RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXX	CASE:  PD-2013-01561
BRANCH OF SERVICE:  Army	BOARD DATE:  20141028
SEPARATION DATE:  20041006

SUMMARY OF CASE:  The evidence of record indicates this covered individual (CI) was an active duty SPC/E-4 (74D/Chemical, Biological, Radiological and Nuclear Specialist) medically separated for multiple joint pain.  The condition could not be adequately rehabilitated to meet the requirements of his Military Occupational Specialty or physical fitness standards.  He was referred for a Medical Evaluation Board (MEB).  The joint pain, characterized as “chronic multiple joint arthralgias as a direct result of systemic allergic reaction to Robaxin,” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other conditions were submitted by the MEB.  The PEB adjudicated “chronic multiple joint arthralgias possibly as a result of systemic allergic reaction to Robaxin…” as unfitting, rated 0% with likely application of the US Army Physical Disability Agency (USAPDA) pain policy.  The CI made no appeals and was medically separated.

CI CONTENTION:  “Veteran developed severe impairments to include multiple joint pains, fatigue, and generalized weakness.”

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 joint pain and contended and associated fatigue and generalized weakness are addressed below.  No additional conditions are within the DoDI 6040.44 defined purview of the Board.  Any condition 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.

RATING COMPARISON:

Service PEB – Dated 20041006	VA* - (5 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Multiple Joint Arthralgias	5099-5002	0%	Joint Pain	5099-5025	40%	20050202	
Other x 0 (Not in Scope)	Other x 2	
Combined:  0%	Combined:  40%	
*Derived from VA Rating Decision (VARD) dated 20050324 (most proximate to the date of separation [DOS])

ANALYSIS SUMMARY:  IAW DoDI 6040.44, the Board’s authority is limited to making recommendations on correcting disability determinations.  The Board’s role is thus confined to the review of medical records and all evidence at hand to assess the fairness of PEB rating determinations, compared to Veterans Affairs Schedule for Rating Disabilities (VASRD) standards, based on ratable severity at the time of separation.

Chronic Multiple Joint Arthralgias with Fatigue and Generalized Weakness.  In February 2004 the CI had an allergic reaction to Robaxin.  He initially presented with an allergic rash.  On 20 February 2004 he was hospitalized for severe pain and swelling in in the hands, wrists, elbows, knees and ankles.  He was treated with high dose steroids (Prednisone) with resolution of the swelling.  The polyarthritis (multi-joint pain) did not resolve.  A rheumatology evaluation dated 16 March 2004 noted all day stiffness and constant pain in multiple joints; made worse by activity.  The physical examination was significant for a drug rash, steroid acne, hand and wrist tenderness to palpation (TTP) bilaterally and painful motion of the shoulders.  The examiner opined that the acute polyarthritis was a part of the allergic reaction and that there was no evidence of a chronic inflammatory or non-inflammatory arthritis.  The examiner noted that the steroid and etanercept could mask signs of a chronic inflammatory or non-inflammatory arthritis.  A bone scan performed on 6 April 2004 revealed stress changes in the acromioclavicular (shoulder and collar bone articulation), knees, ankles, and feet consistent with a physically active soldier.  There was also increased reactivity at the right acromioclavicular joint indicative of a stress injury or inflammatory arthritis.  Despite steroid, narcotic and non-steroidal medication therapy, the CI continued to report multi-joint pain.

At the narrative summary (NARSUM) examination performed 4 months prior to separation; the CI reported stiffness in multiple joints when he rested longer than 30 minutes and pain in his joints after 30 - 60 minutes of activity.  He rated the pain 3-4/10 on “good days” and 7/10 on “bad days.”  He reported that he was relieved from duty on “bad days.”  His medications included Ultram, Naprosyn and Percocet.  The physical examination was significant for discomfort in multiple joints on movement including the wrists, shoulders, knees and ankles.  There was no mention of fatigue or muscle weakness.

