RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01719
BRANCH OF SERVICE:  Army
DATE OF PLACEMENT ONTO TDRL:  20070905            DATE OF REMOVAL FROM TDRL:  20080625

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Food Service Specialist) medically separated from the Temporary Disability Retired List (TDRL) for “eczema” rated at 0%.  

CI CONTENTION:  The applicant’s not unfitting bilateral knee condition continues to worsen and negatively impacts her daily activities.  Her 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 – 20070813/20080613	VARD – 20071208	
Condition	Code	Rating	Condition	Code	Rating
Proximate	
		TDRL
Placement	TDRL Removal			TDRL
Placement	TDRL Removal	
Eczema	7899-7806	30%	0%	Eczematoid Dermatitis with Facial Acne	7806	30%	30%	
Retropatellar Pain Syndrome	Not Unfitting	Retropatellar Pain Syndrome, Left Knee	5299-5014	10%	10%	
		Retropatellar Pain Syndrome, Right Knee	5299-5014	10%	10%	
COMBINED RATING:  30% → 0%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

Eczema.  The earliest note in the service treatment record dated 25 July 2003 indicated the CI had a rash of the arms and legs with scaling and flaking.  She had several clinic visits in 2003 for eczema where treatment with triamcinolone cream 0.1% (a topical steroid) was helpful.  In November 2005 the CI complained of dry skin where on examination there was roughness along the anterior neck, back and hands with multiple patches of the neck, forearms, hands, trunk, and both thighs.  Treatment consisted hydroxyzine (an antihistamine) and triamcinolone lotion.  In January 2006 the diagnosis of atopic eczematous dermatitis was made based on scaling patches of the posterior neck and flexor portions of the upper extremities.  Treatment consisted of a skin cleanser (Cetaphil), fluocinonide ointment (a topic steroid), and Aquaphor (washable petrolatum).  In May 2007 the CI had a telemedicine consultation with a dermatologist who recommended a treatment protocol, which also included Protopic ointment (tacrolimus, a topical macrolide immunosuppressant).  In August 2007 she was examined by an allergist who determined the eczema involved 40.5% of her skin surface and opined that in the military her skin involvement with eczema varied from 40%-70% of the skin surface area and that field conditions, working in the heat, and sweating aggravated the eczema and working as cook near stoves aggravated her skin itching and the eczema, but outside the military a “minimal problem with skin.” 

The Medical Evaluation Board (MEB) narrative summary (NARSUM) addendum dictated on 7 June 2007 based on an examination of 5 May 2007 noted the CI had eczema since about age 15 and she itched with sweating, rough clothing, wool, oranges, lemons, and wheat thins.  She used Atarax (hydroxyzine, an antihistamine) and Benadryl (diphenhydramine, an antihistamine), which interfered with her ability to work.  She did not have allergic rhinitis or asthma, but had atopic dermatitis.  Skin testing was negative for food and pollens.  On examination the CI had some patches of old inflammation on her arm[s], inner thigh[s], back, and abdomen.  The allergist’s impression was that the CI had atopic dermatitis not related to foods and he opined that her mild eczema from his examination and history would not be considered unfitting for duty.

For the MEB examination, the CI reported on DD Form 2807-1 dated 16 May 2007, sensitivity to chemical, dust, and sunlight and listed allergies to dust pollen, anything with citric acid, animal dander, hot/cold weather for eczema and sweating.  The MEB physical examiner noted on a DD Form 2808 diffuse hyperpigmentation in the upper back and listed a P3 profile along with the diagnosis of severe atopic eczema as one of the significant or disqualifying defects.  The commander’s statement dated 23 May 2007 indicated the CI had limitations according to her profile as well as no wool or scratchy fabrics, avoidance of dust, mold, animal dander, and cleaning products or perfumes; and, the CI had to have access to medical care capable of providing high dose steroids and other therapy for eczema exacerbations.  A permanent P3 profile was issued in July 2007 for atopic dermatitis with restrictions of exercising in a temperature controlled setting and avoidance of prolonged exposure to heat above 80 degrees Fahrenheit or humidity greater than 60% due to skin flare ups.  Additionally she had to have access to hypoallergenic hygiene items and could not wear body armor or chemical protective gear for greater than 1 hour in hot environments.

