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AF | PDBR | CY2013 | PD-2013-02624
Original file (PD-2013-02624.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXX    CASE: PD-2013-02624
BRANCH OF SERVICE: Army  BOARD DATE: 20150115
SEPARATION DATE: 20050708


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an activated National Guard E-4 (Nuclear Biological Chemical Specialist) medically separated for a right knee condition. The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty. He was issued a permanent P3L3 profile and referred for a Medical Evaluation Board (MEB). The knee condition, characterized as “meniscal tear right knee” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. The MEB also identified and forwarded two other conditions (rheumatoid arthritis and osteoarthritis) as failing retention standards. The Informal PEB adjudicated “chronic pain right knee due to medial meniscus tear” as unfitting, rated 10%, citing criteria of the US Army Physical Disability Agency (USAPDA) pain policy. The remaining conditions were determined to have existed prior to service (EPTS) and not p ermanently aggravated beyond natural progression by such service . The CI made no appeals and was medically separated.


CI CONTENTION: “My arthritis in my joints having become increasingly worse and painful. The condition in both my knees cause any kind of continuess use impossible. My degenerative disc disease in my back keeps my down and at home most days.”[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 when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting. Any conditions outside the Board’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/Naval Records. Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate. The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards to the unfitting medical condition at the time of separation. The Board 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, operating under a different set of laws. The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation.


RATING COMPARISON :

Service IPEB – Dated 20050613
 VA - (12 Mos. Post-Separation)
Condition
 Code Rating Condition Code Rating Exam
Chronic Pain Right Knee, Due to Medial Meniscus Tear 5099-5003 10% Medial Meniscal Tear Right Knee 5260-5024 10% 20060708
Rheumatoid Arthritis 5002 EPTS/
Not PSA
 Rheumatoid Arthritis Involving Hands, Elbows and Wrists 5002 NSC 20050615
Osteoarthritis of Knees 5003 EPTS/
Not PSA		 Degenerative Joint Disease Left Knee 5260-5003 NSC 20060708
Other x 0 (Not in Scope)
 Other x 6 (Not in Scope) 20060708
RATING: 10%
 COMBINED RATING: 30%
Derived from VA Rating Decision (VARD) dated 20060724 ( most proximate to date of separation [DOS]).


ANALYSIS SUMMARY:

Chronic Pain Right Knee Due to Meniscal Tear. The narrative summary (NARSUM) noted the CI to develop right knee pain while training for a physical training (PT) test in 2004. A magnetic resonance imaging (MRI) of the knee, obtained In January 2005, revealed a tear of the back portion of the right medical meniscus (knee cartilage). No surgery was recommended for this condition. On a clinic exam on 5 October 2004, range-of-motion (ROM) of the knee was “full” without motor weakness. An orthopedic evaluation, undated, noted in its content to be performed during the MEB process, ROM of the knee was flexion of 135 degrees and extension of 0 degrees (normal flexion-140 degrees; extension-0 degrees). At the April 2005 MEB/NARSUM evaluation, 3 months prior to separation exam, the CI was reported to have an antalgic gait. The MEB physical exam noted that the CI was unable to heal or toe walk without pain in his knee. Examination of the knee revealed no swelling or edema. ROM of the knee was flexion of 115 degrees and extension of 0 degrees. Motor, sensory and reflex exams were normal. No instability of the knee was recorded.

At the VA Compensation and Pension (C&P) General exam performed on 15 June 2005, a month prior to separation, the CI reported the knee condition caused no incapacitation and he was receiving no treatment. On physical examination, the gait was noted to be antalgic requiring a cane for ambulation. No swelling of the knee was present. ROM was flexion of 140 degrees and extension was reduced 10 degrees, both with painful motion. No instability of the knee was reported. Motor and sensory exams were normal. An evaluation dated 14 December 2005; the CI’s gait was normal with normal motor, sensory and reflex examinations. At the VA C&P Joint examination, performed on 8 July 2006, 12 months after separation, gait was normal. Flexion and extension were normal without painful motion. No instability of the knee was noted. Motor and reflex exams were normal. Routine X-rays of the knee were normal.

The Board directed attention to its rating recommendation based on the above evidence. The PEB and the VA both rated the knee condition at 10% using different codes. The PEB rated using the USAPDA pain policy; the VA used code 5260-5024 (limitation of flexion/tenosynovitis). A higher rating of 20% under this code requires a reduction of knee flexion to 30 degrees. The Board consensus was that the record in evidence supported a rating of 10% for painful motion IAW §4.40 and §4.59. The Board agreed that the record in evidence did not support a compensable rating for the knee for loss of flexion (code 5260) or instability (code 5257). The Board considered a rating under code 5261 (limitation of extension). Under this code a 10% rating requires a loss of extension of 10 degrees. The Board noted the differences in the extension findings on the NARSUM exam (0 degrees) and VA General Exam (10 degrees loss), both proximate to separation. The Board agreed that the findings on the PEB exam more accurately reflected the pathology demonstrated on MRI, which would not impact ROM, and the findings of normal extension in the preponderance of clinical examinations in the record. The Board, therefore, gave higher probative value to the NARSUM exam which supported no compensable rating under code 5261. The Board agreed that the record supported a rating no higher than 10% for the knee condition under code 5262 (impairment of the tibia). The Board found no other appropriate codes for rating consideration and no pathway to a rating higher than 10% for the right knee 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 right knee condition.

