RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX		CASE:  PD-2014-04049
BRANCH OF SERVICE:  Army                                                                  SEPARATION DATE:  20061126

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-6, Light Wheel Vehicle Mechanic, medically separated for “gout pain in knees, ankles and feet,” with a disability rating of 20%.  

CI CONTENTION:  “Please consider all conditions.”  The CI’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 - 20061005	VARD - 20070703	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Gout…in Knees, Ankles, and Feet…	5017	20%	Gout	5017	20%	20070203	
			Pes Planus with Plantar Fasciitis, Hallux Valgus Left Foot, Residuals, Right Foot Injury	5276	Not Service Connected	
			Residuals, Right Ankle Injury	5271	Not Service Connected	
			Residuals, Left Ankle Injury	5271	Not Service Connected	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Gout.  According to service treatment records (STRs) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s gout condition began in 2001 after he noted swelling of the right foot.  X-rays in July 2002 ordered for right foot pain for 3 days after a parade march were negative.  In March 2003 the CI had an inversion injury of the right foot and a rolled left ankle in October 2004 with negative X-rays.  A podiatry note in November 2004 indicated the CI was found to have an increased uric acid after anti-inflammatory medication and an antibiotic failed to resolve the pain, swelling and redness of the left ankle.  The CI was then treated with indomethacin (a nonsteroidal anti-inflammatory drug (NSAID)) followed by prednisone (a steroid).  He had a strong family history of gout and his diet included large quantities of pork, bacon, and steak almost daily.  After an acute onset of swelling of the right foot at the 2nd and 3rd metatarsophalangeal (MTP) region in December 2004, an aspirate was performed, which confirmed the diagnosis of gouty arthritis.  Treatment consisted of Motrin (ibuprofen, an NSAID) and allopurinol (to lower uric acid) along with follow-up laboratory studies for uric acid.  According to the NARSUM the CI was treated three to four times per year for exacerbations, although he did not require hospitalization, and was given P2 profiles since he could not always run to the maximum due to the gout. He had fewer exacerbations/flares on allopurinol and ibuprofen by February 2005; however, because of a flare when he had difficulty getting into boots, the dose of allopurinol was increased, although he had achieved a stable uric acid level.  In December 2005 the CI presented with chronic right ankle problems and magnetic resonance imaging (MRI) suggested injury to the anterior talofibular and calcaneofibular ligaments and peroneal tendons consistent with a prior inversion injury.  In May 2006 the CI reported another “toe attack” and right knee swelling with pain, which was treated with prednisone and Roxicet (oxycodone, a narcotic and acetaminophen, a pain reliever).  Allopurinol, which had been self-discontinued during a flare, was reinstituted with colchicine along with a steroid injection in the knee joint after aspiration revealed gout crystals on 1 June 2006.  A repeat aspiration and steroid injection were performed on 7 June 2006.  On 22 June 2006 the CI complained of discomfort of both knees and had a slight effusion of the right knee.  Symptoms also involved the right wrist, right ankle, and right knee, left leg and left foot.

At the MEB examination dated July 2006, 4 months prior to separation, the CI reported right ankle pain, knee pain, great toe pain, occasional left foot pain and recurrent chronic gout.  Physical examination revealed right toe edema/swelling, right toe adjacent to great toe and medial deviation with swelling, and moderate symptomatic pes planus.  The NARSUM examination performed on 13 July 2006, 4 months prior to separation, revealed the CI’s right big toe with erythema and swelling, the right second toe with erythema and swelling, and a right wrist postoperative scar.  There was a full range of motion (ROM) of the knees from 0-140 degrees with right knee pain at full flexion.  The knees were otherwise normal without crepitus, laxity, edema or erythema.  Strength was normal. The hip had full ROMs and normal strength.  There was some pain and slight weakness due to pain upon right ankle inversion and eversion at maximal effort, but the ROMs were full.  Gait and stance were normal.  Gout was not active at the time of the examination although the CI’s uric acid was 12.7 mg/dL (normal 3.5-7.2) on 22 June 2006, having ranged from a low of 5.7 to a high of 13.2 over the prior 2 years, while his hemoglobin and hematocrit were at 14 g/dL and 42.7% on 5 July 2006 and his weight was 212 pounds.  

