RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01680
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20040912

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was  an active duty Army E-4, Line of Sight Forward Heavy Crewmember, medically separated for eosinophilic fasciitis, with a disability rating of 0%. 

CI CONTENTION:  His blood disease is causing further conditions and would not allow re-entry into the military.  The applicant’s complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44.  It is limited to those conditions determined by the Physical Evaluation Board (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 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 PEB - 20040512	VARD - 20041004	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Eosinophilic Fasciitis	7899-7821	0%	Eosinophilic Fasciitis of Left Forearm	7821-5024	10%	20040601	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Eosinophilic Fasciitis.  The CI first noted problems with stiffness of his left forearm while deployed in 2003 and was evacuated from theater for possible compartment syndrome.  This was excluded as a diagnosis in orthopedics and he was referred to dermatology.  Eosinophilic fasciitis, a rare and poorly understood disease, was diagnosed based on serologic (blood), radiographic, and pathology (biopsy) studies.  He was treated with both high dose steroids and an anti-metabolite drug (Methotrexate) without benefit.  He was then entered into the Medical Evaluation Board (MEB) process.  The narrative summary (NARSUM) was dictated on 27 January 2004, 8 months prior to separation.  The above history was noted.  On examination, the left forearm was thickened and hardened to touch from the wrist to the elbow with some extension up the left upper arm.  An evaluation of the wrist in physical therapy (PT) on 29 March 2004 showed limitations in extension and radial deviation compared to the right and to VA normal values (64/80 and 35/52) respectively, left/right.  Flexion was actually greater on the left and ulnar deviation showed no difference between the left and right.  Flexion and extension of the elbows were similar on the left and right.  At the VA Compensation and Pension (C&P) examination performed on 1 June 2004, 3 months prior to separation, the CI reported that he could no longer do pushups and spared his left arm when exercising in the gymnasium.  No systemic problems were recorded (he had gained weight on the steroids) and he could sustain heavy physical effort.  He was noted to have thickened skin and soft tissue over the left forearm extensor surface (opposite the palmar side).  For the wrist, flexion was normal.  Extension, ulnar deviation, and radial deviation were reduced compared to VA normal values (48/80, 21/45 and 11/20) respectively, measured/VA normal values.  Supination (hand up on a flat surface) and pronation (hand down on a flat surface) were near normal.  He was restricted from vigorous activities with his left arm, but otherwise had no limitations.  The record shows that the CI was dispensed steroids on 12 November 2003, 8 December 2003, 20 January 2003, and again on 23 March 2004.  A rheumatology note dated 27 January 2004 recommended the addition of Methotrexate (an 11 week supply was dispensed).  The VA C&P noted that the CI was still on Methotrexate, but without clear benefit.  He had stopped the steroids.  

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB rated the eosinophilic fasciitis at 0%, coded 7899-7821 (analogous to cutaneous manifestations of collagen vascular diseases) noting that less than 2% of the body was involved.  Collagen vascular diseases (also called connective tissue diseases) are systemic diseases the manifestations of which include fatigue, joint pain, fevers, weakness, joint stiffness, body aches, and skin manifestations.  The CI did not manifest any of these other than the stiffness associated with the soft tissue infiltration of the left forearm.  The Board noted that the use of either steroids or systemic therapy in the previous 12 months warranted a higher rating under this code, but also noted that the code implied a systemic rather than local condition.  The VA rated the condition at 10%, coded 7821-5024 (tenosynovitis).  The use of the tenosynovitis code by the VA allowed for the assignment of a rating for limitation in motion.  The Board also considered other coding options.  The code for dermatitis is 7806; while the skin was thickened, it was localized and the functional limitation was from the muscles and fascia.  The Board then considered code 5308 (Group VIII muscles, wrist and finger extensors).  The VA C&P examination was the most proximate to separation and documented that the limitations in function were limited to avoidance of strenuous effort of the left forearm and that the skin manifestations were confined to the left arm.  While the CI had been placed on a trial of steroids, this was not successful and discontinued at separation.  He was also placed on Methotrexate, but this was not shown to be beneficial either.  The Board considered than there was no specific code available for eosinophilic fasciitis.  The code 5308 was determined to best describe the disability in evidence with consideration of VASRD §4.10 (functional impairment) §4.40 (functional loss).  The Board considered if the impairment was at the moderate or moderately severe level and, mindful of VASRD §4.3 (reasonable doubt), determined that a moderately severe level of impairment was supported.  After due deliberation and considering all of the evidence the Board recommends a disability rating of 20% for the eosinophilic fasciitis condition, coded analogously as 5399-5308.  

BOARD FINDINGS:  In the matter of the eosinophilic fasciitis condition, the Board unanimously recommends a disability rating of 20%, coded 5308 IAW VASRD §4.73.  There were no other conditions within the Board’s scope of review for consideration.  The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of his prior medical separation:  

CONDITION	VASRD CODE	RATING	
Eosinophilic Fasciitis 	5399-5308	20%	
RATING	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20131108, 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 XXXXXXXXXXXXXXXXXXXXX, AR20160006817 (PD201401680)

1. 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,
accept the Board's recommendation to modify the individual's disability rating to 20%
without re-characterization of the individual's separation. This decision is final.

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 this memorandum.

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:

CF:
( ) DoD PDBR
( ) DVA