RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00426
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20051107

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Fuel Journeyman, medically separated for “seronegative rheumatoid arthritis,” with a disability rating of 20%.

CI CONTENTION:  The CI contends that her condition has progressed and has had subsequent surgeries.  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 based upon a 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 - 20050829	VARD - 20060412	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Seronegative Rheumatoid Arthritis	5002	20%	Rheumatoid Arthritis	5002	20%	20060523	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Seronegative Rheumatoid Arthritis.  According to service treatment records (STRs) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s seronegative rheumatoid arthritis condition began in July 2003 after complaining of foot pain at which time she was diagnosed with neuromas (benign neural tumors) and was treated with injections.  In November 2003 she was diagnosed with a left second toe dislocation and underwent an open reduction and pin fixation on 1 December 2003.  Postoperatively and after the pin removal, the CI had some pain with running, which raised consideration of a partial torn flexor tendon.  In April 2004 the CI had left wrist pain, which was diagnosed as tenosynovitis and was treated with Naprosyn (naproxen, a nonsteroidal anti-inflammatory drug (NSAID)), while in July 2004 she was diagnosed with a stress fracture of the second left metatarsal.  Because of persistent left wrist pain, magnetic resonance imaging (MRI) of her left wrist was performed in November 2004, which was consistent with pannus/synovitis (fibrovascular tissue/inflammation) at the left wrist joint and distal radioulnar joint with fluid near the extensor carpi ulnaris (muscle on the ulnar side of the forearm) that can be seen with an inflammatory arthropathy such as rheumatoid arthritis or other related conditions.  In December 2004 X-rays demonstrated bilateral erosions of the metatarsal and proximal phalanx of the great toe, most likely representing early bony manifestations of an arthropathy such as rheumatoid arthritis.  The hands and wrists were unremarkable with probable intra-osseous cysts only.  An internist felt the findings were consistent with a systemic inflammatory arthropathy such as rheumatoid arthritis or other related conditions, but noted the negative CRP (C-reactive protein, levels of which rise with inflammation). Treatment consisted of meloxicam, an NSAID.  A consultant rheumatologist diagnosed rheumatoid arthritis in January 2005.  A laboratory study in February 2005 for rheumatoid factor was negative and the erythrocyte sedimentation rate was normal at 20.  A chest X-ray in February 2005 was normal.  Beginning in February 2005 treatment consisted of methotrexate (an antimetabolite), prednisone (a steroid), and folic acid (a vitamin used with methotrexate).  In March 2005 the CI complained of 8/10 pain (10/10 being the worst pain) in both ankles, feet and back along with left wrist soreness.  Percocet (oxycodone, a narcotic and acetaminophen, a pain reliever) was added to the treatment regimen.  Bone mineral analysis (to determine osteopenia/osteoporosis) was normal in March 2005.  The CI tolerated the methotrexate, but when she tried to wean/discontinue her prednisone on at least two occasions in June and July 2005, she had a flare of symptoms of pain and swelling in the feet and wrists.  

At the NARSUM examination on 21 July 2005, 4 months prior to separation, the CI had warmth, tenderness and edema at the first, second, and third metacarpophalangeal (MCP) joints bilaterally as well as the first and second proximal interphalangeal (PIP) joints bilaterally.  At the radial aspect of both wrists there was trace warmth, tenderness and edema.  Elbows, shoulders, hips and knees were free of synovitis.  No nodules were noted at her elbows.  Bilateral forefoot plantar tenderness with trace warmth at the metatarsophalangeal (MTP) joints bilaterally was noted.  She had a mildly antalgic gait secondary to pain.  On 29 July 2005, the rheumatoid factor was positive at a 1:4 dilution (approximately 80 IU/mL).  In August 2005 the MEB forwarded “seronegative rheumatoid arthritis” for PEB adjudication.  A note in September 2005 indicated the CI weaned off prednisone approximately 1 month earlier and was stable since then.  A chest X-ray in January 2006 was normal. 

At the 23 May 2006 VA Compensation and Pension (C&P) evaluation, performed 7 months after separation, the CI reported joint pains beginning in April 2004  in her feet, ankles, knees, hands, wrists, and shoulders.  Post-separation the CI ran out of her medication and had a severe flare-up of her rheumatoid arthritis with swelling, inflammation, and pain of the hand joints, wrists, shoulders, feet, ankles, and knees.  With medications including prednisone and Humira (adalimumab, an immune modulator (biologic)/tumor necrosis factor (TNF) inhibitor) the CI had an excellent response and her joints were doing well.  Morning stiffness was less than 30 minutes and there were no swollen joints.  The CI had a positive rheumatoid factor and a negative ANA (anti-nuclear antibody, to determine connective tissue disease).  X-rays of her hands showed narrowing of the wrist joints with periarticular osteopenia (loss of mineralization of the bones), while X-rays of her feet showed erosions of the first and fifth MTP joints consistent with rheumatoid arthritis.  The CI had no inflammation of the hand joints (PIPs and MCPs).  The wrists, elbows, and shoulders were all nontender and had good ranges of motion (ROMs).  Her hand grip was good.  There was no tenderness of the MTP joints, but there was some deformity of the joints with subluxation of the feet. There was no swelling, tenderness, or effusions of the ankles.  Knees and hips had a good ROMs.  The examiner noted the CI had rheumatoid arthritis, which was seropositive and supported by physical examination and radiological and laboratory data.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the seronegative rheumatoid arthritis condition 20%, coded 5002 (arthritis rheumatoid).  The VA also rated the seronegative rheumatoid arthritis condition 20% coded 5002 (arthritis rheumatoid), based on the VA C&P examination 7 months after separation, citing a rheumatoid factor of 153, which was high.  Board members discussed whether a 40% rating was warranted using code 5002; however, there were not “symptom combinations productive of definite impairment of health objectively supported by examination findings or incapacitating exacerbations occurring 3 or more times a year” nor was there reported weight loss and anemia warranting a higher rating.  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 rheumatoid arthritis condition, which by the time of separation was seropositive.  

BOARD FINDINGS:  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.  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 20150602, w/attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAF/MR
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD  20762

Dear XXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2015-00426.

After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was appropriate.  Accordingly, the Board recommended no re-characterization or modification of your separation.

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding and their conclusion that re-characterization of your separation is not warranted.  Accordingly, I accept their recommendation that your application be denied.

Sincerely,

Attachment:
Record of Proceedings