An MEB Addendum (orthopedics) dated 1 September 2006 indicated the CI had chronic bilateral knee pain for approximately two years in the absence of trauma, but did have one episode of severe gout in the right knee, but no gouty attacks in the left knee.  He was able to run and passed his PT test 3 months earlier.  Because of the knee pain, he was unable to lift any heavy objects or work under vehicles.  He also noted bilateral ankle pain, which prohibiting him from performing his PT pain-free. On examination the ROMs of his knees bilaterally were 0 to 135 degrees without crepitus (grinding).  He had no laxity, but did have tenderness to palpation in the lateral aspect of the patellae bilaterally.  He had no tenderness to palpation about his ankles and his ROM was dorsiflexion of approximately 10 degrees and plantar flexion of approximately 30 degrees.  He had a significant pes planus deformity, although he walked with a normal gait.  Examination of the right foot revealed no significant deformity of his second toe with normal function and no tenderness to palpation.  An MRI of the right knee revealed some evidence of cartilage injury on the lateral aspect of his patella.  X-rays of the ankles were normal and there was significant pes planus deformity.  The diagnosis of bilateral knee patellofemoral syndrome and bilateral pes planus was made.  Surgery was not needed and his pain was well controlled, although “he would function well if it were not for the duties require of him as a military soldier.”  An MEB Addendum (Rheumatology) dated 7 September 2006 indicated the CI had been having attacks of gout three to five times per year on average with resulting work absence 1-2 weeks per year.  Flares had reduced with the use of hypouricemic therapy (allopurinol).  Right ankle pain was associated with prior ligamentous injuries and chronic knee pain with occasional small knee effusions after exercise.  Physical therapy and elastic sleeves did not provide much benefit.  On examination, the CI walked with a non-antalgic gait.  Joints were without effusions or deformities.  There was a full ROM throughout and mild periarticular right ankle soft tissue swelling.  His knees had patellar crepitance, laxity and positive patellar inhibition tests bilaterally.  There were no rashes or tophi (uric acid crystal deposits in the skin or joints).  His weight was 211 pounds.  ROM measurements performed on 13 September 2006 with three repetitions were right ankle dorsiflexion 15 degrees, plantar flexion 30 degrees, inversion 30 degrees and eversion 20 degrees, the latter two motions with pain; right knee extension 0 degrees with pain and flexion 130 degrees; and left knee extension 0 degrees and flexion 128 degrees.    

At the VA Compensation and Pension (C&P) examination on 3 February 2007, performed 2 months after separation, the CI reported flares of gout in both ankles and both knees associated with pain described as squeezing, burning, oppressing, sharp and sticking.  Additionally, he had knee pain with stiffness, swelling on and off, weakness during bending, and lack of endurance going up stairs, which was diagnosed as patellar femoral syndrome. He also had pain in the right foot second toe and right hand from gout. On examination the right wrist was tender with dorsiflexion 60 degrees and palmar flexion 70 degrees, both with pain.  Examination of the knees, ankles and feet examinations were normal.  On 13 August 2007, almost 9 months post-separation, the CI complained of right foot pain for 3 days and reported his prior flare up was 3-4 months earlier.  On examination he had a mildly swollen, red, warm right big toe with some involvement of the ankle.  Treatment of the gout consisted of colchicine, Vicodin (hydrocodone, a narcotic and APAP (acetaminophen), a pain reliever), Motrin, and prednisone.  His weight was 210 pounds.
  
The range of motion (ROM) examinations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the charts below.  

Knee ROM
(Degrees)	MEB ~3 Mo. Pre-Sep
	VA C&P ~2 Mo. Post-Sep
	
	Left	Right	Left	Right	
Flexion (140 Normal)	135	135	140	140	
Extension (0 Normal)	0	0	0	0	
Comment	Tenderness to palpation lateral aspect of patellae bilaterally and posteriorly bilaterally			
§4.71a Rating	0%	0%	0%	0%	

	

Ankle ROM
(Degrees)	MEB ~3 Mo. Pre-Sep
(20060901) p.36	VA C&P ~2 Mo. Post-Sep
(20070203) p.144	
	Left	Right	Left	Right	
Dorsiflexion (20 Normal)	10	10	20	20	
Plantar Flexion (45)	30	30	45	45	
Comment	No tenderness to palpation bilaterally			
§4.71a Rating	0%	0%	0%	0%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 20% rating under the 5017 code (gout) using code 5002 (arthritis rheumatoid (atrophic), citing gout with onset of symptoms in 1999 and diagnosis in 2001.  Symptoms included pain in knees, ankles, and feet (rated for one to two exacerbations in a year with a well-established diagnosis).  The VA also assigned a 20% rating using an analogous 5017-5002 code (gout-arthritis rheumatoid (atrophic) As an active process:  One or two exacerbations a year in a well-established diagnosis) based on the VA C&P examination 2 months after separation, citing gout.  Board members discussed whether the CI warranted a higher rating of 40%, which requires “Symptom combinations productive of definite impairment of health objectively supported by examination findings or incapacitating exacerbations occurring three or more times a year.”  The NARSUM indicated the CI was treated three to four times per year, which was supported by examination findings early in the course of disease; however, the CI’s condition stabilized as long as he continued his medication and avoided food known to induce flares.  However, a rheumatology addendum to the MEB NARSUM indicated the CI had “been having attacks of gout three to five times per year on average with resulting work absence 1-2 weeks per year,” although “flares had reduced with the use of hypouricemic therapy (allopurinol).”  Based on the NARSUM and rheumatology reports Board members discussed whether the CI’s condition had met the 40%.  The Board majority agreed that the CI’s condition did not meet the 40% rating threshold.  All Board members did agree that the CI did not meet the criteria for a 60% rating in the absence of weight loss and anemia productive of severe impairment of health or severely incapacitating exacerbations occurring four or more time a year or a lesser number over prolonged periods.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board majority concluded that there was insufficient cause to recommend a change in the PEB adjudication for the gout condition.  