Rheumatoid Arthritis Condition. The CI’s military service started in the Army National Guard from June 1985 to September 1986; membership in the US Navy Reserve from August 1986 to January 1987; and service in the US Coast Guard from January 1987 to June 1992. From July 1992 until February 2003, the CI had a civilian break with no military service. In February 2003 the CI rejoined the Army National Guard where he remained until his separation on 8 July 2005. The record in evidence documents the CI presented to a rheumatologist in April 1999 with a 6-month history of painful swelling of his hands. The CI reported onset of hand pain and swelling in 1994 at the end of the day while working as a mechanic and he had moved from several jobs because of pain in his hands. The physician noted that he had seen the CI in 1995 and 1996 for similar episodes. Laboratory blood tests for rheumatoid arthritis (RA) were weakly positive. The CI was again seen by rheumatology on 26 January 2000 with complaint of recurrent pain and swelling in his hands. Laboratory blood tests were highly suggestive, but not diagnostic of a RA condition. On a follow-up evaluation on 3 February 2000, the CI now noted pain in his hands and knees. The examiner noted the rheumatoid blood test to be “obviously positive” and opined that the picture was probably “consistent with RA.” Treatment with RA specific medication was begun (Plaquenil). At a clinic evaluation on 16 May 2000, the CI reported no change in his symptoms, but the examiner reported less swelling, noting “the Plaquenil is working.” At the VA C&P Joint examination on 4 December 2000, the CI reported joint pain that had been “present and increasing since 1995.” He noted that his hands became painful and obviously swollen with heavy use beginning “back in 1999.” He reported that others would comment on the swelling in his fingers. At this time, the CI had discontinued his RA medication. On physical examination the hands were normal. The examiner reported that a recent RA test was quite positive. The examiner opined that he was uncertain whether the CI had RA or another arthritic condition. The service treatment record contains no further entries from this time until 2004.

The CI returned to the military in 2004. He reported onset of hand and knee pain while preparing for a PT test. At the rheumatology evaluation on 14 September 2004, the test for RA was positive. The examiner opined that the condition was a “variant” of RA. On a rheumatology evaluation on 5 October 2004, the CI again reported onset of hand pain 6 to 7 years prior. On evaluations 21 and 28 October, and 22 November 2004, different rheumatologists concluded that a RA-type of arthritis condition was present but disagreed whether the condition was RA, a variant of RA or another type of arthritis. The patient was taking no RA medication at this time. On rheumatology evaluations in April 2005, the rheumatologist had “strong suspicion” that the condition was RA and began RA specific medication (Methotrexate and Prednisone). At the NARSUM evaluation on 22 April 2005, examination of the hands revealed good grip strength, slight swelling over the middle finger joints of both hands, without tenderness or pain. There were no other clinical findings of RA. On a rheumatology evaluation on 9 January 2006, 6 months after separation, examination revealed no pain in the hands wrists and knees. ROM of these joints was “good.” The CI was taking no medication at this time. A rheumatology evaluation on 1 May 2006, 10 months after separation, the CI reported his hands to “swell intermittently.” ROM of the hands and wrists was normal without pain.

The Board directed attention to its rating recommendation based on the above evidence. The PEB and the VA both adjudicated the arthritis condition as EPTS, not permanently service-aggravated and not subject to rating. The Board noted throughout the record that rheumatology experts agreed that the CI had an RA-like arthritis condition but disagreed as to the precise diagnosis; whether, RA, variant of RA, etc. The Board will discuss this condition using the nomenclature of RA for simple clarity.

The Board undertook to determine if the RA condition EPTS. The Board agreed the record provided no evidence of any arthritic condition during military service prior to 1992. The Board noted the evaluations of multiple rheumatology providers, the diagnosis and treatment of an arthritic condition with specific RA medication and the statements in the record in evidence discussed above. The Board concluded that the evidence in record was clear and convincing that the arthritis condition appeared during the period from 1992 to 2003, when the CI was not in the military and, thus, did EPTS.

The Board then undertook to determine if the condition was permanently aggravated by military service. The Board agreed that well-established medical principles document that hand pain and swelling are known consequences of an arthritic condition and that they may wax and wane without known stimulus. The Board unanimously agreed that, based on acceptable medical practice, the symptoms in this case were related to the arthritis condition. The Board further agreed that this condition and associated symptoms represent, with virtual medical certainty, the natural progression of known and established complications of a rheumatoid-like arthritis condition. The Board concluded there was no evidence of activity while in military service that permanently aggravated this pre-existing condition beyond its natural progression given the near normal findings on clinical examinations after separation. The Board noted the CI to have less than 8 years of active duty at time of separation, and thus, the RA condition was not compensable IAW 10 USC §1207a for adjudication. In summary, the Board unanimously agreed this condition was EPTS and was not permanently service-aggravated.

Osteoarthritis Condition. The Board consensus was that this arthritis condition was part and parcel of the overall systemic arthritis condition of the CI. It is included in the discussion above and will be discussed no farther. The Board unanimously agreed this condition was EPTS and was not permanently service-aggravated.


BOARD FINDINGS: IAW DoDI 6040.44, provisions of DoDI 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. As discussed above, PEB reliance on the USAPDA pain policy for rating the knee condition was operant in this case and the condition was adjudicated independently of that policy by the Board. In the matter of the right knee condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication. In the matter of the RA and osteoarthritis conditions, the Board unanimously recommends no change from the PEB determination. 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 20131026, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans Affairs Treatment Record








XXXXXXXXXXXXXXX
President
DoD 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 XXXXXXXXXXXXXXX, AR20150010431 (PD201302624)


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

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