RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00799
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20051018

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Automated Logistical Specialist, medically separated for “right knee pain” and “Reynaud’s syndrome,” rated 0% and 0%, respectively, with a combined disability rating of 0%.

CI CONTENTION:  Knee condition is worse.  The 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 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 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 - 20050803	VARD - 20060614	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Knee Pain … Osgood-Schlatter’s Disease	5099-5003	0%	Osgood Schlatter Disease, Right Knee	5299-5262	10%	20051208	
Raynaud’s Syndrome	7199-7117	0%	Raynaud’s (Syndrome) Phenomenon	7117	0%	20051208	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:

Right Knee Pain.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s right knee pain condition began in 2001 and intensified in 2004 after a gradual onset of right-sided knee pain without specific trauma or injury.  Radiographic imaging (X-ray) in April 2004 showed right knee changes (old osteochondrosis adjacent to the tibial tubercle and patellar tendon degeneration) consistent with Osgood-Schlatter’s disease.  There was no surgical indication.  

The 5 May 2005 MEB NARSUM examination, 6 months prior to separation, noted complaints of right-sided anterior knee pain with functional limitations.  The physical examination showed tenderness over the tibial tuberosity.  There was no laxity, instability, or effusion.  The CI had “full active and passive range of motion [ROM]” of the knee with no crepitus.

At the 24 May 2005 MEB physical therapy evaluation, 5 months prior to separation, the CI reported right knee pain, swelling, and stiffness.  He noted a snapping sensation and heard a popping sound in his knee.  Physical examination noted “limping was observed.”  Repetitive ROM was flexion to 133, 133, 132 degrees (normal 140) and extension to -4 degrees each time (normal 0); painful motion was not addressed.

At the 2 June 2005 MEB examination (recorded on DD Forms 2807 and 2808), 5 months prior to separation, the CI reported right knee pain with activity and episodic swelling.  Physical examination documented a nodular right proximate tibia.

At the 8 December 2005 VA Compensation and Pension (C&P) evaluation, 2 months after separation, the CI reported right knee pain and stiffness.  Physical examination showed normal gait and posture.  The right knee had an abnormal anterior tibial nodule, “locking” pain and crepitus.  There was no instability or laxity.  ROM was flexion to 135 degrees and extension to 5 degrees with painful motion; additional pain followed with repetition.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the right knee pain condition 0%, analogously coded 5099-5003 (degenerative arthritis), citing normal ROM and no ligamentous laxity.  The PEB also noted this condition was characterized as EPTS (existed prior to service), but was compensable under 10 USC.  The VA rated the right knee pain condition 10%, analogously coded 5299-5262 (tibia and fibula, impairment), based on the C&P examination 2 months after separation, citing ROM limited by pain and “no weakness, laxity instability, lack of endurance, incoordination, or ankylosis.”

There was clear evidence of tibial pathology on both examinations closest to separation.  There was no limitation of motion which supported a rating under the diagnostic codes for limitation of flexion or extension (5260, 5261).  However, there was evidence of tibial pathology and painful motion or functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45).  The examinations proximate to separation did not demonstrate the presence of ligamentous instability or laxity (5257), and there was no history of dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258), or history of surgery to remove a meniscus (5259) to support a rating under those respective codes.  There was no fracture, non-union, or malunion of the femur to support consideration under code 5255.  There was insufficient evidence of moderate knee or ankle disability for any rating higher than 10% analogous to code 5262.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the right knee condition, coded 5299-5262.

Raynaud’s Syndrome (Phenomenon) (RP).  According to STRs and the MEB NARSUM, the CI’s Raynaud’s condition began in 2001 after noticing cold-induced color changes of his hands and toes accompanied by pain.  The CI was first seen in the rheumatology clinic in March 2005 for evaluation of Raynaud’s phenomenon.  The June 2005 rheumatology note indicated the CI was taking Norvasc and was still having daily episodes lasting for 20-30 minutes that occasionally interfered with his job.

