RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  xxxxxxxxxxxxxxxxxxx	CASE:  PD-2013-01650
BRANCH OF SERVICE:  Army	BOARD DATE:  20150527
SEPARATION DATE:  20040608

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-3 (Communications Specialist) medically separated for rheumatoid arthritis.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS) or satisfy physical fitness standards.  He was issued a permanent P4U3 profile and referred for a Medical Evaluation Board (MEB).  The “rheumatoid arthritis” condition was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other condition was submitted by the MEB.  The Informal PEB adjudicated “rheumatoid arthritis” 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:  “I could barely move in the morning due to the physical pain to this day I have days where I cannot pick up or feed my infants.” [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:  

IPEB – Dated 20040316	VA* - (~11 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Rheumatoid Arthritis	5002	20%	Rheumatoid Arthritis, Left Wrist	5002-5215	10%	20050505	
			Rheumatoid Arthritis, Right Wrist	5002-5215	10%	20050505	
			Rheumatoid Arthritis, Left Hand	5002-5228	0%	20050505	
			Rheumatoid Arthritis, Right Hand	5002-5228	0%	20050505	
			Rheumatoid Arthritis, Polyartricular	5002-5260	0%	20050505	
			Rheumatoid Arthritis, Bilateral Ankles	5002-5271	0%	20050505	
			Rheumatoid Arthritis, Bilateral Feet	5002-5283	0%	20050505	
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 2	
RATING:  20%	RATING:  20%	
*Derived from VA Rating Decision (VARD) dated 20050824 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY:  

Rheumatoid Arthritis.  The record indicated that the CI developed pain in the hands, wrists, knees, and feet with morning stiffness in December 2002.  Evaluation by rheumatology in 2003 diagnosed rheumatoid arthritis (a disease characterized by inflammation of the joints with swelling, pain, and limitation of motion which can cause permanent joint damage if not successfully treated).  Bilateral wrists and multiple hand and finger joints became swollen and tender.  Treatment with oral Sulfasalazine did not adequately resolve joint swelling and the CI was started on injected etanercept (Enbrel-a biopharmaceutical; TNF blocker ‘immunosuppressant’).  The CI had a 1-2 month period where he ran out of etanercept and symptoms increased requiring a course of systemic steroids (and restarting etanercept) that reduced swelling and symptoms.  By the NARSUM exam in December 2003, the CI was taking etanercept, Indocin (an anti-inflammatory) and Prednisone (systemic steroid) medications.  He reported his rheumatoid arthritis was 75% improved, his stiffness had resolved and he was engaging in most of his usual physical activities.  Exam on 2 December 2003 showed that “the previously noted swelling and inflammation was reduced or absent.”  Exam documented a well-nourished well developed male with a weight of 176 pounds (service entry physical dated July 2002 had a weight of 175 pounds).  The hemoglobin and hematocrit were normal (no anemia).  The DD Form 2808, Report of Medical Examination, 5 February 2004, documented limited range-of-motion (ROM) of both wrists noting “cannot fully dorsiflex bilateral wrists,” and tenderness to the top of the right foot.  The summary indicated rheumatoid arthritis with pain in bilateral TMJs (jaw), wrists, elbows feet and shoulders.  The commander’s statement, 6 February 2004, stated:  “He no longer has full range of motion in his arm and has other ailments that contribute to his inability to perform his duties.”  

At the VA Compensation and Pension (C&P) exam performed 11 months after separation, the CI reported that most of his problems included bilateral feet, ankles, knees, wrists, and hands.  He noted occasional swelling and had fatigue.  Exam documented bilateral wrist swelling and tenderness with painful ROM to VA normal limits.  X-rays of the wrists documented narrowing of the joint space and osteoarthritic changes bilaterally.  Exam documented bilateral ankle mild swelling and tenderness with warmth and mild pain at 20 degrees of dorsiflexion (normal 20).  Bilateral hands and feet had tenderness and swelling with no decreased ROMs or objective evidence showing functional loss due to pain, weakened movement, excessive fatigability with use, incoordination or flare-ups.  Exam documented essentially normal back, shoulders, elbows, and hips (no swelling, tenderness, limitation of motion, or guarding of movement).  X-rays of the knees, ankles and feet were all normal.  

The Board noted that the VA granted additional compensable joint ratings (bilateral knees, ankles and feet; plus the left hand) for chronic residuals in 2012 (over 5 years after separation); however, at the time of separation, only the bilateral wrists had chronic residuals for rating per the VA (see chart above).  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the rheumatoid arthritis condition, coded 5002 (rheumatoid arthritis [atrophic]) as an active process) at 20%, while the VA rated each wrist at 10% for a combined 20% as well as 0% ratings for multiple other effected joints (separate joint ratings for chronic residuals).  There were no incapacitating episodes, no anemia or weight loss, and no definite impairment of health to support a rating higher than the 20% adjudicated by the PEB under code 5002.  The Service exam did not document objective evidence of chronic residuals such as limitation of motion or ankylosis (frozen/zero motion) of any joints aside from the bilateral wrists (at 10% each) to warrant consideration for rating joints separately at a combined rating above 20%.  IAW §4.71a, involved joints may be individually rated with individual ratings combined for final rating; however, they may not be added with a rating under diagnostic code 5002.  The Board adjudged that each wrist could be rated at 10% each, but that no other joints were compensable at the time of separation.  Separately rating the wrists at 10% each (instead of a 20% 5002 rating) would not be favorable to the CI.  

The Board unanimously agreed that no higher rating for the condition could be achieved through individual joint ratings at the time of separation.  The Board was unable to find any pathway to a higher rating given any applicable VASRD code.  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 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.  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 rheumatoid arthritis 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 20130910, 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 xxxxxxxxxxxxxxxxxxxxxxx, AR20150012439 (PD201301650)

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						 
CF: 
(  ) DoD PDBR
(  ) DVA