DEPARTMENT  OF  THE NAVY
SECRETARY OF THE NAVY COUNCIL OF REVIEW BOARDS 720 KENNON STREET SE STE 309 WASHINGTON NAVY YARD, DC 20374

From: To:

IN   REPLY  REFER  TO:
1850
CORB:003
20 Feb 20

Director, Secretary of the Navy Council of Review Boards 
PD-2017-00440

Subj:	PHYSICAL DISABILITY BOARD OF REVIEW (PDBR)

Ref:	(a) DoDI 6040.44
(b) PDBR ltr dtd 3 Jan 19

1.	Pursuant to reference (a), the PDBR reviewed your case and forwarded its recommendation (reference (b)) to the Department of the Navy.

2.	On 12 February 2020, the Assistant Se6retary of the Navy (Manpower & Reserve Affairs) accepted the recommendation of the PDBR of no change to your characterization of separation or disability rating assigned by the Department of the Navy's Physical Evaluation Board.

3.	The Secretary's decision on your PDBR application is final and is not subject to appeal or additional review by the Board for Correction of Naval Records.

RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXXXXX		CASE: PD-2017-00440 BRANCH OF SERVICE: MARINE CORPS	SEPARATION DATE: 20091230

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E3, Aircraft Maintenance Support Equipment Electrician/ Refrigerator Mechanic, medically separated for “fibromyalgia” with a disability rating of 20%.

CI CONTENTION:  No specific contention was made. 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 Medical Evaluation Board (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 – 20091022	VARD – NA		
	Condition	Code	Rating	Condition	Code	Rating	Exam		
	Fibromyalgia	5025	20%	

VA Examination Not Released		
	Patellofemoral Pain Syndrome of Both Knees	Cat II			
	Bilateral Trochanteric Tendinitis of Hips	Cat II			
	Musculoligamentous Strain of Cervical Spine	Cat II			
	Depressive Disorder	Cat II			
	Recurrent Inversion Sprain of Both Ankles	Cat II			
	COMBINED RATING: 20%	COMBINED RATING OF ALL VA CONDITIONS: NA		
	
ANALYSIS SUMMARY:

Fibromyalgia. According to the service treatment record and MEB narrative summary (NARSUM), the CI’s fibromyalgia began around September 2007 with left knee pain diagnosed as patellar femoral syndrome. The pain progressed to include the right knee, both hips and elbows, and the lower back, with most of the pain in the knees and hips. Treatment consisted of tramadol (opioid- like medication), which provided some pain relief, but did not change overall symptoms. She tired easily and more so at the end of the day, and arthralgias began gradually and progressively

worsened. While left knee X-rays on 18 July 2008 were negative, left ankle imaging showed a slight deformity of the distal tibial metadiaphysis (a portion of a long bone) suggesting the presence of a developing exostosis. Left foot X-rays revealed no periosteal reaction to suggest a subacute healing fracture, and hip X-rays were negative.

On 28 October 2008, a sports medicine examination indicated multiple areas of pain over the trapezius area and upper and mid back as well as the bilateral quadriceps. There was diffuse tenderness over the anterior aspect of the knees, but minimal pain on external and internal hip rotation. The provider felt there was a rheumatological basis for the diffuse myalgias, and considered fibromyalgia as a possible cause. A rheumatology evaluation on 10 December 2008 noted waxing/waning of pain of varying joints, depression, 16 positive trigger points, and fatigue. At a follow-up on 4 March 2009, the CI reported she could not perform in a martial arts program due to her symptoms. The rheumatologist noted symptoms remained consistent with fibromyalgia and included a history of depression and waxing/waning pain. Laboratory studies were normal, and a pain reliever and antidepressant/nerve medication were added to the treatment protocol. The 4 March 2009 MEB NARSUM examination, 10 months prior to separation, noted an initial complaint of left knee pain that progressed to involve the right knee, the low back, and bilateral hips and elbows. Physical examination noted the CI was an alert, well- developed and well-nourished female, in no acute distress. There was no clubbing, cyanosis, or edema, and all joints had full range of motion without synovitis. The examiner noted 16/18 fibromyalgia tender areas.

At a 17 November 2009 flight medicine examination, 1 month before separation, the CI reported that non-steroidal anti-inflammatory drugs and amitriptyline (anti-depressant) did not help with the pain, and requested a refill of tramadol, as it had been “the only thing thus far” that helped. The provider had concerns about tramadol use with her requirement to drive and operate heavy machinery, and recommended trazodone (antidepressant and sedative) before sleep, and acetaminophen (pain reliever) instead. Cymbalta (antidepressant) and neurontin (for nerve pain) were also suggested for fibromyalgia treatment if the other prescriptions were not effective. During the 1 December 2009 MEB examination (recorded on DD Form 2807-1), 1 month before separation, the CI reported joint pain from fibromyalgia. The CI did not consent to release VA records.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the fibromyalgia 20%, coded 5025 (fibromyalgia). The PEB listed patellofemoral pain syndrome of both knees, bilateral trochanteric tendinitis of hips, musculoligamentous strain of cervical spine, depressive disorder, and recurrent inversion sprain of both ankles as related Category II diagnoses contributing to the disability in this case. However, panel members concluded that these diagnoses could not be reasonably justified as separately unfitting; nor would separate ratings be achievable without violation of VASRD §4.14 (avoidance of pyramiding).

The panel noted that code 5025 describes fibromyalgia as “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.” A 40% rating requires symptoms that are “constant, or nearly so, and refractory to therapy.” The CI had muscle pain, which was always present in varying degrees and locations, but obtained some relief with tramadol. While her symptoms were not entirely eliminated with medication, they were not completely refractory to therapy, and thus, a rating higher than 20% was not achievable. 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 fibromyalgia.

BOARD FINDINGS: In the matter of the fibromyalgia and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication. In the matter of the Category II patellofemoral pain syndrome of both knees, bilateral trochanteric tendinitis of hips, musculoligamentous strain of cervical spine, depressive disorder, and recurrent inversion sprain of both ankles, the panel recommends no change from the PEB determinations as not separately unfitting. 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 20170214, w/atchs Exhibit B.  Service Treatment Record