RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX.	CASE:  PD-2015-01596
BRANCH OF SERVICE:  NAVY 	SEPARATION DATE:  20080619

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E2, Seaman Apprentice, medically separated for “polyarthralgias of unclear etiology” with a disability rating of 0%.  

CI CONTENTION:  The CI made no specific contention.  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 - 20080430	VARD - 20090106	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Polyarthralgias of Unclear Etiology	5099-5002	20%
minus 20%	Chronic Disability of the Left Shoulder	5009-5201	NSC	20081029	
			Chronic Disability of the Right Shoulder	5009-5201	NSC	20081029	
			Chronic Disability of the Left Wrist	5009-5215	NSC	20081029	
			Chronic Disability of the Right Wrist	5009-5215	NSC	20081029	
			Chronic Disability of the Lumbar Spine	5009-5242	NSC	20081029	
			Chronic Disability of the Left Knee	5009-5260	NSC	20081029	
			Chronic Disability of the Right Knee	5009-5260	NSC	20081029	
			Chronic Disability of the Left Ankle	5009-5271	NSC	20081029	
			Chronic Disability of the Right Ankle	5009-5271	NSC	20081029	
Noncompliance with Medical Treatment	Cat II	For Above Conditions	
Leukopenia, Likely Constitutional	Cat II	No VA Placement	
Positive Rheumatoid Factor	Cat II	For Above Conditions	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  NSC	

ANALYSIS SUMMARY:  

Polyarthralgias of Unclear Etiology.  According to the service treatment record (STR) and Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s polyarthralgias condition began in April 2007 after straining his groin while running during boot camp.  He subsequently developed pain in multiple large joints.  

At the 19 July 2007 internal medicine evaluation, 11 months prior to separation, the CI reported pain of 9/10 in both knees, lower back and hips, “but he did not appear uncomfortable sitting in the chair or climbing on to the exam table, which he was able to do without assistance or visible discomfort.”  There was no abnormal appearance to the joints and no signs of synovial swelling.  Both knees were tender.  There was no painful motion of any joint documented.  

At the 24 August 2007 sick-call evaluation, 10 months prior to separation, the CI complained of joint pain in the fingers, wrist, shoulders, knees, ankle, toes and lower back with no relief from physical therapy or medications.  He noted that he had full range of motion but with increased pain.  Physical examination showed the CI appeared uncomfortable but in no acute distress.  The back and neck were tender.  The shoulders were tender with limited motion (unspecified).  Both knees and ankles had pain elicited by motion.  

The 1 March 2008 MEB NARSUM examination, 3 months prior to separation, noted complaints of pain in multiple large joints particularly the shoulders, knees, and elbows without morning stiffness.  During early evaluations the CI had positive inflammatory markers and a positive rheumatoid factor.  There were no complaints of non-joint symptoms or poor health.  The history included numerous missed appointments and non-compliance with medication.  The CI was taking no medication for his pain.  Physical examination showed the CI was well-developed, well nourished, mildly overweight, in no acute distress and had no appearance of being uncomfortable.  There were normal neck and back findings.  Musculoskeletal examination documented no tenderness of the joints of the hands or wrists.  There was mild tenderness of the patellofemoral areas of both knees, but the lateral and medial joint lines of both knees were non-tender and there was no knee laxity or instability.  The examiner indicated the CI’s condition was not consistent with rheumatoid arthritis, but was most likely a reactive arthritis or arthralgias, but that evaluation and treatment was obstructed by the CI’s failure to follow through with recommended tests, treatments, and specialty consultations.  

During the 5 March 2008 MEB examination (recorded on DD Forms 2807-1 and 2808), 3 months prior to separation, the CI reported sharp pain in his shoulders with limited movement, stiffness in his lower back, constant pain in his joints, and his knee (unspecified) giving out when he stood or walked.  The examiner noted a history of summarized polyarthritis of the shoulders, wrists, elbows and knees; and a history of pain since May 2007.  Physical examination showed “stiffness and pain both wrists and elbows,” “stiffness-pain both wrists-knees and back,” and “pain and stiffness at lumbar spine.”  