At the VA Compensation and Pension (C&P) examination dated 15 October 2007, performed 2 months after separation, the CI reported the eczema started when she was 15 years old and “got worse after I entered the service.”  She noted it was worse when she was outside and better if she stayed inside in bed.  Topical creams helped “a little.”  On examination there were red, dry patches around both eyes, on the anterior and posterior chest, on the bilateral arms and bilateral thighs.  There were no open lesions or crusting and approximately 50% of her exposed areas were affected and 30% of the entire body was affected.    

Post-separation on 30 May 2008 the CI was evaluated by a dermatologist who noted the CI stated she had eczema since age 14-15 years old, had some improvement with medication, and was exacerbated when assigned to a southern duty station and during deployment as well as with the heat and work environment as a cook.  She had 3% to 5% BSA [body surface area] involvement on examination, all on the mid upper back.  Treatment protocols for use of creams on the body and lotions on the face along with non-sedating antihistamines during waking hours and a sedating antihistamine for non-waking hours to help control the itch were discussed.  Her skin involvement was minimal and the examiner opined that whether or not the CI met retention standards was equivocal for minimal skin involvement; however, the CI indicated the eczema interfered with her ability to work.  The NARSUM TDRL examination also dated 30 May 2008 likewise noted the CI had a 3% to 5% BSA involvement, based on a total body skin examination, on her mid upper back in an area she could not reach (to apply medication) that showed some very mild eczematous changes with just dry skin and some flaking in areas based on a total body cutaneous examination.  She did not have any other skin conditions other than some mild comedonal acne on her face.  The diagnosis of eczematous dermatitis due to dry skin and exposure to heat as a cook, during deployment, or at her duty station did interfere with satisfactory performance of her duty.  A remote VA examination on 28 January 2010, 19 months post-separation, revealed greater the 5% but less than 20% involvement of the total body area affected with hyper and hypopigmented changes in skin.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 30% rating using code 7899-7806 (Dermatitis or eczema) for eczematous dermatitis involving 40% of the total body surface area for TDRL placement.  The VA likewise assigned a 30% rating using code 7806 for eczematoid dermatitis with facial acne and directed a future examination in September 2009.  The Board noted that at the MEB NARSUM the CI had 40.5% of her skin surface involved with a note indicating flares resulting in from 40% to 70% involvement, while the VA examiner noted 30% involvement.  A 60% rating using code 7806 requires “More than 40 percent of the body or more than 40 percent of exposed areas affected, or; constant or near-constant systemic therapy during the past 12 months.”  Therefore, a 60% rating for TDRL placement is not unreasonable, although the CI did not need or use constant or near-constant systemic therapy.  

For TDRL removal the PEB assigned a 0% rating using code 7899-7806 for eczema requiring topical treatment.  The Board noted the TDRL NARSUM separation examiner indicated 3% to 5% involvement of the skin with eczema.  However, a VA examination, approximately 19 months post-TDRL removal, offers a low probative value input because it was more than 12 months post-separation, where the examiner noted greater than 5% and less than 20% skin involvement of the eczema.  The Board noted that the wording “3% to 5% involvement” means “at least 5 percent,” according to VASRD code 7806, which warrants a 10% rating, although the PEB interpreted the “3% to 5% involvement” to mean “less than 5 percent,” for which it assigned the 0% rating.  The Board understands that percentages used for rating both TDRL placement and TDRL separation are very close to the wording of VASRD §4.118 (Schedule of ratings—skin) code 7806; nevertheless VASRD §4.7 (Higher of two evaluations) provides guidance and support for the position the Board ought to recommend.  Furthermore, the VA examination 19 months post-separation does justice to the Board’s rating stance, since that examination captured the ever changing status of eczema, which is well known to fluctuate based on environmental exposures, not only in a military status, but also in a non-military or former military civilian status.

After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 60% for the eczema condition at TDRL placement and a disability rating of 10% for the eczema condition at TDRL removal.

Contended PEB Condition-Retropatellar Pain Syndrome.   The Board’s main charge is to assess the fairness of the PEB’s determination that the retropatellar pain syndrome condition was not unfitting.  The retropatellar pain syndrome condition was profiled L2 with limitations of no repetitive squatting, kneeling or lunging and no jumping or running; marching was permitted at her own pace; and she was limited from moving with a fighting load, wearing chemical defense equipment (more likely related to the eczema condition), and constructing an individual fighting position. The condition was not explicitly implicated in the commander’s statement, but the profile restrictions listed in the statement related to her knees rather than the eczema.  However, the condition was not judged to fail retention standards.   

