RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2017-02861
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070711

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Health Care Specialist, medically separated for “low back pain” and “fibromyalgia syndrome,” rated 10% and 0%, respectively, with a combined disability rating of 10%.  

CI CONTENTION:  The CI requested review of his low back, fibromyalgia and additional conditions not identified by the Medical Evaluation Board (MEB) and Physical Evaluation Board (PEB).  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 - 20070418	VARD - 20071010	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Low Back Pain	5237	10%	Degenerative Joint Disease, Lumbar Spine	5242	10%	20070914	
Fibromyalgia Syndrome	5025	0%	Fibromyalgia	5025	40%	20070914	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

Chronic Low Back Pain (LBP).  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s back condition began in April 2005 after he was required to march with a pack during advanced individual training.  Lumbar MRI in September 2006 showed a disc protrusion at L5-S1 with mild compression of the L5-S1 nerve root and mild neuroforaminal narrowing bilaterally.  

At the 31 October 2006 MEB neurosurgical consultation, the CI reported LBP and right lower extremity pain, aggravated by sitting, standing, lying on back and leaning forwards or backwards.  Physical examination showed an antalgic gait with a slight limp on the right.  There was diffuse lumbar tenderness, but no muscle spasm.  Straight leg raise testing to elicit radicular symptoms was positive on the right.  There was poor ROM of the back with moderate restriction due to pain.  Strength was described as “difficult to assess due to patient’s effort and diffuse joint pain,” but appeared normal and equal bilaterally.  Surgical options were discussed, but it was decided to pursue conservative treatment with the goal of partial relief of the CI’s symptoms.  

The 5 April 2007 MEB NARSUM examination, 3 months prior to separation, noted complaints of constant LBP that occasionally radiated down the right lower extremity to the foot.  Physical examination showed an antalgic gait with tenderness, but no mention of spasm.  Thoracolumbar range of motion (ROM) after three repetitions was flexion of 70 degrees (normal 90) and combined ROM of 195 degrees (normal 240).  The examiner noted there was severe pain with flexion and extension.  Straight leg raise testing was positive on the right.  Piriformis tests of the hips were positive.  There was decreased sensation in the right S1 distribution.  

At the 14 September 2007 VA Compensation and Pension (C&P) examination, 2 months after separation, the CI reported constant LBP with flare-ups every two or three months that lasted 5 to 6 hours.  During flare-ups he used a cane.  Physical examination showed an antalgic gait.  The examiner noted “the thoracolumbar spine had normal forward flexion to 0-90 degrees and he was able to flex to 40 degrees, after repetitive motion flexion was reduced to 38 degrees, which is a 2 degree loss.”  CI had a tendency to lean forward.  Back ROM after repetition was flexion of 40 degrees and combined ROM of 145 degrees, with painful motion.  Strength and sensation were intact.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, coded 5237 (lumbosacral strain)  The VA also rated the back condition 10%, coded 5242 (degenerative arthritis of the spine), based on the C&P examination, citing combined ROM between 120 and 235 degrees.  

The panel agreed that a 10% rating, but no higher, was justified for limitation of flexion (greater than 60 degrees but not greater than 85 degrees) and/or combined ROM (greater than 120 degrees but not greater than 235 degrees, as reported on the MEB NARSUM examination.  The panel interpreted the slightly confusing wording of the VA examination as documenting flexion of 40 degrees, however, the VA Rating Decision interpreted the ROM at the C&P examination as flexion of 90 degrees.  The primary reason the panel placed greater probative value on the MEB NARSUM examination was that there was no evidence of flexion limited to that degree documented prior to separation.  However, the panel also considered that the discrepancy in interpretations introduced a factor of uncertainty to the VA evidence.  There was no evidence of intervertebral disc syndrome which resulted in incapacitating episodes requiring physician-prescribed bed rest to warrant consideration of rating under the alternate VASRD formula for that condition.  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 back condition.  

