Author: JOHN J. D'ORAZIO
Last saved by: ADA, ROBERT P CIV USAF SAF/MRBD
Company: Pre-installed Company

RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	 CASE:  PD 1201556	
BRANCH OF SERVICE:  AIR FORCE 	 BOARD DATE:  20130606
SEPARATION DATE:  20070220		 

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SSgt/E-5 (3C051, Information Assurance Technician) medically separated for inflammatory arthritis.  The CI had a long history of joint pain, with complaints of wrist pain as early as 1997, which later included pain in her knees, back and neck, along with swelling in her knees.  Various conservative treatments were implemented throughout the years, including physical therapy, rest, medication, and chiropractic care.  In 2006 the CI was referred to Rheumatology, where she was diagnosed with inflammatory arthritis.  This condition could not be adequately rehabilitated to meet the requirements of her Air Force Specialty (AFS) or physical fitness standards, so she was issued a P4 profile and referred for a Medical Evaluation Board (MEB).  The arthritic condition, characterized as “inflammatory arthritis” was forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123.  No other conditions were submitted by the MEB.  The PEB adjudicated “inflammatory arthritis” as unfitting and rated 20% IAW Department of Defense (DoD) and Veteran’s Affairs Schedule for Rating Disabilities (VASRD) guidelines.  The PEB also found “tobacco abuse” and “obesity, BMI 33.07” as Category III conditions (not separately unfitting).  The CI made no appeals and was medically separated with that 20% Service disability rating.

CI CONTENTION:  “My initial rating was given for "One or Two exacerbations a year in a well-established diagnosis."  This should be changed as anyone who has been diagnosed with RA would have a lesser amount of exacerbations after diagnosis as they would have been treated.  What the rating fails to recognize is the multiple exacerbations prior to diagnosis.  Upon review of my records you will find multiple medical appointments for swelling of the knee.  I also had multiple appointments for pain and swelling in my hands, which were written off as Carpal Tunnel because I was a computer operator.  I later learned that I was never actually tested for Carpal Tunnel.  Each knee appointment should be considered and incapacitating exacerbation, as I was unable to run, squat, jump or stand for more than 15 minutes.  With some of these exacerbations I was put on a profile, sent to physical therapy and given Motrin.  Usually within a week or two of the profile ending the swelling would return.  At one point I asked my doctor not to put me on a profile, as I needed to prepare for my PT test, the alternatives they gave me were ineffective.  At no time did any of my doctors recommend looking further into it.  It wasn't until the pain got so bad that my supervisor insisted I request my doctor send me to a specialist.  The orthopedic surgeon did X-rays' and MRI's and did find a synovial cyst.  He was unconcerned with the cyst, however, he was concerned with the number of times my knee had swollen and recommended I see a rheumatologist.  During one of my appointments my knee was exacerbated, and the doctor took about 60cc's of fluid from it.  I was also given a Cortizone injection and told that should help for a few months, it lasted only a few days.  When the lab work came back for the fluid from my knee, I was finally diagnosed with Sero-Negative Arthritis. I was put up for a medical review board and after fighting for my career I was separated with only 20% as by this time I had been on medication for a few months and it was now a well established diagnosis.”  [sic]  

SCOPE OF REVIEW: The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e. (2).  It is limited to those conditions determined by the PEB to be unfitting for continued military service and those conditions identified but not determined to be unfitting by the PEB when specifically requested by the CI.  The Service rating for the unfitting inflammatory arthritis condition is addressed below; no other conditions meet the criteria for board consideration.  Any conditions or contention not requested in this application or otherwise outside the Board’s defined scope of review remain eligible for consideration by the Service Board for Correction of Military Records. 

RATING COMPARISON:  
   
Service PEB – Dated 20061030 | VA – CI did not consent to release VA records
Condition | Code | Rating | Condition | Code | Rating | Exam
Inflammatory Arthritis | 5009 | 20% | Not Available
Tobacco Abuse | Cat III |
Obesity, BMI 33.07 | Cat III |
No Additional MEB/PEB Entries |
Combined:  20% | Combined:  Unknown
Derived from email contact with CI indicating no consent to release VA records.   

