RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-05384
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20051228

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty O4, Chemical, Biological, Radiological and Nuclear Specialist, medically separated for “chronic back pain,” “[bilateral] droopy shoulder syndrome,” and “fibromyalgia,” rated 10%, 0% and 0%, respectively, with a combined disability rating of 10%.

CI CONTENTION:  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 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 FPEB -20050701	VARD - NA	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Back Pain	5237	10%	No VA Examination Proximate to Separation in Evidence	
Bilateral Droopy Shoulder Syndrome	8599-8513	0%		
Fibromyalgia	5299-5025	0%		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  NA	

ANALYSIS SUMMARY:

Chronic Back Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI underwent laminectomy and diskectomy at L5-S1 in September 2000 and an L5-S1 fusion in December 2003.  An MRI dated 21 December 2004 demonstrated status post an L5-S1 fusion instruments without postoperative complication or nerve root compromise.

The 13 December 2004 MEB NARSUM neurology examination, 12 months prior to separation, noted complaints of chronic low back pain.  Physical examination showed normal upper and lower extremity motor strength, but the left foot had diminished pinprick sensation.  Repetitive-“trunk” range of motion (ROM), performed by physical therapy (PT) on 19 January 2005, revealed flexion of 50 degrees (normal 90) and combined ROM of 140 degrees (normal 240).  Painful motion was not addressed.  There was no VA examination proximate to separation in evidence.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, coded 5237 (lumbosacral strain), citing combined limitation of motion.  Panel members agreed that a 20% rating, but no higher, was justified for limitation of flexion (greater than 30 degrees but not greater than 60 degrees), as reported on the PT ROM examination.  There was no documentation of intervertebral disc syndrome with incapacitating episodes, which would provide for a higher rating under that formula.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 20% for the back condition, coded 5241 (spinal fusion).

Bilateral Droopy Shoulder Syndrome.  According to the STR and MEB NARSUM, the right-handed CI’s droopy shoulder syndrome manifested in January 2000 as chronic, bilateral, right greater than left, hand numbness and shoulder pain.  Neuromuscular experts diagnosed droopy shoulder syndrome based on clinical presentation and normal electrodiagnostic (EMG) studies.  Despite several supportive devices to elevate the shoulders, no relief was achieved.

A neurology clinic note dated 3 December 2004 documented the CI’s report of bilateral elbow and hand numbness that caused functional limitations.  The CI was not able to hold her hands to her head or type.  Physical examination showed a normal posture, stance and gait.  Upper and lower extremity motor strength was normal.  The right medial forearm and pinky finger, and left lateral forearm and thumb had diminished pinprick sensation and normal reflexes.  

The MEB NARSUM neurology examination noted complaints of chronic, bilateral, right greater than left, hand numbness and shoulder pain with flexion, abduction or traction on the shoulders or arms.  Physical training, carrying objects or holding her arms in positions required by deskwork or driving exacerbated the pain.  Continuation of these activities caused distal upper extremity weakness marked by loss of grip strength.  Physical examination showed full strength in the upper and lower extremity muscle groups, but pinprick sensation was diminished in the bilateral medial forearms and fifth digits, and only 50% of bilateral thumb and lateral forearm sensation.  Upper extremity reflexes were normal.  The examiner diagnosed droopy shoulder syndrome as the cause of the bilateral upper extremity symptoms and a major cause of functional disability.  

During the 22 December 2004 MEB examination (recorded on DD Forms 2807-1 and 2808), 12 months prior to separation, the CI reported bilateral arm pain and numbness secondary to droopy shoulder syndrome.  Physical examination revealed bilateral shoulder and elbow tenderness.  

At a neurology clinic visit on 29 August 2005, 4 months prior to separation, the CI reported intermittent bilateral hand numbness and weakness with pain.  Physical examination revealed significant right greater than left trapezius muscle spasm.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral shoulder condition 0%, analogously coded 8599-8513 (all radicular groups, paralysis), citing the condition was “essentially equivalent to thoracic outlet syndrome without any history of trauma or injury.  Physical examination noted 5/5 upper extremity strength and EMG studies [were] within normal limits.”

Panel members noted the CI had limitations when performing activities such as typing, driving, or physical training.  Droopy shoulder syndrome can occur with brachial plexus stretching (spinal nerves that send signals to the shoulders, arms and hands), which results in pain and numbness when the arms are placed in various positions.  Although upper extremity muscle strength and EMG studies were normal, the CI experienced bilateral arm functional impairment during daily work and soldiering activities.  Panel members agreed that code 8713 (neuralgia, all radicular groups) was a more appropriate code since pain and numbness were the predominant symptoms rather than involvement of the upper extremity muscles, albeit the CI had impaired bilateral grip strength.  The PEB assigned a 0% rating for the shoulder condition, but did not account for bilateral arm involvement.  The panel majority determined that the STR and VA bilateral arm evidence most nearly approximated “mild” impairment in support of a 20% rating for each arm IAW VASRD §4.124a and 4.7.  However, the minority member asserted that only the right arm was unfitting and ratable at 20%.  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 right arm, coded 8799-8713, and a disability rating of 20% for the left arm, also coded 8799-8713.

