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AF | PDBR | CY2013 | PD-2013-02628
Original file (PD-2013-02628.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXX    CASE: PD-2013-02628
BRANCH OF SERVICE: Army  BOARD DATE: 20150310
SEPARATION DATE: 20051026


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Petroleum Supply Specialist) medically separated for psoriatic arthritis. The arthritis condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty. He was issued a permanent P3, U3, L3 profile and referred for a Medical Evaluation Board (MEB). The arthritis condition, characterized as “psoriatic arthritis,” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. No other conditions were submitted by the MEB. The Informal PEB adjudicated “psoriatic arthritis manifested by hand and knee pain” as unfitting, rated 20%, with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD). The CI made no appeals and was medically separated.


CI CONTENTION: “My conditions were more severe at the time of my discharge. I wasn’t given the proper treatment for my issues.”


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 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 :

IPEB – Dated 20050808
 VA - (9 Mos. Post-Separation)
Condition
 Code Rating Condition Code Rating Exam
Psoriatic Arthritis 7816-5002 20% Psoriatic Arthritis 5099-5009 20% 20060713
Psoriasis (skin) not separately unfit Psoriasis 7816 60% 20060713
Other x 0 (Not In Scope)
 Other x 3
Combined: 20%
 Combined: 80%
Derived from VA Rating Decision (VA RD ) dated 200 60808 ( most proximate to date of separation [ DOS ] ).



ANALYSIS SUMMARY:

Psoriatic Arthritis. The CI, who had a history of psoriasis (skin condition characterized by thickened scaly plaques) since approximately 1998, subsequently developed psoriatic arthritis, an inflammatory (rheumatologic) arthritis that occurs in up to 30% of people who have psoriasis. Review of service treatment records (STR) shows the CI experienced an episode of hand swelling and pain in November to December 2002 and Achilles tendonitis in February 2003. The CI experienced joint pain while deployed to Iraq in 2003. At the time of his post deployment medical examination on 30 October 2003, the CI reported experiencing problems with joint pain. At clinic evaluations in December 2003, the CI reported an episode of hand swelling 7 months before followed by joint pain affecting his wrists, hands, knees and left ankle. The CI presented to clinic on 27 February 2004 complaining of joint pain aggravated by strenuous activities such as running and requested a profile for no running. Examination noted tenderness of the knees but no other abnormal joint findings. The physician issued a duty limiting profile. On 8 March 2004, evaluation by a civilian rheumatologist, noted complaint of joint pain of hands, wrists and knees. On examination, there was tenderness of hand joints without swelling. The other joints were normal on examination. Treatment with non-steroidal anti-inflammatory medication was recommended for “early” psoriatic arthritis. A permanent duty limiting profile for joint pain was issued in March 2004. At a follow-up evaluation by the civilian rheumatologist on 24 May 2004, the CI reported continued pain of the hands and knees with generalized stiffness. On examination there was no swelling or inflammation evident.

The CI’s command was concerned about the limitations due to joint pain and the CI subsequently underwent a fitness for duty examination on 30 June 2004, and referral for MEB. At the time of evaluation by a military rheumatologist on 18 August 2004, the CI reported hand stiffness, knee pain and upper back pain and was unable to perform strenuous military duties. Examination of the joints was normal. X-rays of knees and hands showed no evidence of joint damage due to arthritis. The diagnosis of early psoriatic arthritis was confirmed. Treatment with Methotrexate (an immunosuppressive medication used for inflammatory arthritis) was initiated but was stopped due to nausea after 2 weeks. Follow-up evaluation with the military rheumatologist on 7 December 2004, noted the CI was performing full duties in-Garrison but complained of continued pain and swelling of both hands and knee pain. The examination showed no swelling, tenderness, warmth, or limitation of motion. The rheumatologist ordered a magnetic resonance imaging (MRI) scan of the hands to assess for evidence of joint inflammation not detectable by physical examination. An MRI scan on 28 December 2004, of both hands was normal showing no evidence of inflammatory arthritis. The CI experienced a flare of his arthritis in April 2005 and at the time of rheumatology evaluation on 25 April 2005, there was swelling, warmth and tenderness of hand joints. The rheumatologist affirmed a diagnosis of psoriatic arthritis and prescribed entanercept, an immunosuppressive medication, for the arthritis.