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that bilateral knee pain, ankle pain, and bilateral pes planus were not unfitting.  The bilateral knee pain, ankle pain, and bilateral pes planus were profiled and the bilateral knee pain was implicated in the commander’s statement, which noted the CI was “incapacitated to stand and walk with proper use of his legs.”  However, the bilateral knee pain, ankle pain, and bilateral pes planus were not judged to fail retention standards, but were instead subsumed under the diagnosis of gout by the PEB and were discussed above.   There was no performance-based evidence that could separately differentiate each condition from the overriding symptomatology of gout, which can involve not only one joint, but many joints.  Therefore, while the conditions as a group in conjunction with gout may have interfered with satisfactory performance at separation, unbundling each condition did not find that any one of the conditions rose to the level of being separately unfitting sufficient to have significantly interfered with satisfactory duty performance at separation. After due deliberation, and 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 knee pain, ankle pain and bilateral pes planus conditions; and so, no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the gout condition and IAW VASRD §4.71a, the Board majority recommends no change in the PEB adjudication.  The single voter for dissent submitted the appended minority opinion.  In the matter of the contended bilateral knee pain, ankle pain, and bilateral pes planus conditions, the Board unanimously recommends no change from the PEB determinations as not separately unfitting, but the conditions remain subsumed as components of the gout condition.  There were no other conditions within the Board’s scope of review for consideration.  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, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

Minority Opinion.  The CI’s gout condition should be rated 40% using code 5017 rather than 20%, and in order to do so requires an understanding of gout, and more importantly, how it is different than rheumatoid arthritis on which the 5002 code is based.  Gout, more often than not, begins spontaneously and is marked by excruciating pain, edema, and inflammation of the MTP of the great toe.   However, the great toe is not the sole joint involved.  Other sites include the insteps, ankles, wrists, finger joints, and knees and affected joints are erythematosus, hot, and tender, which simply stated are extremely painful and consistent with a “definite impairment of health objectively supported by examination findings.”  However, in between attacks the joints may return to normal.  While the pattern may resemble rheumatoid arthritis, the joints are generally not marked by synovitis or permanent structural alterations.  Furthermore, elevation of uric acid is related to dietary indiscretions with alcohol and purine containing foods such as meat and shellfish among the more common causes, while diuretics, radiocontrast dyes, and dehydration also being contributory to uric acid elevation and gout genesis.  Therefore, gout can and does flare up intermittently even when medication seemingly controls the serum uric acid level.  

The STR clearly demonstrated the CI had been incapacitated while on active duty sufficient to warrant a 40% rating based on the commander’s statement which referred to involvement of his knees and the MEB addendum, which indicated the CI had been having attacks of gout three to five times per year on average with resulting work absence 1-2 weeks per year.  The majority cited a VA examination at 3 months post-separation in which the conditions of patellar femoral syndrome, arthritis swelling in knees, left ankle gout flare, and bilateral knees were reported not to cause incapacitation; however, a VA examination 9 months post-separation documented a flare of the right foot for 3 days, which required aggressive therapy and also referred to a prior flare 3-4 months earlier.  Therefore, the probative value of the integral of the commander’s statement, MEB addendum, and the VA examination 9 months post-separation exceed and trump the VA examination at 12 months post-separation, which failed to address the most common anatomical site for presentation of gout, the foot.   

For all the aforementioned reasons, the CI warrants a 40% rating for gout having unequivocally met the requirements of “Symptom combinations productive of definite impairment of health objectively supported by examination findings or incapacitating exacerbations occurring 3 or more times a year” prior to and at least up to 9 months post-separation despite the one contrary VA examination.

Therefore, the minority voter recommends the following modification to the ROP:

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 gout condition, coded 5017.  

Furthermore, the minority voter recommends that the Board findings be modified to read:

The Board recommends that the CI’s prior determination be modified as follows; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Gout	5017	40%	

SAMR-RB						

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

19 DEC 2016

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for 
AR20160017809 (PD201404049)

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:

Enclosure

CF: 
(  ) DoD PDBR
(  ) DVA