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AF | PDBR | CY2013 | PD-2013-02082
Original file (PD-2013-02082.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXX  CASE: PD-2013-02082
BRANCH OF SERVICE: Army  BOARD DATE: 20140812
SEPARATION DATE: 20030304


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SPC/E-4 (12B/Combat Engineer) medically separated for an arthritic condition. The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty or satisfy physical fitness standards. He was issued a permanent P3 profile and referred for a Medical Evaluation Board (MEB). The arthritic condition, characterized as “ankylosing spondylitis” was forwarded to the Physical Evaluation Board (PEB) as medically unacceptable IAW AR 40-501. No other conditions were submitted by the MEB. The PEB adjudicated “HLA B27 associated sacroiliitis” as unfitting, rated 20%. The CI made no appeals and was medically separated.


CI CONTENTION: “Ankylosing Spondylitis is a severely dibilitating disease making daily life difficult. Arthritis has also affected the rest of my body.”


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 rating for the unfitting HLA B27 associated sacroiliitis (ankylosing spondylitis) condition is addressed below; and, no additional conditions are within the DoDI 6040.44 defined purview of the Board. 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 Board for Correction of Military Records. The Board acknowledges the CI’s information regarding the significant impairment with which his service-connected condition continues to burden him; but, must emphasize that the Disability Evaluation System has neither the role nor the authority to compensate members for anticipated future severity or potential complications of conditions resulting in medical separation. That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws. Post-separation evidence is probative to the Board’s recommendations only to the extent that it reasonably reflects the disability at the time of separation.


 RATING COMPARISON :

Service IPEB – Dated 20021105
 VA - (~3 mos. Pre-Separation)
Condition
 Code Rating Condition Code Rating Exam
HLA B27 Associated Sacroiliitis 5099-5002 20% Ankylosing Spondylitis Of The Lumbar Spine (Rating Schedule Amended September 26, 2003; Evaluation
Protected Under 5292)		 5240 20% 20021212
Other x 0 (Not in Scope)
 Other x 0 20021212
Combined: 20%
 Combined: 20%
Derived from VA Rating Decision (VA RD ) dated 20 110128 ( most proximate VARD in evidence to date of separation [ DOS ] ). It appears there was an original VARD near the time of separation; and based on remote VARD, assumed that DC 5240 was the only condition rated by the VA at that time.

ANALYSIS SUMMARY:

Ankylosing Spondylitis Condition. Absent direct inciting trauma, the CI developed sudden and severe low back pain (LBP) in late 2001 and first sought medical care in March 2002. Initially, he was hospitalized for 5 days with a discharge diagnosis of right-sided lumbosacral pain and instructed to follow-up with physical therapy. Despite therapy and medications, his LBP worsened. He was hospitalized for an additional 11 days (23 April - 03 May 2002) secondary to syncope (passing out) from an initial report of excess consumption of pain medication taken for back pain. Additional radiology and laboratory work-up during his inpatient stay revealed bilateral sacroiliac (SI) inflammation and positive HLA-B27 (Human Leukocyte Antigen B-complex [HLA-B] is a genetic protein marker found on white blood cells; the 27 refers to an additional protein variation within the gene complex). The diagnosis of ankylosing spondylitis was entertained and, his discharge diagnosis remained right-sided lumbosacral pain with SI inflammation. His painful symptoms spread to multiple joints to include bilateral ankles, right knee and left wrist lending to a provisional diagnosis of polyarthralgias (multi-joint pain) and was referred to rheumatology in June 2002 (9 months prior to separation) who initially diagnosed “spondyloarthopathy” (…a family of chronic diseases of joints, sometimes referred to as spondyloarthritis). X-rays revealed bilateral iliac sclerosis (hardening of bone) with erosions present. The rheumatologist’s physical examination (PE) noted tenderness to both sacroiliac (SI) joints and eventually, the CI was diagnosed with HLA-B27 associated sacroiliitis. The record did not reveal the CI as having any associated systemic involvement such as rashes, gastrointestinal symptoms, inflammatory eye symptoms, or oral lesions that can be found within the spondyloarthropathy category of conditions.