Fibromyalgia.  According to the STR and MEB NARSUM, rheumatology began to treat the CI’s fibromyalgia in 1994; however, the CI recalled hip pain since 1985.  The CI was initially diagnosed with systemic lupus erythematosus (SLE) marked by a positive ANA (antinuclear antibody) test, decreased lymphocyte and total white blood counts, joint involvement with arthralgias and arthritic changes, a photosensitive rash and Raynaud’s phenomenon.  Both SLE and Raynaud’s phenomenon were well controlled.  Subsequently fibromyalgia and irritable bowel syndrome were diagnosed.  Fibromyalgia was treated with muscle relaxants, tricyclic (antidepressant), tramadol (an opioid-like medication) and Gabapentin (for nerve pain) with variable success.  The CI reported good and bad days with subjective joint swelling and feelings of fullness, especially in the hands, which sometimes had a burning sensation.  She experienced bilateral knee aches and described “problems bending and a burning sensation.”

The 19 April 2004 MEB NARSUM rheumatology examination, 20 months prior to separation, noted ongoing fibromyalgia concerns.  Physical examination showed no synovitis or effusions, and “full” extremity and bilateral shoulder ROM with slight shoulder crepitation.  There was no trochanteric (hip) discomfort, a negative leg roll and “normal” hip ROM.  There was no knee effusion, crepitus, laxity or meniscal tear.  There were 10/18 “tender spots” including the bilateral occipital region (lower back of head), bilateral mid trapezius, anterior costochondral areas (top of sternum), forearms and bilateral proximal knee fat pad areas (below patella).  Her arms and lower extremities were slightly tender.  The examiner indicated the fibromyalgia was stable but the CI had persistent myofascial (muscle pain disorder) discomfort related to chronic back pain.  The fibromyalgia was a secondary process.  

During the MEB examination, the CI reported widespread painful joints and frequent trouble sleeping.  Physical examination revealed trigger points in the back, chest, hips and thighs.  There was bilateral shoulder, elbow and knee tenderness.  

At the 2 May 2005 MEB rheumatology addendum, 7 months prior to separation, the CI reported that she minimized her prior subjective complaints in order to maintain an appearance that she could perform her assigned duties.  She was more bothered by fatigue during the day and took caffeine pills to function.  Physical examination showed mild tender spots consistent with fibromyalgia.  She scored 75.45 on the Fibromyalgia Impact Questionnaire, which signified a poor prognosis. 

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the fibromyalgia 0%, analogously coded 5299-5025 (fibromyalgia), citing intermittent use of pain medications.

Panel members noted that the VASRD rating for fibromyalgia requires “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.”  The CI required continuous medication for control and the PEB noted the pharmacy record noted intermittent use of pain medications.  However, the STR revealed use of muscle relaxants, an antidepressant and medications for joint, muscle and nerve pain. Although the CI underwent steroid injections predominantly for lower back pain, they also treated her fibromyalgia.  An increased Gabapentin dosage was specifically made for her fibromyalgia.  Consequently, the panel agreed that the evidence supported a 10% rating for a requirement of continuous medication for fibromyalgia control.  The STR did not support the presence of episodic fibromyalgia exacerbations present more than one-third of the time for a 20% rating.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the fibromyalgia, coded 5025.

BOARD FINDINGS:  In the matter of the back condition, the panel recommends a disability rating of 20%, coded 5241 IAW VASRD §4.71a.  In the matter of the bilateral droopy shoulder syndrome, the panel majority recommends a disability rating of 20% for the right arm, and a disability rating of 20% for the left arm, both coded 8799-8713 IAW VASRD §4.124a.  In the matter of the fibromyalgia condition, the panel recommends a disability rating of 10%, coded 5025 IAW VASRD §4.71a.  The single voter for dissent recommended re-characterization to 40% instead of 60%, but did not elect to submit a minority opinion.  

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 Back Pain	5241	20%	
Droopy Shoulder Syndrome, Right Arm	8799-8713	20%	
Droopy Shoulder Syndrome, Left Arm	8799-8713	20%	
Fibromyalgia	5025	10%	
COMBINED	60%	

The following documentary evidence was considered:

AR20190008644, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX

I accept the recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) to re-characterize your separation as a disability retirement with the combined disability rating of 60% 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 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.  Inquiries concerning your correction of records should be addressed to the U.S. Army Physical Disability Agency, (AHRC-DO), 
	A copy of this decision has also been provided to the Department of Veterans Affairs.