RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00515
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20050928

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an Reserve E5, Medical Technician, medically separated for “Multijoint Arthralgia” with a disability rating of 10%.  

CI CONTENTION:  “Review all conditions.”  The complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The panel’s scope of review is defined in DoDI 6040.44.  It is limited to review of disability ratings assigned 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 or non-compensable.  Any conditions outside the panel’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 panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The panel’s assessment of the PEB rating determination is based on 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(s) at the time of separation.  The panel 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 panel 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 - 20050613	VARD - 20090304	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Multijoint Arthralgia	5099-5021	10%	Lumbar IVDS	5243	0%	20090114	
			Bilateral Elbow	5201	NSC		
			Cervical Myofascial Strain	5237			
			Bilateral Ulnar Nerve 	5201			
			Left Wrist Carpal Tunnel	8515			
COMBINED RATING: 10%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:

Multijoint Arthralgia.  According to the service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s multijoint arthralgia (joint pain) condition began in August 2001.  The CI reported an injury of her neck and non-dominant left upper extremity, sustained while lifting a litter off a helicopter.  She reported pain of the left forearm that radiated up to the shoulder.  Left elbow X-rays on 3 September 2001 were normal and left wrist X-rays noted “mild” soft tissue swelling without evidence of a fracture.  Cervical X-rays showed partially developed cervical ribs (risk factor for thoracic outlet syndrome- see below) and minimal neuroforaminal narrowing on the left at C7-T1.  Magnetic resonance imaging of the C-spine on 28 January 2002 showed mild degenerative disc disease without spinal canal stenosis or neuroforaminal compromise.  Orthopedic evaluation on 2 February 2002 noted full neck range of motion (ROM) with normal strength, sensation, and reflexes of the bilateral upper extremities. The orthopedic specialist’s assessment was that there was no evidence that the left upper extremity symptoms were related to neck pathology.  Electrodiagnostic studies were performed and showed stable changes at C8-T1 that were interpreted as consistent with radiculopathy or injury to the lower trunk of the brachial plexus.  A neurological evaluation on 15 February 2002 also noted a normal exam and the impression was that the left arm pain was not a radiculopathy or plexus injury but was an atypical neuropathic pain process.  An MRI of the brain in April 2002 to evaluate for multiple sclerosis showed some non-specific white matter lesions felt to be more consistent with chronic microvascular ischemia but repeat imaging was recommended in 6 months.  An evaluation in spine clinic on 30 September 2002 also concluded with a nonspecific diagnosis of cervical spine pain and recommended physical therapy and anti-inflammatory medication.  

The 25 August 2003 MEB neurological NARSUM examination, 24 months before separation, the CI reported intermittent left arm numbness and burning pain precipitated by flexion or abduction of the shoulder.  The neurological examination showed normal cranial nerve exam, normal strength, sensation, and reflexes of all extremities, with normal gait, including heel and toe.  There was tenderness to pressure over the left occipital nerve and a positive Tinels sign at the left wrist.  The MEB neurology assessment was C8-T1 radiculopathy and mild left carpal tunnel syndrome (CTS).  The MEB neurologist determined the CI fell below retention standards related to the radiculopathy but met retention standards due to the CTS.  

There were four treatment notes in the STR in the subsequent 2 years before separation in record.  There were two notes for evaluation of right elbow pain from late October 2004 to late January 2005.  A January 2005 elbow MRI, 9 months before separation, showed right lateral epicondylitis.  There was a June 2005 emergency room (ER) visit, 4 months before separation, for complaint of low back pain graded 3/10, without trauma, that noted muscle spasm.  The most recent visit for LBP prior to the ER visit was in July 2002, which noted nonspecific LBP.  

The 5 November 2004 MEB NARSUM examination, 11 months prior to separation, noted complaints of polyarthralgia and neuralgia (nerve pain) of the upper extremities and low back.  The CI was on prescription anti-inflammatory medication daily.  The physical examination showed “very mild” diffuse swelling surrounding the lateral epicondyle of the right elbow.  There was pain with resisted wrist and index finger extension on the right.  There was full ROM of the joints of both lower extremities without muscle tenderness.  There was no joint deformity or crepitus.  Neurovascular exam of all extremities was normal.  

At the remote VA Compensation and Pension (C&P) evaluation, 14 January 2009, 40 months after separation, the physical examination indicated the CI was right hand dominant.  She had a normal gait and posture.  Neurological examination of the upper extremities was normal with full strength, sensation, and reflexes.  The VA examiner indicated that the CI showed greater ROM of the neck and back with movements during the exam than with specific ROM testing and indicated the CI had full ROM of the cervical and thoracolumbar spines, with minimal discomfort.  There was no evidence of cervical intervertebral disc syndrome or peripheral nerve involvement and the recommended diagnosis of the claimed cervical nerve condition was cervical myofascial strain.  There was variable tenderness to palpation of the upper thoracic region.  There was no muscle spasm or radiating pain with movement.  Neurological examination of the lower extremities was showed normal strength and reflexes with a sensory deficit of the left lateral thigh.  Straight leg raise testing to elicit lumbar radicular symptoms was negative bilaterally.  The diagnosis was lumbar intervertebral disc syndrome involving the left sciatic nerve.  There was “possible” slight tenderness over the right medial condyle.  There was full ROM of the elbow and wrists, without guarding or apparent pain, with no additional loss of ROM with repetitive motion.  Bilateral hand dexterity and finger ROM was normal, with normal hand strength.  The VA examiner stated a diagnosis was not possible for the claimed left wrist carpal tunnel, bilateral ulnar nerve condition and bilateral elbow condition based on evidence during examination.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the multijoint arthralgia condition 10%, coded 5099-5021 (analogous to myositis).  The VA rated the lumbar intervertebral disc syndrome condition 0% coded 5243 (intervertebral disc syndrome), based on the C&P examination 40 months after separation, citing unreliable ROM testing.  The VA denied service-connection for cervical myofascial strain, bilateral elbow condition, bilateral ulnar nerve condition and left wrist carpal tunnel, citing no permanent residuals or chronic disabilities.  

The PEB provided a 10% rating and the panel reviewed to see if a higher rating was supported with any other applicable VASRD code.  In the 2 years before separation, there were only three treatment notes in record.  The MEB NARSUM examination was the most proximate examination to separation and the only objective abnormality recorded was right elbow swelling and pain with resisted motion.  Proximate to separation there was no evidence of occasional incapacitating episodes for a higher rating under 5021.  There no evidence of sufficient limitation of forearm or elbow ROM (5206, 5207, 5208) or any evidence of elbow impairment (5209) to support a higher rating under these codes.  The panel also considered coding and rating the CI’s condition analogous to a systemic condition such as fibromyalgia (5025).  However, the CI was not diagnosed with a systemic disorder during active duty that could account for arthralgia of multiple joints such as fibromyalgia, rheumatoid arthritis, or MS and had not been at the time of the remote VA examination.  The panel therefore agreed this rating approach was not warranted. There was therefore no higher rating available than 10% with any alternative VASRD code.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded that there was insufficient cause to recommend a change in the PEB adjudication for the multi-joint arthralgia condition.  

BOARD FINDINGS:  In the matter of the multijoint arthralgia condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  There are no other conditions within the panel’s scope of review for consideration.  The panel, therefore, recommends that there be no modification or re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150602, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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

Dear XXXXXXXXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2015-00515.

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,

XXXXXXXXXXXXXXXXXX
Director
Air Force Review Boards Agency

Attachment:
Record of Proceedings