ANALYSIS SUMMARY:  

Inflammatory Arthritis.  In 1997, the CI presented with right wrist pain and numbness which was diagnosed and treated as an extensor tendonitis.  In 1999, she then presented with left wrist pain and a right fifth digit deformity.  She was treated conservatively and diagnosed with carpal tunnel.  In 2000, she presented with right knee after an injury.  X-ray evaluation demonstrated a knee effusion, but was otherwise negative.  In 2001, she presented with bilateral knee pain.  The CI’s symptoms evolved to include pain in the digits, foot, neck, and back accompanied by occasional swelling and morning stiffness.  The CI was evaluated and treated by chiropractor, orthopedics, physical therapy, and rheumatology.  Her diagnoses included tendonitis of the wrist, bilateral carpal tunnel syndrome, chronic knee and wrist pain, backache, and cervicalgia.  Magnetic resonance imaging (MRI) study of the right knee, June 2006, eight months before separation, suggested inflammatory arthropathy.  There were no significant degenerative changes, no fractures, and no evidence of ligamentous abnormalities.  In June 2006, an orthopedic evaluation revealed full range of motion of the right knee with signs of inflammation; the CI was referred to rheumatology for right knee and hand pain with swelling.  Rheumatology consultation, September 2006, diagnosed seronegative inflammatory arthritis.  Laboratory studies were normal (ESR, RF, ANA, HLA B27).  At the MEB/NARSUM, 14 September 2006, approximately five months prior to separation, the CI reported the intermittent use of wrist brace for symptom relief, difficulty climbing stairs and standing for long periods of time.  She reported significant improvement with medication and indicated her symptoms did not limit her job performance (computer operator).  The NARSUM physical examination documented tenderness of the first digit joint, right hand swelling, non-tender wrists, and ROM was “good.”  The Board directs attention to its rating recommendation based on the above evidence.  The PEB rated the condition 20% coded 5009 (arthritis, other), which requires ratings under the rheumatoid arthritis code 5002.  The CI did not consent to VA medical record release; therefore, the Board’s analysis was confined to the evidence at hand.  A higher rating of 40% under this code requires documented evidence of definite health impairment or 3 or more incapacitating exacerbations a year.  Although her profile restricted lifting more than 15 pounds, prolonged standing, running, sit ups, pushups, squatting, and jumping, the Commander’s statement indicated the CI’s condition had not interfered with the performance of her daily duties and required only a half day of missed work every 4-6 weeks.  There was no evidence in the treatment record of prescribed quarters for her condition.  A careful review of the treatment records did not support a higher rating because there was no evidence of definite health impairment or a sufficient number of incapacitating exacerbation to meet the 40% criteria.  There was no radiographic finding of any joint pathology, no evidence of ratable peripheral neuropathy, and no compensable limitation in motion.  The Board considered the application of §4.40, functional loss and agreed it was not applicable in this case.  There were no other applicable VARSD coding options to rate the condition.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the inflammatory arthritis condition.  

BOARD FINDINGS:  IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication.  The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised.  In the matter of the inflammatory arthritis condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  There were no other conditions within the Board’s scope of review for consideration. 

RECOMMENDATION:  The Board, therefore, recommends that there be no recharacterization of the CI’s disability and separation determination, as follows:  

UNFITTING CONDITION | VASRD CODE | RATING
Condition | 5009 | 20%
COMBINED | 20%

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20120824, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

			
	           XXXXXXXXXXXXXXXXXXXX, DAF
	           Director of Operations
	           Physical Disability Board of Review

SAF/MRB
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD 20762

Dear XXXXXXXXXXXXXXXXXXXX:

	Reference your application submitted under the provisions of DoDI 6040.44 (Title 10 U.S.C. § 1554a), PDBR Case Number PD-2012-01556.

	After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was appropriate.  Accordingly, the Board recommended no re-characterization or modification of your separation.

	I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding and their conclusion that re-characterization of your separation is not warranted.  Accordingly, I accept their recommendation that your application be denied.

							Sincerely,

XXXXXXXXXXXXXXXXXXXX
Director
Air Force Review Boards Agency

Attachment:
Record of Proceedings

PD 12-01556