The VA Compensation and Pension examination performed 5 months after separation, was not in the treatment records, but was referenced in a VARD dated 24 March 2005.  The VARD referenced reports of constant daily pain of the ankles, daily intermittent pain of both wrists and hands and twice weekly shoulder pain mostly with cold weather.  The physical examination was referenced as evidence of an antalgic gait with the use of a cane for ambulation; normal ankle ROM bilaterally; bilateral knee limitation of flexion to 70 degrees with mild pain, decreased endurance and easy fatigability; bilateral wrist TTP with limitation of palmar flexion to 60 degrees; and significant bilaterally shoulder tenderness with limitation of forward flexion and abduction to 90 degrees.  Diagnoses of degenerative joint disease of bilateral shoulders, multiple joint arthralgia, and muscle weakness were rendered.  There was notation that the disability was not listed in the rating schedule and therefore, would be rated analogous to functional impairment, anatomical localization and symptoms.

The Board directs attention to its rating recommendation based on the above evidence.  The PEB adjudicated the chronic multiple joint arthralgias as unfitting with a disability rating of 0%, coded 5099-5002, analogous to rheumatoid arthritis.  The PEB noted that a 0% rating is assigned when a condition does not meet the criteria for a minimum rating.  The VA rated the chronic multiple joint arthralgias at 40%, coded 5099-5025 analogous to fibromyalgia.  The Board considered whether criteria were met for a higher rating analogous to 5002 or 5025.  The treatment records evidenced wide spread musculoskeletal pain with stiffness requiring multiple pain medications with intermittent control which met criteria for a minimum rating (10%) under VASRD code 5025.  There was also evidence of at least one acute exacerbation, the initial allergic response, requiring hospitalization and which was “well diagnosed” within a year of separation, which met criteria for a minimum rating (20%) under diagnostic code 5002.  The Board then considered whether there was evidence for a higher rating under either coding option.  The Board noted that the NARSUM and VA examinations documented chronic multiple joint arthralgias with painful motion, despite steroid, narcotic, and non-steroidal medication therapy.  The Board determined that the constant and refractory to therapy threshold had been met for a 40% rating under VASRD code 5025.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 40% for the chronic multiple joint arthralgias 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.  As discussed above, PEB likely reliance on the USAPDA pain policy for rating chronic multiple joint arthralgias was operant in this case and the condition was adjudicated independently of that policy by the Board.  In the matter of the chronic multiple joint arthralgias condition, the Board unanimously recommends a disability rating of 40%, coded 5099-5025 IAW VASRD §4.71a.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  The Board recommends modifying the case determination as follows and recharacterization of discharge to reflect permanent disability retirement, effective the date of medical separation:

UNFITTING CONDITION	VASRD CODE	RATING	
Chronic Multiple Joint Arthralgias	5099-5025	40%	
COMBINED	40%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20130923, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

						

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, AR20150006647 (PD201301561)

1.  Under the authority of Title 10, United States Code, section 1554(a), I approve the enclosed recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) pertaining to the individual named in the subject line above to recharacterize the individual’s separation as a permanent disability retirement with the combined disability rating of 40% effective the date of the individual’s original medical separation for disability with severance pay.  

2.  I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of the memorandum:

	a.  Providing a correction to the individual’s separation document showing that the individual was separated by reason of permanent disability retirement effective the date of the original medical separation for disability with severance pay.

	b.  Providing orders showing that the individual was retired with permanent disability effective the date of the original medical separation for disability with severance pay.

	c.  Adjusting pay and allowances accordingly.  Pay and allowance adjustment will account for recoupment of severance pay, and payment of permanent retired pay at 40% effective the date of the original medical separation for disability with severance pay.

	d.  Affording the individual the opportunity to elect Survivor Benefit Plan (SBP) and medical TRICARE retiree options.

3.  I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures.

BY ORDER OF THE SECRETARY OF THE ARMY:

Encl						
						
CF: 
(  ) DoD PDBR
(  ) DVA