Fibromyalgia Syndrome.  According to the STR and MEB NARSUM, the CI’s fibromyalgia began in approximately February 2006 after his unit began extensive runs with full combat gear.  After the first run the CI noted aching in his knees.  In June 2006 the CI reported joint complaints involving the shoulders, elbows, wrist, hands, hips, knees and ankles.  Blood work revealed the CI was HLA-B27 positive (genetically inherited proteins associated with many autoimmune/inflammatory diseases) and the CI was referred to rheumatology.  At a rheumatology examination on 18 July 2006, the CI reported pain in the elbows, knees hips, lower back and ankles.  He noted swelling of his fingers, but not elsewhere.  He reported morning stiffness lasting 20 minutes.  Anti-inflammatory medications had not been helpful.  A bone scan on 28 July 2006 showed moderate uptake in the shoulders, sternoclavicular joints, anterior first rib ends, elbows and sacroiliac joints, and mild uptake in the wrists and knees consistent with stress related changes or degenerative changes.  Following additional blood work for inflammatory or connective tissue diseases, the rheumatologist diagnosed fibromyalgia after concluding there was no inflammatory component present based on the CI’s history, laboratory testing or clinical examination.  

The commander’s statement noted that due to the arthritis and back conditions, even basic tasks like walking, standing for extended periods, bending and lifting were difficult and painful.  The commander noted despite compliance with profiles and treatment the CI’s pain had increased and his ability to perform had decreased.  

The 5 April 2007 MEB NARSUM examination, 3 months prior to separation, noted complaints of fibromyalgia.  Physical examination showed an antalgic gait.  There was full ROM of the cervical spine, shoulders, elbow, hands, wrists, hips, knees, ankles and feet without evidence of synovitis (joint lining inflammation).  Tender points included the anterior chest, elbows and knees.  The diagnosis was “fibromyalgia with low grade pain symptoms in the joints 65% of the time and severe pains in the joints 35% of the time, associated sleep disturbance, weather modulating factors and few tender points.”  

