluded that a rating of 10% and no higher was therefore justified for the migraine HAs condition, coded 8100.  

Although the panel recommended that the migraine HAs condition was a separately unfitting condition and not part of the FM condition, the resulting combined rating recommendation was the same as that of the PEB.  The panel found that unbundling the FM and migraine HA conditions did not result in a ratings benefit to the CI and therefore the panel recommends no change to the PEB’s combined adjudication.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded there was insufficient cause to recommend a change in the PEB adjudication for the FM condition.  

Contended PEB Condition:  Plantar Fasciitis.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended condition was not unfitting.  The contended condition was not profiled, implicated in the commander’s statement or judged to fail retention standards.  There was no performance-based evidence from the record that the condition significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded there was insufficient cause to recommend a change in the PEB fitness determination for the contended condition and so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the fibromyalgia with migraine headaches condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the contended plantar fasciitis condition, the panel unanimously recommends no change from the PEB determination as not unfitting.  There are no other conditions within the panel’s scope of review for consideration.  The panel, therefore, recommends there be no modification or re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160914, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

AR20180005407, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found your separation disability rating and your separation from the Army for disability with severance pay to be accurate.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed), and I accept its recommendation.  I regret to inform you that your application to the DoD PDBR is denied.  

	This decision is final.  Recourse within the Department of Defense or the Department of the Army is exhausted; however, you have the option to seek relief by filing suit in a court of appropriate jurisdiction.

Sincerely,					      
Enclosure