The 22 June 2005 MEB rheumatology addendum, 4 months prior to separation, noted a history of cold-induced color changes of his hands with the classic color changes of pale white, blue, and then red accompanied by pain.  “The symptoms occur daily.  They can last for 20-30 minutes at a time.  They are definitely related to cold weather, but also occur in air conditioning environments.”  He had, at times, had trouble with morning physical training exercise, secondary to the cool weather in the morning.  He denied any previous history of any cold-induced injuries such as frostbite.  Physical examination showed no peripheral edema, clubbing, sclerodactyly (thickening and tightness of finger or toe skin), digital ulcers, telangiectasias (blood vessels causing threadlike red lines or patterns on the skin), and no calcinosis (calcium deposits on the skin).  There was no joint swelling or warmth and the nail bed capillary examination and peripheral pulses were normal.  The rheumatologist planned for a trial of increased Norvasc (started in March 2004 without effect) and reevaluation if that was not effective.

At the 8 December 2005 VA C&P evaluation, 2 months after separation, the CI reported suffering from RP since 2001.  History included suffering for 4 years from erythromelalgia involving the fingers and toes of bilateral extremities.  It occurred as often as one time per month and each episode lasted for 2 hours.  Additionally the CI reported that he had suffered from RP involving the fingers and toes.  It occurred about once a day.  Treatment was daily Norvasc.  Physical examinations of the extremities showed normal skin, vascular and neurologic results.  There were no objective findings of erythromelalgia or RP.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the RP condition 0%, coded 7199-7117 (Raynaud’s syndrome), citing an unremarkable rheumatological examination.  The VA rated the Raynaud’s condition 0%, also coded 7117, based on the C&P examination 2 months after separation, citing erythromelalgia episodes occurring at least one time per month.  The Board majority noted the VA did not rate the CI’s reported “as often as 1 time per day” Raynaud’s symptoms based on 4.7 (higher of two evaluations).

RP does not typically have any examination findings unless provoked by a cold stimulation test.  The CI did not have any secondary signs of Raynaud’s such as digital ulcers or skin changes.  RP is therefore rated on frequency of “characteristic attacks,” which per the VASRD notation for code 7117, “consist of sequential color changes of the digits of one or more extremities lasting minutes to hours, sometimes with pain and paresthesias, and precipitated by exposure to cold or by emotional upsets.  These evaluations are for the disease as a whole, regardless of the number of extremities involved or whether the nose and ears are involved.”

The rheumatologist’s notes and the MEB rheumatology addendum indicated the CI’s attacks were daily and included symptoms in air-conditioned environments.  Both examinations were conducted in June 2005 during the summer months and indicated continued daily episodes of RP.  The single mention of less than daily, or nearly daily, symptoms was documented by the “review of symptoms” in the 9 June 2005 MEB obstructive sleep apnea (OSA) addendum, approximately 4 months before separation, for daytime somnolence and snoring.  The review indicated “during these summer months, he has had no further difficulty with his Raynaud's phenomena.”  The VA examiner, 2 months after separation, indicated symptoms of fingers and toes “erythromelalgia” once a month and RP “as often as 1 time per day.”  Erythromelalgia is a disorder with paroxysmal attacks of severe burning pain, reddening, hyperalgesia, and sweating, involving one or more extremities, usually triggered by warmth or exertion, and are usually relieved by cold.  The CI was not diagnosed with erythromelalgia, but the term may have been used by the VA examiner to indicate throbbing and burning pain and redness in the skin.  The CI was diagnosed with RP and the VA examiner indicated that erythromelalgia was once a month; however, he also indicated that the CI had RP “as often as 1 times per day.”

The criteria for rating RP is extracted below:  

7117 	Raynaud’s syndrome: 
		With two or more digital ulcers plus autoamputation of one or more 
			digits and history of characteristic attacks	100  
		With two or more digital ulcers and history of characteristic attacks	60  
		Characteristic attacks occurring at least daily	40 
		Characteristic attacks occurring four to six times a week	20  
		Characteristic attacks occurring one to three times a week	10  
	Note: For purposes of this section, characteristic attacks consist of sequential color changes of the digits of one or more extremities lasting minutes to hours, sometimes with pain and paresthesias, and precipitated by exposure to cold or by emotional upsets. These evaluations are for the disease as a whole, regardless of the number of extremities involved or whether the nose and ears are involved.  

