RECORD OF PROCEEDINGS
                     PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXX                    BRANCH OF SERVICE:  marine corps
CASE NUMBER:  PD1000067                                   SEPARATION
DATE:  20060731
BOARD DATE:  20100802


SUMMARY OF CASE:  Data extracted  from  the  available  evidence  of  record
reflects that this covered  individual  (CI)  was  an  active  duty  Cpl/E-4
(0311, Rifleman) medically separated from the Marine  Corps  in  July  2006.
The  medical  basis  for  the  separation  was  oligoarticular  inflammatory
arthritis (OIA). The CI did not respond adequately  to  perform  within  his
military occupational specialty  (MOS),  was  unable  to  participate  in  a
physical fitness test, and  underwent  a  Medical  Evaluation  Board  (MEB).
Unspecified inflammatory polyarthropathy and  right  shoulder  rotator  cuff
tear were forwarded to the Physical  Evaluation  Board  (PEB)  as  medically
unacceptable IAW SECNAVINST 1850.4E.   Additional  conditions  supported  in
the Disability Evaluation System (DES) file are discussed  below,  but  were
not forwarded  for  PEB  adjudication.   The  PEB  adjudicated  the  OIA  as
unfitting, rated 20%, with application of SECNAVINST 1850.4E,  DoDI  1332.39
and the VA Schedule for Rating Disabilities (VASRD), respectively.  The  PEB
categorized the rotator cuff tear as a category II condition related to  the
unfitting condition.  The CI made no appeals, and  was  medically  separated
with a 20% disability rating.


CI’s CONTENTION:  “The VA found reason for the rating to be higher.”


RATING COMPARISON:

|Service IPEB – 20060518           |VA ( 4 Mo. after Separation) – All     |
|                                  |Effective 20060801                     |
|Condition                         |Code                                   |
|TOTAL Combined:  20%              |TOTAL Combined: 70%                    |


ANALYSIS SUMMARY:  The Board acknowledges the  sentiment  expressed  in  the
CI’s application, i.e., that there should be additional disability  assigned
for  his  other  conditions  and  for  the  gravity  of  his  condition  and
predictable consequences which merit consideration for a  higher  separation
rating.  While the  DES  considers  all  of  the  service  member's  medical
conditions, compensation can only be offered for  those  medical  conditions
that cut short a service member's career, and then only  to  the  degree  of
severity present at the time of final disposition.  However, the  Department
of Veterans Affairs, operating under a different  set  of  laws  (Title  38,
United States Code), is empowered to periodically re-evaluate  veterans  for
the purpose  of  adjusting  the  disability  rating  should  the  degree  of
impairment vary over time.

Oligoarticular Inflammatory Arthritis.  The CI was  originally  referred  to
rheumatology in October 2005, for persistent complaints of  right  shoulder,
left  elbow,  and  proximal  interphalangeal/metacarpophalangeal  pain   and
swelling present for six months.  The CI also  had  a  history  of  shoulder
pain for approximately  two  years  and  was  on  limited  duty  due  to  an
atraumatic right knee  effusion  that  began  in  September  2005.   The  CI
complained of associated morning stiffness that lasted two to  three  hours.
Examination revealed swelling and tenderness of  the  right  shoulder,  left
elbow, left first and second metacarpophalangeal  joints  and  right  second
and  third  proximal  interphalangeal  joints.   Rheumatoid  lab  work   was
negative, and  the  working  diagnosis  was  OIA.   The  CI  was  placed  on
doxycycline (history of tick bite),  given  a  steroid  injection,  and  his
limited duty was continued.  The CI had slight improvement with the  steroid
injection  and  was  ultimately  started  on   an   immunosuppressive   drug
(methotrexate)  along  with  oral  corticosteroids.    Due   to   persistent
swelling,  the  methotrexate  was  increased  and  another   immune   system
suppressor was prescribed (humira).  Although his  condition  improved  with
medication he continued to be symptomatic, and did  not  respond  adequately
to perform within his MOS or to participate in a physical fitness test.