At the 14 September 2007 VA C&P examination, 2 months after separation, the CI reported fibromyalgia symptoms precipitated by any type of physical activity.  Treatment was ibuprofen or acetaminophen daily since diagnosis.  He reported constant pain in the shoulders, elbows, wrists, hips, knees, ankles and feet with unexplained fatigue and paresthesias of the toes and fingers, constant right shoulder pain graded 2-3/10, morning stiffness and weakness.  Ibuprofen provided some relief and ice and rest also alleviated his shoulder pain during flare-ups, which occurred four or five times per months lasting 3 to 4 hours.  He denied functional impairment, but reported intermittent left shoulder pain during flare-ups that was less frequent and less severe than the right shoulder and constant right elbow pain without effect on his occupation or daily activities with benefit from ibuprofen, ice and rest.  The CI also reported less frequent and less severe symptoms of intermittent left elbow pain (two or three times per month for 1 to 2 hours), left and right wrist pain, right greater than left (one or two times per month lasting 1 to 2 hours) with no effect on his daily activities.  He reported right and left hip pain (three or four times per month lasting 1 to 2 hours), left knee pain (three or four times per month for 30 minutes), which was intermittent, causing difficulty putting on shoes and socks, with benefit from ibuprofen and rest.  Right knee pain was constant and caused difficulty going up and down stairs and running, with flare-ups four to six times per month lasting 3 to 4 hours, helped by ibuprofen, ice and elevation.  The CI reported constant ankle pain, with flare-ups six to eight times per month lasting 8 to 12 hours, with difficulty going up and down stairs during flare-ups and some relief from ibuprofen.  He reported intermittent bilateral foot stiffness and swelling, with benefit from ibuprofen and rest, precipitated by cold weather and rain with no effect on his daily activities or usual occupation.  Physical examination noted an antalgic gait and a tendency to lean forward.  There was good ROM of the cervical spine.  There was non-compensable pain-limited motion of the right hip and non-compensable limitation of left hip.  The right knee showed full ROM and the left knee showed non-compensable limitation of knee flexion.  There was no evidence of instability or meniscal pathology.  Ankle ROM was normal bilaterally.  Shoulder ROM was normal bilaterally.  There was no crepitus, instability or swelling of either shoulder.  There was non-compensable limitation of both the left and right elbows.  There was non-compensable limitation of palmar flexion of both wrists.  Finger ROM was normal except for non-compensable, symmetrically decreased proximal interphalangeal joint motion.  The CI was able to touch all fingers to the proximal transverse crease of the palm and he was able to oppose all fingers to the thumb.  The feet were normal to inspection.  There was pain with eversion of the right foot in the metatarsals.  Palpation of the left foot was normal.  The CI had normal arches and there was normal alignment of the feet.  Screening blood work for rheumatologic or inflammatory disorders was negative.  Fibromyalgia tender points were suboccipital, upper trapezius, supraspinatus, sternomastoid, costochondral junction, elbows and knees.  Right and left shoulder X-rays were normal.  There were degenerative changes of the right and left elbows with soft tissue swelling on the left.  Right and left foot X-rays showed degenerative changes.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the fibromyalgia 0%, coded 5025 (fibromyalgia), citing generalized discomfort manifested few tender points, sleep disturbance, weather modulating factors and unremarkable lab data.  The VA rated the fibromyalgia condition 40%, coded 5025, based on the C&P examination, citing widespread constant musculoskeletal pain with tender points, fatigue and joint pain (due to strain or tendonitis), which cannot be separated from the fibromyalgia.  The CI reported constant low grade joint pain with exacerbations “35%” of the time at the MEB NARSUM examination and at the VA examination he detailed there was constant pain of some joints with exacerbations, but intermittent pain in other joints, all alleviated by anti-inflammatory medication (ibuprofen), rest and ice.  Neither the MEB NARSUM nor VA examination documented objective evidence of widespread pain related to fibromyalgia.  After lengthy discussion, the panel majority agreed the CI’s disability in regards to fibromyalgia more nearly approximated the 20% rating criteria than the 10% or 40% criteria for fibromyalgia symptoms “that are episodic, with exacerbations often precipitated by environmental or emotional stress or by overexertion, but that are present more than one-third of the time.”  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel majority recommends a disability rating of 20% for the fibromyalgia, coded 5025.  

BOARD FINDINGS:  In the matter of the back condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the fibromyalgia, the panel majority recommends a disability rating of 20% coded 5025 IAW VASRD §4.71a.  The single voter for dissent recommended no change but did not elect to submit a minority opinion.  There are no other conditions within the panel’s scope of review for consideration.  

The panel recommends the CI’s prior determination be modified as follows; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective the date of medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic Low Back Pain	5237	10%	
Fibromyalgia	5025	20%	
COMBINED	30%	

The following documentary evidence was considered:  

Exhibit A.  DD Form 294, dated 20170424, w/atchs  
Exhibit B.  Service Treatment Record  
Exhibit C.  Department of Veterans Affairs Record  

AR20190009864, 

Dear XXXXXXXXXXXXXXXXXXXX:

I accept the recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) to re-characterize your separation as a permanent disability retirement with the combined disability rating of 30% effective the date of your medical separation for disability with severance pay.  Enclosed is a copy of the Board’s recommendation and record of proceedings for your information.

	The re-characterization of your separation as a permanent disability retirement will result in an adjustment to your pay providing retirement pay from the date of your original medical separation minus the amount of severance pay you were previously paid at separation.
 
	The accepted DoD PDBR recommendation has been forwarded to the Army Physical Disability Agency for required correction of records and then to the U.S. Defense Finance and Accounting Service to make the necessary adjustment to your pay and allowances.  These agencies will provide you with official notification by mail as soon as the directed corrections have been made and will provide information on your retirement benefits.  Due to the large number of cases in process, please be advised that it may be several months before you receive notification that the corrections are completed and pay adjusted.  Inquiry concerning your correction of records should be addressed to the U.S. Army Physical Disability Agency, (AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557.

	A copy of this decision has also been provided to the Department of Veterans Affairs.