The Board consensus was that the rheumatologist’s notes, the MEB rheumatology addendum examination, and the VA examination corroborated a higher probative value than the MEB OSA addendum-related review of symptoms.  The Board majority adjudged that the CI’s frequency of characteristic attacks more closely approximated “four to six times a week” to support a 20% rating as reflexed by the VA examination most proximate to separation; but did not satisfy the “often” daily symptoms to support a 40% rating.

After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board majority recommends a disability rating of 20% for the RP condition, coded 7199-7117. 

BOARD FINDINGS:  In the matter of the right knee condition, the Board unanimously recommends a disability rating of 10%, coded 5099-5262 IAW VASRD §4.71a.  In the matter of the RP condition, the Board majority recommends a disability rating of 20%, coded 7199-7117 IAW VASRD §4.104.  The single voter for dissent submitted the appended minority opinion.  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; 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	
Right Knee Pain…	5299-5262	10%	
RP	7199-7117	20%	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150601, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MINORITY OPINION:  The minority member concurs with the majority recommending a disability rating of 10% for the right knee condition, coded 5299-5262.

The minority member disagrees with the majority’s rating rationale for the RP.  The majority voters based their rating recommendation entirely on subjective reporting by the CI at the MEB rheumatology addendum and VA examinations.  There was no objective evidence supporting the CI’s report of characteristic attacks, and no objective Raynaud’s testing such as nailfold capillaroscopy or cold stimulation in evidence.  Therefore, if the subjective reporting is to be used as the sole basis for rating, then all statements regarding frequency of characteristic attack must have high probative value.  

During the 9 June 2005 MEB OSA addendum examination, 4 months before separation, the examiner stated that “during the summer months, he has no further difficulty with his Raynaud's phenomena.”  This statement conflicted with the CI’s report approximately one month earlier on 22 June 2005, during the MEB rheumatology addendum examination when he reported cold-induced color changes of his hands with the classic color changes of pale white, blue, and then red accompanied by pain, and that he was still having [cold-induced] episodes daily even though the examination was done in the summer.

At the 8 December 2005 VA examination, 2 months after separation, the CI reported that he suffered for 4 years from RP involving the fingers and toes, and that it occurred “as often as 1 time per day,” which conflicts with his earlier report of “no further difficulty during the summer months” and claim of “symptoms [that] occur daily.”  Further, there was no functional impairment, and the condition did not prevent him from exertion, or from performing any exercise, and the condition did not result in any time lost from work.  The examiner also noted there were no RP symptoms present at the time of the examination.  

The rating schema for Raynaud’s is based on frequency of characteristic attacks.  In this case, that evidence could only be found in the subjective reports, which were contradictory and not supported by any objective evidence.  The PEB and the VA did not use the CI’s subjective reporting as a basis for rating.  The PEB rated the Raynaud’s condition at 0% based upon an unremarkable examination.  The VA also rated the Raynaud’s condition at 0% based on a non-compensable evaluation because there was no documentation of characteristic attacks that occur one to three times a week.

The minority voter agrees that the PEB (and VA) approach for rating the total disability of the CI’s Raynaud’s condition was accurate and fair, and recommends no change to the PEB rating of 0%.  

In the matter of the right knee condition the minority voter recommends a disability rating of 10%, coded 5299-5262, and modified as follows, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Right Knee Pain…	5099-5262	10%	
RP	7199-7117	0%	
COMBINED	10%	

AR20170005110, XXXXXXXXXXXXXXXXXXXXX 

Dear XXXXXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found your separation disability rating and your separation from the Army for disability with severance pay to be accurate.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed).  
I regret to inform you that I reject the Board’s recommendation and your application to the DoD PDBR is denied.  There is insufficient justification to support the Board’s recommendation in accordance with Army and Department of Defense regulations.

	This decision is final.  Recourse within the Department of Defense or the Department of the Army is exhausted; however, you have the option to seek relief by filing suit in a court of appropriate jurisdiction. 

Sincerely,
						     
Enclosure