At the VA Compensation and Pension (C&P) exam performed on 13 July 2006, 9 months after separation, the CI reported that the Enbrel worked “terrifically well,” although it was discontinued for 6 months when he left the military, and he had a flare of the rash and arthritis which required a course of systemic (oral) steroids. The examiner stated, “… they did restart the Enbrel and he is doing terrifically well both skin and joint wise.” The CI reported mild flare-ups of the joints that occurred every 2 to 3 weeks and bothered him, but he was able to continue working through them and they eventually dissipated (CI was working as an airplane fueler at an airport). The examiner did not describe any active inflammation or functional loss of any joints and stated, “The problems with his joints do seem to exist, however they are very well controlled with medication at this point in time.” The CI also complained of mild upper and lower back pain for years, but examination demonstrated normal gait, strength, and range- of-motions; and it was not linked to his psoriatic arthritis. In regards to his joints, the examiner concluded that there were no significant effects on the CI’s usual occupation and there were no effects on performing daily activities. The examiner stated that, “He [the CI] feels that the flares do not affect him much. He continues to work and function through the flareups/pain.”

The Board directed attention to its rating recommendation based on the above evidence. The PEB rated the psoriatic arthritis at 20% (coded 7816-5002 psoriasis – arthritis rheumatoid), for “One or two exacerbations a year in a well-established diagnosis.” The VA rated the psoriatic arthritis 20% (coded 5099-5009 Arthritis, other types), citing one or two foot flare-ups per year, which last more than 2 weeks, and mild hand flare-ups every to 2 to 3 weeks. Psoriatic arthritis is not listed as a specific code in the VASRD, and the Board concluded that the condition was best rated analogously as rheumatoid arthritis (code 5002), as directed in §4.71a under codes 5004 through 5009. Noting flares of symptoms in April 2003, April 2005 and after his service separation, the Board found that severity of the CI’s condition was best described as, “One or two exacerbations a year in a well-established diagnosis,” corresponding to a rating of 20%. A higher rating was not supported as the CI did not demonstrate definite impairment of health, incapacitating exacerbations occurring three or more times a year or a lesser number over prolonged periods. The Board considered whether the condition should be rated for chronic residuals such as limitation of motion or ankylosis, favorable or unfavorable, for the specific joints involved, as described under code 5002. However, neither the STR or VA exams described any specific joint that had symptoms that were severe and persistent enough to support a separate joint rating under §4.71a based on range-of-motion, painful motion, or functional loss (§4.40). 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 psoriatic arthritis condition.

Contended PEB Condition. The Board’s main charge was to assess the fairness of the PEB’s determination that the psoriasis skin condition was not separately unfitting. The Board’s threshold for countering fitness determinations requires a preponderance of evidence, which is higher than the VASRD §4.3 (reasonable doubt) standard used for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.

The STR indicated that the CI had a rash that dated back to 1999, and that he was diagnosed with mild psoriasis (plaque type) involving his hands, knees elbows, forearms, thighs, feet, and scalp. The psoriasis did not lead to an MEB, he separated from the service in May 2001, and the psoriasis was rated at 10% (code 7816, psoriasis) by the VA. The CI reentered the service in November 2001, but there was no mention of his psoriasis in the entrance examination, and the skin was indicated as normal. However subsequent documented psoriasis involving scalp, elbows, and gluteal fold treated with topical medications. While deployed to Iraq, the CI reported a flare of skin rash affecting his hands at the time he experience hand swelling and joint pain. A clinic record entry on 6 May 2003 recorded psoriasis of the scalp, hands, feet and elbow for the preceding 25 days treated with topical medication. By 12 December 2003, a clinic examination noted the presence of the scaly rash on his scalp, elbows, right forearm and knees and he was prescribed topical medication. The CI presented to clinic on 27 February 2004 complaining of joint pain aggravated by strenuous activities such as running and requested a profile for no running. A clinic encounter on 16 March 2004 recorded presence of psoriatic plaques on the tips of the elbows (olecranon), knees and a few on the scalp. In addition there was a rough eczematous pruritic (itchy) rash on dorsal hands, wrists and thighs which was treated with topical medication. By 26 April 2004, the skin examination noted psoriasis on the elbows and scalp but no other problems. At the time of the fitness for duty examination for the arthritis on 30 June 2004, the skin examination noted scaly plaques on the hands, scalp and knee. The CI was referred for MEB due to arthritis.