The earliest note in the STR in August 2003 indicated the CI sought medical care for pain and swelling in both knees that had been present for 3 years.  Treatment consisted of naproxen (a nonsteroidal anti-inflammatory drug (NSAID)) and extra strength acetaminophen (a pain reliever).   An MRI in January 2004 of the right knee was normal.  Orthotics were dispensed for pes planus and knee pain in February 2004.  Chronic knee pain was again diagnosed in June 2005 and treatment consisted of a profile and pain medication.  X-rays of the knees were normal in November 2005.  A physical therapist evaluated the knee pain in November 2005 and noted the range-of-motion (ROM) measurements to be 0-135 degrees for each knee and therapy was instituted and continued through late March 2006.  An MRI of the right knee in March 2007 was again normal.  Orthopedic evaluation in May 2007 noted no effusion with ROM measurements of 0-130 degrees bilaterally with mild tenderness to palpation medially and laterally along the joint lines with no evidence of a meniscal tear (negative McMurray’s test) and there was no instability of the ligaments.  The orthopedic surgeon opined that the CI met the retention criteria IAW AR 40-501 as she had a full ROM and stable knees.  However, she was referred for a brace consult for the pain localized in the knees.  In June 2007, the CI reported painful knees, the right greater than the left, though the left locked, and the knees were often crepitant (with a grinding sensation) and painful with sitting or climbing stairs.  Examination of the knees did not demonstrate crepitance and there was a little frank edema anteriorly with negative McMurray’s tests bilaterally, negative ballottement (to determine increased fluid over the patella (kneecap), and no posterior edema, but with lateral tenderness.  The diagnosis of an old disruption of the anterior cruciate ligament was made and the CI was referred to orthopedics.  The MEB examiner noted there was a positive patellar grind on the right greater than the left with otherwise normal knee examinations.  At the VA C&P in October 2007 examination the CI reported an injury to her right knee in 2000 and complained of knee swelling with running and pain with prolonged standing, going up and down steps, and bending.  She used a brace when running, exercising or for prolonged walking.  Pain in the left knee was attributed “to favoring” her right knee.  She used Icy Hot (a topical pain reliever) and elevation, which helped for flare pain.  Examination of the knees revealed crepitus bilaterally without edema.  The ROM measurements were 0-140 degrees bilaterally; with repetition there was increased pain, weakness, lack of endurance, fatigue and incoordination with flexion to 120 degrees with no loss of motion; and the knees were stable. 

The aforementioned was reviewed and considered by the Board.   There was no performance based evidence from the record that the retropatellar pain syndrome condition significantly interfered with satisfactory duty performance.  After a detailed discussion due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the bilateral retropatellar pain conditions and so no additional disability ratings are recommended.

BOARD FINDINGS:  In the matter of the eczema condition, the Board unanimously recommends a disability rating of 60%, coded 7899-7806 IAW VASRD §4.118 for TDRL placement and a disability rating of 10%, coded 7899-7806 IAW VASRD §4.118 for TDRL removal.  In the matter of the contended retropatellar pain syndrome conditions, the Board unanimously recommends no change from the PEB determination as not unfitting.  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 her prior medical separation:  

CONDITION	VASRD CODE	RATING	
		TDRL	PERMANENT	
Eczema	7899-7806	60%	10%	
RATING	60%	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140226, 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, AR20160007309 (PD201401719)

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 (000 PDBR) pertaining to the individual named in the subject line above to
constructively place the individual on the Temporary Disability Retired List (TDRL) at
60% disability rather than 30% for the period September 5, 2007 to June 24, 2008 and
then following this period no re-characterization of the individual's separation as a
permanent disability retirement with the combined disability rating of 10%.

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:

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

b. Providing orders showing that the individual was separated with a permanent
combined rating of 10% effective the day following the TDRL period with no
recharacterization of the individual's separation.

c. Adjusting pay and allowances accordingly. Pay and allowance adjustment will
provide 60% retired pay for the temporary disability retired period effective the date of
the individual's original medical separation and adjusting severance pay as necessary
to account for the additional TDRL time in service.

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