The narrative summary (performed 5 months prior to separation) indicated that the CI could no longer run or perform any heavy lifting. The PE revealed an antalgic gait and limited lumbosacral range-of-motion (ROM) secondary to pain. ROM was measured as “full” to the shoulders, elbows and knees and “full with stiffness and or pain” in the hips, fingers, wrist and neck. At the VA Compensation and Pension exam (performed 3 months prior to separation), the CI reported continued LBP with occasional right leg weakness and pain. Symptom aggravators included heavy lifting, prolonged standing or descending stairs. His pain level remained at 5/10 despite medication use. The examination revealed tenderness to the upper and mid-thoracic spine (T2-T6) and bilateral SI joints. There were no paraspinal muscle spasms present. All other body symptoms were without abnormality. The goniometric ROM evaluations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized below.

DOS 20030304
Thoracolumbar ROM
(Degrees)		 MEB ~5 Mo. Pre-Sep
(20020930)
VA C&P ~3 Mo. Pre-Sep
(20021212)
Flexion (90 Normal) Fingertips 11” from floor 80 Full ROM
Extension (30) 30
R Lat Flexion (30) Fingertips to fibular head 30
L Lat Flexion (30) Fingertips to fibular head 30
R Rotation (30) 20
L Rotation (30) 20
Combined (240) 210 FROM
Comment s pasm; antalgic gait painful motion ; assisted device
§4.71a Rating 20 % 10% -20%

The Board directs attention to its rating recommendation based on the above evidence. The MEB documented trunk flexion as the ability to reach the finger tips to 11 inches from the floor which approximates 80 degrees of thoracolumbar flexion. Additionally, “fingertips to the level of the fibular head” is an accepted descriptive pictorial of normal thoracolumbar lateral flexion of at least 30 degrees. Although coded differently, both the PEB and VA rated the condition at 20% utilizing codes from the current VA Schedule for Rating Disabilities (VASRD) §4.71a rating standards; however, the separation date reflects prior spinal guidelines are to be utilized. The 2003 VASRD coding and rating standards for the spine, which were in effect at the time of the CI’s separation, were updated 23 September 2002 for code 5293 (incapacitating episodes), and then changed to the current §4.71a rating standards on 26 September 2003. The older VASRD standards for rating based on ROM impairment were subject to the rater’s opinion regarding degree of severity, whereas the current standards specify rating thresholds in degrees of ROM impairment. The VASRD normal ROM values were not in effect prior to 26 September 2003, and are for the combined thoracolumbar spine segment, whereas the older spine criteria considered the thoracic and lumbar spine segments separately. The PEB provided no specific rationale for its 20% rating citing only laboratory and radiographic evidence; presumably, based upon 5002 (arthritis, rheumatoid), for “one to two exacerbations a year in a well-established diagnosis.” The original VARD was absent from the case file and the VA’s use of current spinal code 5240 (ankylosis spondylitis) was specifically referenced with “evaluation protected under [the prior coding standards] 5292.”

Board members first considered the confines of this “systemic” versus “local” medical condition and its parameters for rating. Even though the underlying medical condition has a systemic (laboratory) finding, the nature of the spondyloarthropathy category of diseases are very similar involving the attachments between the low back and pelvis...aka, the SI joints. Overwhelmingly, this case displayed such a local focus of bilateral involvement and therefore, IAW VASRD §4.45 (Joints) which states “The lumbosacral articulation and both sacroiliac joints are considered to be a group of minor joints, ratable on disturbance of lumbar spine functions.” Board members agreed that a single rating under the VASRD spine guidelines was appropriate.

Board members then considered and agreed that the two hospitalizations within a year prior to separation would support the interim spinal code of 5293 incapacitation criteria at 20%. Board members also considered 5292 (limitation of lumbar motion) and deliberated that the totality of both the MEB and VA exams indicating limited ROM coupled with the need for an assisted walking device would exceed the mild (10%) and be sub-threshold for the severe (40%) criteria under code 5292; therefore, members agreed that the condition more accurately is supported by the moderate (20%) impairment level. Members also agreed that there were no other residuals of limitation of motion or ankylosis of any other involved joint which were applicable and or advantageous to the CI’s current 20% rating in accordance with the general rating formula for diseases and injuries of the spine. 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’s adjudication for the HLA-B27 associated sacroiliitis 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 sacroiliitis 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 re-characterization of the CI’s disability and separation determination.


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20131101, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans’ Affairs Treatment Record



                          
XXXXXXXXXXXXXXXXX
President
Physical Disability Board of Review

SAMR-RB                            


MEMORANDUM FOR Commander, US Army Physical Disability Agency
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557


 SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXX, AR20150002511 (PD201302082)

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                                                  XXXXXXXXXXXXXXXXX
                                                      Deputy Assistant Secretary of the Army
                                                      (Review Boards)
                                                     
CF:
( ) DoD PDBR
( ) DVA

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