A commander’s statement on 7 July 2004 noted the diagnosis of rheumatoid arthritis and detailed the associated physical restrictions on his duties, but did not mention the psoriasis or any restrictions related to that diagnosis. On 31 August 2004 clinic record entry noted history of psoriasis on the elbows, knees and scalp for 2 years and the 7 December 2004 rheumatology examination also noted the presence of psoriasis plaques on the elbows, knees and scalp. The CI presented to the rheumatology clinic on 25 April 2005 for a flare of arthritis at which time a recurrence of the pruritic rash was noted on the hands, forearms and thighs which was again treated with topical medication. As noted above, the rheumatologist prescribed etanercept for the arthritis. By the time of the dermatology evaluation on 23 May 2005 (5 months prior to separation) the itchy rash was no longer present and on examination the dermatologist observed the “Classic silvery scaling plaques on elbows, gluteal cleft, and scalp [consistent with] psoriasis.” He noted the presence of the arthritis and concurred with the treatment with etanercept recommended by the rheumatologist. At the VA C&P exam on 13 July 2006 (9 months after separation), the CI stated that the etanercept, “worked terrifically well.” He reported that he a flare when he stopped his medication after discharge from the service but following restarting the etanercept he was “doing terrifically well both skin and joint wise.” On examination he had multiple 2-cm rounded plaque-like exfoliative areas on both buttocks, lateral aspects of the calves, and both elbows (less than 5% of exposed areas and less than 5% of the total body area was affected). The examiner described the rash as, “Very minor and small affected area. I would say this is 90% better then when flared off of Enbrel.”

The Board first considered whether the psoriasis skin disease was separately unfitting for military service. Psoriasis is not normally found to be unfitting for duty, as it is usually controlled with topical creams (including topical steroids). However, it can be unfitting if it is severe, persistent, and affect’s the member’s ability to perform his duties, or if the required treatment affects the member’s duties. The Board noted that the CI had the psoriasis skin condition since 1999 with plaques variably occurring on the scalp, elbows, back of the hands, knees, and gluteal cleft treated with topical medication. The CI experienced a few transient episodes of an itchy rash which was characterized as eczematous and resolved each time with topical treatment. By the time of the last dermatology examination in May 2005, the psoriasis skin condition remained essentially unchanged when compared to the numerous examinations since 1999. Throughout the time from 1999 to the time of referral for MEB due to arthritis, there was no duty limiting profiles or evidence of interference with performance of military duties due to the psoriasis skin condition. Although psoriasis was listed on the final physical profile in October 2004, there was no duty limitations related to the skin condition.

The Board noted that treatment with etanercept for a condition that is not otherwise unfitting may be cause for a determination of unfit due to the limitations in deployment environments and the need for periodic medical monitoring for side effects. However, the Board noted that the CI’s skin disease was generally mild to moderate, had remained stable over several years, did not interfere with military duties, and had not required systemic immunosuppressive treatment. The development of the functionally-impairing arthritis prompted initiation of the etanercept medication. The Board concluded that absent the associated arthritis, the skin disease would not have prompted such treatment and would not have been a cause for referral to the MEB nor would have been determined to be unfitting. The Board could not find evidence in the physical profile, the commander’s statement, or elsewhere in the STR that documented any significant interference by the psoriasis skin disease with the performance of duties at the time of separation, nor were any physical findings documented by the MEB or VA examiners which would logically be associated with significant disability. After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend the psoriasis skin disease as a separately unfitting 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 psoriatic arthritis condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication. In the matter of the contended psoriasis skin condition, the Board unanimously recommends no change in the PEB adjudication as not separately unfitting. 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 20131120, 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 , AR20150012721 (PD201302628)

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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