RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2013-01992
BRANCH OF SERVICE:  Army	BOARD DATE:  20140603
SEPARATION DATE:  20050215

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SPC/E-4 (35R/Avionics System Repair Person) medically separated for a polyarticular arthritis condition.  The condition could not be adequately rehabilitated to meet the occupational requirements of her Military Occupational Specialty.  She was issued a permanent P3 profile and referred for a Medical Evaluation Board (MEB).  The polyarticular arthritis condition, characterized as “polyarticular arthritis due to lupus erythematosus” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other conditions were submitted by the MEB.  The Informal PEB adjudicated “chronic polyarticular symptoms secondary to lupus erythematosus” as unfitting, rated 10%.  The CI made no appeals and was medically separated.

CI CONTENTION:  “My condition has worsened over the years and at this time there is no cure for my disease.”

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 polyarticular symptoms secondary to lupus erythematosus 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.  

RATING COMPARISON:

Service IPEB – Dated 20041008	VA – (2 Mos. Pre-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Polyarticular Symptoms Secondary to Lupus Erythematosus	6350	10%	Lupus Erythematous L/Wrist	6350-5215	10%*	20041215	
			Lupus Erythematous R/Wrist	6350-5215	10%*	20041215	
			Lupus Erythematous L/Finger Joints	6350-5229	10%*	20041215	
			Lupus Erythematous R/Finger Joints	6350-5229	10%*	20041215	
Other MEB/PEB Entries x 0	Other x 1	20041215	
Combined:  10%	Combined:  40%	
Derived from VA Rating Decision (VARD) dated 20050407 (most proximate to date of separation [DOS]).   *VARD 20060420 corrected coding effective day after separation.  Each condition was originally coded 6350-5002.

ANALYSIS SUMMARY:  The Board acknowledges the CI’s information regarding the significant impairment with which her service-connected condition continues to burden her; 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.  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 VA Schedule for Rating Disabilities (VASRD) standards, based on ratable severity at the time of separation.

Chronic Polyarticular Symptoms Secondary to Lupus Erythematosus Condition.  Review of the available service treatment record revealed that the CI first developed joint symptoms in April 2003.  She presented in September 2003 with complaints of morning stiffness and pain and swelling of her hands wrists and shoulders.  The presence of finger joint inflammation on examination prompted laboratory evaluation which revealed the presence of a marker of inflammatory arthritis.  Hand X-rays were normal.  The CI was managed by a rheumatologist beginning in December 2003, but those records are not in evidence.

The narrative summary (NARSUM) examiner on 2 June 2004 (8.5 months prior to separation) reported that the CI’s functional limitations were due to polyarticular (multiple joint) arthritis due to lupus.  Involved areas were the fingers of both hands and the wrists.  Sporadic episodes of bilateral knee swelling were reported, but were self-limited.  Symptomatic relief with an anti-inflammatory medication (Vioxx) was noted.  The examiner was silent about other possible manifestations of lupus, except to note that there was no skin involvement (i.e. no rash).  Physical exam showed swelling of the joints of the fingers and of both wrists.

At the separation exam on 2 June 2004 the CI indicated that she was currently in good health.  The examiner noted swelling of the wrists and proximal interphalangeal (PIP) joints (middle knuckles) of the fingers.  Blood pressure was normal and protein was absent from the urine (normal).  On the Report of Medical Assessment, the CI indicated that arthritis limited her ability to work in her primary specialty.  Lab testing for anemia was negative.  The commander’s statement on 2 June 2004 indicated that the CI initially continued to perform her normal duties “at a moderate pace” but more recently was hampered by joint swelling and stiffness.  She was reduced to performing administrative duties.  At an outpatient visit on 31 August 2004 (5.5 months prior to separation) the CI indicated that she was not in any pain.

