RECORD OF PROCEEDINGS

PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXX BRANCH OF SERVICE: Army

CASE NUMBER: PD1100732 SEPARATION DATE: 20070124

BOARD DATE: 20120823

SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SFC/E-7 (92M48 / Mortuary Affairs Specialist), medically separated for rheumatoid arthritis (RA). She did not respond adequately to treatment and was unable to perform within her Military Occupational Specialty (MOS) or meet physical fitness standards. She was issued permanent P3/U3/L3 profiles and underwent a Medical Evaluation Board (MEB). “Rheumatoid arthritis” was forwarded to the Physical Evaluation Board (PEB) as medically unacceptable IAW AR 40-501. No other conditions appeared on the MEB’s submission. The PEB adjudicated the RA condition as unfitting, rated 20% with application of the Veterans Administration Schedule for Rating Disabilities (VASRD). The CI made no appeals, and was medically separated with a 20% disability rating.

CI CONTENTION: The CI requests a higher rating for rheumatoid arthritis explaining the autoimmune nature of the disease and potential for future worsening and complications. She elaborates no specific contentions regarding rating or coding and mentions no additionally contended conditions.

SCOPE OF REVIEW: The Board wishes to clarify that the scope of its review as defined in DoDI 6040.44, Enclosure 3, paragraph 5.e.(2) is limited to those conditions which were determined by the PEB to be specifically unfitting for continued military service; or, when requested by the CI, those condition(s) “identified but not determined to be unfitting by the PEB”. The ratings for unfitting conditions will be reviewed in all cases. Any conditions or contention not requested in this application, or otherwise outside the Board’s defined scope of review, remain eligible for future consideration by the Army Board for the Correction of Military Records.

______________________________________________________________________________

RATING COMPARISON:

*Discontinued effective 20101005 on the 20111123 VARD; after this time, the wrists, ankles and knees were rated individually.

ANALYSIS SUMMARY:

Rheumatoid Arthritis Condition. The CI was diagnosed with RA in 1999 and treated with medications. She responded well to the regime and became asymptomatic in 2003. All medications were then discontinued. Her symptoms recurred, in September 2005 and she was re-started on medications. In October 2005, 15 months prior to separation, imaging of the hands and feet showed bilateral osteoporosis and mild peri-articular swelling of the MCP joints of the hands. No erosions were seen. Bilateral mid (mild) hallux valgus of the feet was seen. There was no evidence of joint erosions. A follow-up DEXA (dual energy X-ray absorptiometry) scan on 31 March 2006 was normal, however, without osteopenia or osteoporosis noted. She was noted to be 208 pounds (5’- 5” tall). The commander’s evaluation, dated 9 months prior to separation, stated that she was non-deployable in a highly deployable MOS due to the medications and laboratory work required to monitor her condition. He also noted that her physical limitations precluded her from meeting the requirements of her MOS and basic soldiering skills. The MEB narrative summary (NARSUM) examination was completed 8 August 2006, 5 months prior to separation and 2 months prior to the final rheumatology appointment. It noted that her symptoms were improved on the current medication regimen. However, she still had trouble with running and jumping, lifting and carrying heavy objects, push-ups, sit-ups and road marching. She complained of swelling and pain in her hands, ankles and the left knee. On exam, she was noted to have tenderness in bilateral hands and wrists, left knee and ankles. There was also swelling of the ankles noted. The left knee had full ROM without instability or crepitus. Gait was mildly antalgic. Laboratory tests for inflammation were negative (normal erythrocyte sedimentation rate and C-reactive protein). A complete blood count (CBC) was also normal indicating that there was no anemia due to chronic inflammation present. At her last rheumatology visit on active duty on 11 October 2006, three months prior to discharge, her symptoms included fatigue and generalized stiffness, but she was able to walk 2 - 2 1/2 miles per day. Her ankles, wrists and elbows were noted to be free of swelling, tenderness and warmth. The ankles had some swelling determined to be secondary to dependant edema and not active arthritis. She had full range of motion (ROM) of the shoulders. She also complained of her jaw “popping” which was thought to be non-inflammatory in nature. The examiner noted that there were no signs of active synovitis (arthritic inflammation of joint). There were no ocular, oral mucosal or dermatologic findings on the examination to indicate other disease complications or medication side effects. The VA Compensation and Pension (C&P) examination was performed on 20 April 2007, 3 months after separation. It noted that she complained of edema, pain, stiffness limiting daily activities. She was symptomatic in the wrists, hands, ankles, feet, and knees bilaterally. She gave a history of constitutional symptoms; these were anemia and fatigue. On examination, her weight was 225 pounds. Gait and posture were normal. Oral and ocular health were normal as was the skin examination. There was no generalized muscle weakness or wasting. Examination of the knees, wrists and ankles was normal other than the limitation of the left knee from pain after repetition. ROM was normal for the ankles and wrists and minimally reduced for the knees, 130⁰ each with a norm of 140⁰. Although the examiner reported that she had difficulty tying her shoes, picking up and tearing a piece of paper and fastening buttons, the examination of the hands and fingers was normal showing normal ROM of all fingers, and normal strength of both hands. Hallux valgus was not seen on this exam. The neurological examination was normal. Imaging of the wrists, hands, knees, ankles and feet were normal with the exception of a bone spur at the PIP joint of the left fifth toe. Sedimentation rate and CBC were again normal, indicating an absence of inflammation and no anemia. The examiner noted there were no constitutional signs, including weight loss, anemia or skin changes, and stated that the “Examination reveals no joint involvement”. Her general health was thought to be mildly impaired. There is no other information post-separation available for review which is within 1 year of separation. However, there are several rheumatology notes from 2 1/2 and 3 years after separation which document continued good control of the RA. The PEB and VA both coded the RA as 5002 and rated it at 20%. The Board noted that the CI was not anemic, was actually gaining weight and had no history of incapacitating episodes. The Board members agreed that the disability did not rise to the level of 40%, which requires definite impairment of health supported by examination findings or three or more incapacitating episodes a year. The Board noted that the VA subsequently rated the joints individually on the 23 November 2011 decision, over 4 years after separation and considered whether there were chronic residuals at the time of separation warranting rating separate from the arthritis condition. The Board considered the final rheumatologic examination, three months prior to separation, which documented excellent control of her RA with “no signs of active synovitis”, and the proximate post-separation VA C&P examination which documented an unremarkable examination of the joints and normal imaging. The Board determined that these findings do not support rating the joints separately for chronic residuals at the time of separation. After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the rheumatoid 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. In the matter of the rheumatoid arthritis condition, the Board unanimously recommends a disability rating of 20%, coded 5002 IAW VASRD §4.71a. 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:

The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20110801, w/atchs.

Exhibit B. Service Treatment Record.

Exhibit C. Department of Veterans Affairs Treatment Record.

XXXXXXXXXXXXXXXXXXXX

President

Physical Disability Board of Review

SFMR-RB

MEMORANDUM FOR Commander, US Army Physical Disability Agency

(TAPD-ZB / ), 2900 Crystal Drive, Suite 300, Arlington, VA 22202

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXXXXXXXXXXX, AR20120016148 (PD201100732)

I have reviewed the enclosed Department of Defense Physical Disability Board of Review (DoD PDBR) recommendation and record of proceedings pertaining to the subject individual. Under the authority of Title 10, United States Code, section 1554a, I accept the Board’s recommendation and hereby deny the individual’s application.

This decision is final. The individual concerned, counsel (if any), and any Members of Congress who have shown interest in this application have been notified of this decision by mail.

BY ORDER OF THE SECRETARY OF THE ARMY:

Encl XXXXXXXXXXXXXXXXXXXX

Deputy Assistant Secretary

(Army Review Boards)

CF:

( ) DoD PDBR

( ) DVA