At his MEB rheumatology exam on 11 April  2006  three  and  one-half  months
before separation, the CI rated his  pain  as  5.5/10,  and  stated  he  was
unable to participate in sports, had difficulty, dressing  himself,  getting
in or out of a bed, bathing  himself,  and  walking  more  than  two  miles.
Physical exam revealed no clubbing, cyanosis, or edema of  his  extremities,
and he had no signs  of  psoriasis.   Examination  revealed  a  right  third
proximal interphalangeal joint with 2+ synovitis and 2+ tenderness,  and  no
associated warmth.  His left knee showed 3+ synovitis,  2+  tenderness,  and
1+ warmth.  Sedimentation rate was minimally  elevated  on  medication.   X-
rays of the involved joints were  read  as  normal.   A  magnetic  resonance
imaging (MRI) of his right shoulder (September  2005)  showed  rotator  cuff
tears, tenosynovitis and signs of inflammation.  The CI was  diagnosed  with
inflammatory arthritis (most  suggestive  of  a  reactive  arthritis  or  an
undifferentiated spondyloarthritis) and a right shoulder rotator cuff  tear.
 The examiner felt that the CI had  not  yet  completed  a  full  course  of
medications, and since his condition was improving, he recommended that  the
medication be continued along  with  rheumatology  follow-up  every  two  to
three months.

The CI was seen by the  VA  one  month  after  separation  after  moving  to
Oklahoma and was still on his medications.  During that exam the  CI  denied
any joint swelling, and the only objective finding was mild fullness of  one
finger joint.  VA follow up appointment revealed that the CI ran out of  his
medications in the October of 2006 and had  been  off  medication  for  more
than a month prior to the VA  compensation  and  pension  (C&P)  exam  on  6
December  2006.   At  that  exam,  four  months  after  separation,  the  CI
complained of episodic localized pain, swelling, stiffness and  weakness  of
his left elbow, both shoulders, left knee and  the  finger  joints  of  both
hands.  He reported incapacitating  episodes  due  to  his  left  knee  pain
occurring once per year that required bed rest.  On  exam,  all  the  joints
listed above, except for his hands, had  decreased  range  of  motion  (ROM)
limited by pain.  He had pain in the second through  fifth  fingers  of  the
right hand after repetitive use.  X-rays of all  the  joints  were  read  as
normal.  The CI was diagnosed with OIA of his left  elbow,  shoulders,  left
knee and right hand.

The PEB rated OIA under the VASRD coded 5009 (arthritis, other types)  at  a
disability rating of 20%; for two or more major joints or two or more  minor
joint groups, with occasional incapacitating exacerbations.  The CI had  had
past exacerbations, but was doing better  on  his  medication  regimen;  the
criteria for a 20% disability were  met.   Although  the  service  treatment
records and the MEB examiner noted painful motion of  the  involved  joints,
no ROM measurements were  recorded  and  there  was  no  evidence  of  joint
instability except  for  the  old  right  shoulder  injury.   There  was  no
evidence in the treatment records that his condition had worsened  prior  to
separation, and  the  VA  exam  in  August  2006  supported  this.   The  VA
separately rated each major joint group under  5002  (using  the  diagnostic
codes for the specific joints involved as  rheumatoid  arthritis)  based  on
painful/limited motion for each joint.  In the VA rating  examination  on  6
December 2006 the presence of painful motion  was  specifically  documented.
In addition, the VA goniometric  ROM  exams  stipulated  onset  of  pain  in
degrees and the amount of limitation.  Prior to the VA C&P exam, the CI  had
stopped his medications and the condition had worsened.  The  VA  rated  the
joint findings as chronic residuals; however, it is clear  from  the  record
that at the time  of  the  MEB  examination  and  at  the  time  of  the  VA
examination the CI had not received a full course  of  treatment  and  still
had active disease.  Thus  the  Board  determined  that  rating  of  chronic
residuals was not  appropriate  at  the  time  of  separation.   The  Board,
therefore, used the MEB examination for the  determination  of  the  rating.
Under the 5009 coding criteria the  Board  deliberated  as  to  whether  the
evidence fit the 40% or the 20% criteria.  The criteria  for  a  40%  rating
are  symptom  combinations  productive  of  definite  impairment  of  health
objectively   supported   by   examination   findings   or    incapacitating
exacerbations occurring  three  or  more  times  per  year.   There  was  no
evidence that the CI  experienced  incapacitating  exacerbations  more  than
once per year so the Board focused its attention on the first  part  of  the
criteria.   Since  the  CI’s  condition  was  improving  and  his  objective
findings had decreased prior to separation, the majority  of  Board  members
felt that he  did  not  meet  the  40%  criteria.   The  single  member  who
advocated for the 40% rating believed  the  CI  met  the  40%  criteria  for
definite impairment of health caused by the  use  of  methotrexate,  humera,
and steroids which both individually, and  more  so  in  combination,  cause
significant immune suppression with all of the expected  consequences.   All
evidence considered, the Board  recommends,  by  simple  majority  decision,
there is not reasonable doubt in the CI’s favor  supporting  a  change  from
the PEB’s rating decision for  the  condition  OIA  with  a  20%  disability
rating.