At the 29 October 2008 VA Compensation and Pension (C&P) evaluation, 4 months after separation, the CI reported bilateral knee pain without other symptoms; bilateral shoulder and wrist stiffness without pain; and low back stiffness and pain.  The CI also reported he did not experience any functional limitations due to those conditions.  X-rays of the lumbar spine, shoulders, wrists, knees and ankles were normal.  Physical examination showed a well appearing individual with normal posture and gait.  Evaluations of the wrists, knees, shoulders, ankles, and lower back were normal, with full painless ROM and no objective indications of any functional limitations.  There was no diagnosis provided for any of the joints claimed because there was no pathology to render a diagnosis.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the polyarthralgias condition 20%, coded 5099-5002 (analogous to rheumatoid arthritis as an active process), then applied a 20% deduction due to noncompliance with medical treatment (likely application of SECNAVINST 1850.4E and/or DODI 1332.39 [rescinded]), resulting in a combined 0% rating.  The Navy PEB’s Category II diagnosis of noncompliance with medical treatment; leukopenia, likely constitutional; and positive rheumatoid factor are intrinsic to the rated condition, and separate ratings cannot be supported without pyramiding (VASRD §4.14); thus, they are appropriately subsumed under the same rating.  

The VA did not service connect the wrists, knees, shoulders, ankles, lower back or polyarthralgias, citing “no medical evidence that demonstrate[d] a diagnosis of a current, physical disability of a disease and/or injury pathology,” that “polyarthralgia is defined as multiple joint pain” and that “pain is not a disability in and of itself (absent clinical, objective findings).”  

The panel adjudged there was insufficient evidence of any specific joints being separately unfitting and ratable at separation.  There was no evidence of “symptom combinations productive of definite impairment of health objectively supported by examination findings or incapacitating exacerbations occurring 3 or more times a year” to warrant any rating higher than 20% under the criteria of disability code 5002.  There was no evidence of any polyarthritis or joint disease on the CI’s entry examination to support any rating deduction.  The panel noted that there is no VASRD-compliant provision for decreasing ratings due to non-compliance, and therefore the PEB’s initial 20% rating (absent deduction) was supported.  

After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 20% for the polyarthralgia condition, coded 5099-5002.  

BOARD FINDINGS:  In the matter of the polyarthralgia condition, the panel unanimously recommends a disability rating of 20%, coded 5099-5002 IAW VASRD §4.71a.  There are no other conditions within the panel’s scope of review for consideration.  The panel recommends the CI’s prior determination be modified as follows, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Polyarthralgias of Unclear Etiology	5099-5002	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150625, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

MEMORANDUM FOR DEPUTY COMMANDANT (Manpower and Reserve Affairs)
		   COMMANDER, NAVY PERSONNEL COMMAND	
	                          
Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS          

Ref:  (a) DoDI 6040.44
	(b) PDBR ltr dtd 28 Sep 17 ICO XXXXXXXXXXXXXXXXXX, former USN
	(c) PDBR ltr dtd 17 Oct 16 ICO XXXXXXXXXXXXXXXXXX, former USMC 
	(d) PDBR ltr dtd 20 Sep 17 ICO XXXXXXXXXXXXXXXXXX, former USMC
	(e) PDBR ltr dtd 28 Sep 17 ICO XXXXXXXXXXXXXXXXXX, former USN
	(f) PDBR ltr dtd 20 Sep 17 ICO XXXXXXXXXXXXXXXXXX, former USMC
	(g) PDBR ltr dtd 20 Sep 17 ICO XXXXXXXXXXXXXXXXXX, former USMC
	(h) PDBR ltr dtd 15 Jun 17 ICO XXXXXXXXXXXXXXXXXX., former USN
	(i) PDBR ltr dtd 20 Sep 17 ICO XXXXXXXXXXXXXXXXXX, former USN
	(j) PDBR ltr dtd 5 Sep 17 ICO XXXXXXXXXXXXXXXXXX, former USMC 

1.  Pursuant to reference (a), the recommendations of the Physical Disability Board of Review set forth in references (b) through (j) are approved.  The official records of the following individuals are to be corrected as follows:

     a. XXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 20 percent disability rating (increased from 0 percent) effective date of discharge. 

     b. XXXXXXXXXXXXXXXXXX, former USMC: Placement on the Permanent Disability Retired List with a 30 percent rating (increased from 20 percent) effective date of discharge.

     c. XXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge. 

     d. XXXXXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 40 percent rating (increased from 20 percent) effective date of discharge.

     e. XXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 10 percent disability rating (increased from 0 percent) effective date of discharge. 

     f. XXXXXXXXXXXXXXXXXX, former USMC: Placement on the Permanent Disability Retired List with a 30 percent rating (increased from 20 percent) effective date of discharge.

     g. XXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge.

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS 

     h. XXXXXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 30 percent rating (increased from 10 percent) effective date of discharge.

     i. XXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 10 percent disability rating (increased from 0 percent) effective date of discharge. 
     
3.  Please take action to implement these decisions and provide notification to the above individuals once those actions are complete.

	XXXXXXXXXXXXXXXXXX
	Acting