At the VA Compensation and Pension (C&P) exam on 15 December 2004 (2 months prior to separation), the CI reported that her symptoms were controlled on a different anti-inflammatory medication (Mobic).  The examiner stated:  “She really does not have any polyarticular symptoms at all.”  Examination showed no evidence of joint inflammation or enlargement.  At a C&P exam on 1 February 2006 (11.5 months after separation) the right hand dominant CI reported more involvement of her fingers and wrists.  Swelling and pain interfered with her ability to lift luggage at her job as a ramp agent for an airline and in writing long papers or using the computer for long periods of time as a full-time college student.  She also complained of generalized morning stiffness that made it difficult to dress in the morning.  Fatigue also occurred throughout the day but did not significantly interfere with her life.  She denied loss of appetite or weight, or fever, chills or night sweats.  The CI was now being treated with an anti-rheumatologic medication (methotrexate).  The most recent laboratory studies in September 2005 revealed the presence of indices suggesting rheumatologic disease (anti-nuclear antibodies and rheumatoid factor); but were negative for systemic inflammation or anemia.  X-rays demonstrated narrowing of some joints in the hands suggestive of rheumatoid arthritis; and the examiner reported that a VA rheumatologist had recently diagnosed rheumatoid arthritis.  Physical examination revealed synovial thickening and tenderness of both wrists (suggesting joint inflammation).  Range-of-motion (ROM) measurement of the right wrist showed dorsiflexion of 75 degrees (normal to 70 degrees) and palmar flexion of 55 degrees (normal to 80 degrees).  There was “little pain” with motion.  The left wrist showed dorsiflexion of 20 degrees and palmar flexion of 28 degrees, with painful motion present at endpoints of ROM.  On the right hand there was swelling and thickening of the 2nd, 3rd and 5th digits (index, middle and little fingers) and they lacked full extension at the PIP joints by 13, 5 and 10 degrees respectively.  Swelling was also present at the 2nd and 3rd MCP joints (knuckle at the junction of hand and finger) and flexion of these joints was limited to the fingertips falling one centimeter (less than half an inch) from the transverse crease of the palm.  The left hand showed synovial thickening only of the left 3rd PIP joint.  It lacked full extension by 15 degrees; flexion was limited to the fingertip falling one centimeter from the transverse palm crease.  The examiner’s impression was the likely diagnosis was rheumatoid arthritis, given clinical findings and absence of other symptoms of lupus.

The Board directs attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under the 6350 code (lupus erythematosus, systemic), which is justified for “exacerbations once or twice a year or symptomatic during the past 2 years.”  The next higher 60% rating requires “exacerbations lasting a week or more, 2 or 3 times per year.”  Board members agreed that the evidence does not support a rating higher than 10% via this pathway.  Another option however is to combine the evaluation of disease residuals.  This was the approach taken by the VA, who assigned separate 10% ratings under a combination 6350-5002 code (5002 – rheumatoid arthritis) for each wrist and each hand (identified as right finger joints and left finger joints, or “group of minor joints”).  In deliberating this pathway, Board members acknowledged that each residual so rated must, by a preponderance of evidence standard, be identified as separately unfitting.  Members agreed that the functional limitations in evidence justified the conclusion that impairment from each wrist and the fingers of each hand were independently unfitting; and, accordingly a separate rating for each is recommended.  Although the NARSUM and MEB examinations identified joint swelling of bilateral wrists and fingers, they were silent regarding ROM, tenderness or painful motion, key elements in rendering a rating recommendation IAW §4.71a.  However, the C&P exam 2 months prior to separation noted completely normal physical findings in the context of absent symptoms.  Based on this exam, which was the closest to the time of separation and therefore assigned higher probative value by the Board majority, members agreed that a 0% rating was justified for each of the four identified areas.  The Board acknowledged there was diagnostic uncertainty in this case, and that rheumatoid arthritis was diagnosed by a VA rheumatologist after separation.  At the time of separation; however, the likely diagnosis was thought to be lupus; and a minimal rating under 5002 stipulates “a well-established diagnosis.”  Board members concluded therefore that the 6530 code was the appropriate code to use.  Given the rating recommendation as just elaborated, the Board concluded that there is no benefit to the CI in rating residuals of the disease.  Therefore, 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 chronic polyarticular symptoms secondary to lupus erythematosus 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.  In the matter of the chronic polyarticular symptoms secondary to lupus erythematous condition and IAW VASRD §4.71a, the Board by a vote of 2:1 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 20131025, 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 XXXXXXXXXXXXXXX, AR20150002525 (PD201301992)

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