Right Shoulder Condition.  The CI injured his right shoulder while  in  high
school, and it resolved with physical therapy.  He was first seen in  August
2005 complaining of bilateral shoulder pain (after  push-ups  and  lifting).
He was given a steroid injection and put on limited duty for two weeks.   At
a follow-up exam on 7 September 2005, the CI was put  on  limited  duty  for
six months with a diagnosis of atraumatic effusion right knee and  bilateral
shoulder impingement. An MRI of the right  shoulder  on  26  September  2005
revealed rotator cuff tears involving the supraspinatus, infraspinatus,  and
subscapularis muscles.  There was  a  large  joint  effusion  with  synovial
hypertrophy  and  internal  debris.   Findings  were  consistent   with   an
inflammatory process, but also could have been from sequela  of  trauma  and
hemorrhage.  At  his  rheumatology  exam  in  October  2005,  the  CI  still
complained of right shoulder pain and had decreased ROM, 1+  synovitis,  and
2+ tenderness.  It was decided to readdress  the  rotator  cuff  tear  after
medically controlling the arthritic condition.  The  non-medical  assessment
(NMA) reported that the CI was unable to meet the requirements  of  his  MOS
due to the arthritis, but there was no  specific  mention  of  his  shoulder
condition.  At the MEB exam  no  inflammation  of  the  right  shoulder  was
noted, and there were no ROM measurements.  Although the CI had been put  on
limited duty from September 2005 until March 2006  for  his  knee  and  both
shoulders, there is no evidence in the treatment records that  the  shoulder
condition was active at the time of  separation.   At  follow  up  exams  in
March and April 2006, the CI complained of knee and hand pain,  but  not  of
shoulder pain.  As mentioned above at the first VA  exam,  one  month  after
separation, the CI had no shoulder complaints.  Since the rotator cuff  tear
was old, the Board determined that the recent right shoulder  flare  up  was
probably due to  the  arthritis,  had  resolved  with  medication  prior  to
separation.   After  due  deliberation  and  in  consideration  of  all  the
evidence, the Board determined that the right  shoulder  condition  was  not
separately unfitting at the time of separation.

Remaining Conditions.  Frequent headaches and several  non-acute  conditions
or medical complaints were also documented.  There was no  evidence  in  the
treatment records that the headaches were  incapacitating.   None  of  these
conditions carried attached profiles and none were implicated  in  the  NMA.
The Board has no reasonable basis for recommending any of them as  unfitting
for an additional separation  rating.   Chronic  left  shoulder  strain  and
patellofemoral pain syndrome of the right knee were noted in the  VA  rating
decision, but were not found in the DES file.  The Board does not  have  the
authority under DoDI 6040.44 to render  fitness  or  rating  recommendations
for any conditions not considered by the DES.  The Board  therefore  has  no
reasonable basis for recommending any additional  unfitting  conditions  for
separation rating.


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.  In the  matter  of  the  OIA  and  IAW  VASRD
§4.71a, the  Board,  by  a  2:1  vote,  recommends  no  change  in  the  PEB
adjudication.  The single voter for dissent who  recommended  a  40%  rating
did not  elect  to  submit  a  minority  opinion.   In  the  matter  of  the
headaches, right rotator cuff tear or any other medical conditions  eligible
for Board  consideration,  the  Board  unanimously  agrees  that  it  cannot
recommend any findings of unfit for additional rating  at  separation.   The
Board unanimously agrees that there were no other  conditions  eligible  for
Board consideration which could be  recommended  as  additionally  unfitting
for rating at separation.


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

|UNFITTING CONDITION                                |VASRD CODE  |RATING |
|Oligoarticular Inflammatory Arthritis              |5009        |20%    |
|COMBINED    |20%    |



The following documentary evidence was considered:

Exhibit A.  DD Form 294 dated 20100103, w/atchs.
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans' Affairs Treatment Record





      President, Physical Disability Board of Review

MEMORANDUM FOR DIRECTOR, SECRETARY OF THE NAVY COUNCIL OF REVIEW
                                         BOARDS

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATION
      ICO XXXXX, FORMER USMC, XXX XX XXXX

Ref:   (a) DoDI 6040.44
          (b) PDBR ltr dtd 23 Aug 11

      I have reviewed the subject case pursuant to reference (a) and, for
the reasons set forth in reference (b), approve the recommendation of the
Physical Disability Board of Review Mr. XXXX’s records not be corrected to
reflect a change in either his characterization of separation or in the
disability rating previously assigned by the Department of the Navy’s
Physical Evaluation Board.




                                        Assistant General Counsel
                                          (Manpower & Reserve Affairs)