11RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01262
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20070418

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Public Affairs Journeyman, medically separated for “ankylosing spondylitis,” with a disability rating of 10%.

CI CONTENTION:  The CI’s condition continues to worsen and negatively affect daily activities.  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 - 20070131	VARD - 20070915	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Ankylosing Spondylitis	5240	10%	Ankylosis Spondylosis, Thoracolumbar Spine	5240 	0%	STR	
			Ankylosis Spondylosis, Cervical Spine	5240	0%		
COMBINED RATING: 10%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Ankylosing Spondylitis.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s arthritic condition began as low back pain without specific trauma in October 2004 while deployed, although he noted he overexerted himself at the gym.  He first sought treatment in April 2005 and was treated with Naprosyn (naproxen, a nonsteroidal anti-inflammatory drug (NSAID)) and Robaxin (methocarbamol, a muscle relaxant).  A note dated 12 December 2005 indicated the CI thought the back pain was from riding repeatedly in the back of a truck during deployment.  He reported having intermittent radiating pain to the legs, but had no bowel or bladder dysfunction.  He also noted he was being treated by a chiropractor, which he continued for 5 months.  However, medication and treatment provided limited relief.  Physical therapy was then instituted in February 2006.  An X-ray series of the lumbar spine dated 22 February 2006 showed questionable sclerotic (thickened) and erosive changes of the right sacroiliac (SI) joint and minimal levocurvature (curvature to the left) and slight loss of the normal lumbar lordosis.  X-rays of the SI joints on 27 February 2006 showed findings suggestive of right sacroiliitis.  Blood tests were positive for rheumatoid factor and HLA-B27 in March 2006.  Rheumatologic workup noted the CI complained of difficulty getting out of bed and morning stiffness.  The diagnosis of ankylosis spondylitis was made.  Initial treatment was with Mobic (meloxicam, an NSAID).  Additional positive lab results included a slightly elevated sedimentation rate and C-reactive protein, which are markers of inflammation.   Magnetic resonance imaging (MRI) on 10 April 2006 demonstrated inflammatory changes involving the sacrum and iliac bones adjacent to the SI joints bilaterally in a relatively symmetric fashion suggestive of a bilateral inflammatory arthritis involving the SI joints, which could be related to ankylosing spondylitis.  Enbrel (etanercept, a biologic anti-inflammatory medication) was added to the treatment protocol in April 2006.  At a clinic visit on 26 May 2006 the CI denied fever, chest pain, shortness of breath, bowel/bladder dysfunction, and nausea or vomiting.  He had no work duty limitations and still performed physical training as tolerated.  Physical examination was within normal limits.  On 18 August 2006 the CI complained of pain between the shoulders, which was improved with chiropractic manipulation treatment.  

The 25 August 2006 MEB NARSUM examination, 8 months before separation, noted the ankylosing spondylitis was controlled with medications and the CI was asymptomatic from the condition.  He continued to perform his primary duties without problems and was recommended to return to duty.  Physical examination was normal with no deformity, no tenderness, and a full ROM of the back.  The examiner concluded the CI was stable with medications and pain free despite performing all aspects of his primary duties, but he required a CBC (complete blood count) and a complete metabolic profile every 3 months.  

Physical therapy was instituted in September 2006 for thoracic pain secondary to ankylosing spondylitis.  At a rheumatology visit in September 2006 the CI had a good functional range of motion (ROM) of the neck.  There was no percussion tenderness in the lumbar spine or the SI joints.  The CI was able to flex forward and place fingertips within approximately one inch of the floor.  The rheumatologist noted that the prolonged morning stiffness and chronic low back pain “dramatically improved with Enbrel.” At a rheumatology visit on 15 November 2006 there was mild percussion tenderness in the thoracolumbar spine.  No scoliosis was obvious on forward flexion from the waist and inspection of the thoracic spine.  Occiput to the wall measurement was 0 [centimeters].  A chest X-ray was unremarkable.  Pulmonary function tests in December 2006, performed for shortness of breath on exertion, revealed an FVC (forced vital capacity) of 97% predicted and an FEV1 (forced expiratory volume at 1 second)/FVC of 94% predicted, which were in the range of normal.  A transthoracic echocardiogram performed on 7 December 2007 demonstrated a trace of mitral and tricuspid regurgitation and was otherwise normal with an ejection fraction greater than 55% and no pericardial or pleural effusions.  There was no VA examination proximate to separation.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the ankylosing spondylitis 10%, coded 5240 (ankylosing spondylitis).  The VA rated the “ankylosing spondylitis, thoracolumbar spine” 0% and rated “ankylosing spondylitis, cervical spine” 0%, coded 5240, based on the service treatment records, citing “no objective evidence” of the CI’s current symptoms.  Although there was insufficient limitation of motion to support a minimum rating, the panel agreed a 10% rating was justified for the presence of tenderness.  There was no muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour, thus the next higher 20% rating was not justified.   There was no documentation of intervertebral disc syndrome (IVDS) with incapacitating episodes which would provide for a higher rating under that formula (for IVDS).  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 ankylosing spondylitis.  

PANEL FINDINGS:  In the matter of the ankylosing spondylitis and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  There were 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 20150613, with attachments
Exhibit B.  Service Treatment Record
Exhibit C. Department of Veterans Affairs Treatment Record

SAF/MRB
XXXXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2015-01262.

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