RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01096
BRANCH OF SERVICE:  Marine Corps	SEPARATION DATE:  20040815

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E6, Assault Amphibious Vehicle Repairer/Technician, medically separated for “symptom complex most consistent with fibromyalgia (FM) or chronic myofascial pain” with a disability rating of 20%.

CI CONTENTION:  Review of additional conditions not identified by the Medical Evaluation Board (MEB) and Physical Evaluation Board (PEB) requested.  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 PEB to be unfitting for continued military service, and when specifically requested by the CI, those conditions identified by the MEB, but determined by the PEB 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.  The panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections when appropriate.  The panel’s assessment of the PEB rating determination is based on review of medical records and all available evidence relevant to application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards for 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, which operates 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 disability at the time of separation.  

RATING COMPARISON:

SERVICE PEB - 20040322	VARD - 20050105	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Symptom Complex…Fibromyalgia or Chronic Myofascial Pain	5025	20%	Fibromyalgia	5025	40%	20041103	
			Disability Causing Fatigue	6899-6824	NSC		
Possible Episode of Reactive Arthritis	Cat II	Multiple Joint Pain	5099-5025	NSC		
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  100%	

ANALYSIS SUMMARY:

Symptom Complex most consistent with FM or Chronic MP.  According to the service treatment record and MEB narrative summary (NARSUM), the CI’s FM or myofascial pain condition began in April 2003 when he experienced painful knee, ankles, and feet swelling following use of an antibiotic while deployed.  He underwent an extensive evaluation including both rheumatology and neurology and was thought to have probable fibromyalgia.  In rheumatology it was noted that narcotics relieved his symptoms but he was concerned about habituation (decrease in the medication’s effectiveness).  

The 13 October 2003 MEB NARSUM examination, 10 months prior to separation, noted complaints of joint pain, scalp hyperesthesia (increased sensitivity to touch), mottling of the hands (spotting/smearing), difficulty holding objects, and drooling.  Physical examination showed the CI to be in no acute distress.  There was tenderness at the neck (C6 and C7), base of the skull, between the shoulder blades, and below the elbows.  The examination was otherwise unremarkable with normal joint motion without joint swelling, absent adenopathy (swollen lymph nodes), and normal neurological and skin examinations.  He was thought to have either FM or a chronic myofascial pain syndrome.  An evaluation in mental health on 23 October 2003 determined there was not a psychiatric condition present.

A neurologic evaluated on 11 February 2004, 6 months prior to separation, reported the CI had good days (nearly symptom-free) but other days were more symptomatic.  He was noted to have a painful gait and sensory loss; the latter in a non-physiologic pattern.  No neurologic disorder was thought to be present.  

There were no further evaluations in evidence until the 3 November 2004 VA Compensation and Pension (C&P) general examination, 3 months after separation.  The CI reported constant symptoms of easy fatigability, headaches, stiffness, sleep disturbance, anxiety, depression, Raynaud’s-like symptoms, and paresthesia.  The CI also reported wrists, elbows, hands, shins, feet, neck, and back impairments.  He reported that he was unable to accomplish any of the activities of daily living including brushing his teeth and dressing himself.  These limitations were due to headaches which required bedrest.  Physical examination showed he was well nourished and in no acute distress.  The gait was normal and there were no signs of abnormal weight bearing.  Tender points (seen in FM) were absent and the muscles, joint, spine, and neurological examinations were normal.  The CI could tie his shoe laces and fasten buttons without difficulty.  No assistive device was in use.  His hands were rough with black grease under the nails due to recent car repair work.  X-rays were normal other than minimal C5-6 and L5-S1 degenerative changes.  It was noted that the FM diagnosis was by history without objective factors.  The examiner noted “it was felt that there was an exaggeration in the veterans [sic] symptoms and it is not consistent with his recent ability to work and fix a diesel car which required a lot of maneuvering and strength.  The effect of the condition on the claimant’s daily activities is the claimant should be able to do all his basic activities of daily living.”

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the FM or myofascial pain condition 20%, coded 5025 (FM [fibrositis, primary fibromyalgia syndrome]).  The PEB also listed a possible episode of reactive arthritis as a related Category II condition (contributed to the primary unfitting condition but was not separately ratable).  The impairment from the reactive arthritis was properly subsumed under the overall rating for the FM or myofascial pain condition IAW §4.14 (avoidance of pyramiding; more than one rating based on the same impairment is prohibited).  The panel also observed that it was listed as a possible diagnosis rather than one firmly established.  The VA rated the FM condition 40%, also coded 5025, based on the C&P general examination, citing the criteria for a 40% rating while noting an essentially normal examination.

The criteria for a 20% rating are: “with widespread musculoskeletal pain and tender points, with or without associated fatigue, sleep disturbance, stiffness, paresthesia, 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, but are present more than one-third of the time.  A higher 40% rating is for symptoms that “are constant, or nearly so, and refractory to therapy.”  
The panel noted the CI reported intermittent relief of his symptoms from narcotics.  He reported having good days that were essentially symptom-free.  During the VA examination the CI reported constant symptoms and essentially total incapacitation although he was able to work on a car.  The VA examiner specifically commented on the inconsistency.  The panel determined that the preponderance of STR evidence did not support a 40% rating.  After due deliberation, considering all 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 or myofascial pain condition.

BOARD FINDINGS:  In the matter of the FM or MP condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  There are no other conditions within the panel’s scope of review for consideration.  Therefore, the panel recommends 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 20160922, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs 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

      In accordance with reference (a), I have reviewed the cases listed below and 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:

		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC

							XXXXXXXXXXXXXXXXXX
	     				Assistant General Counsel
						(Manpower and Reserve Affairs)