RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00648
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20041210 

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E7, Pharmacy Specialist, medically separated from the Temporary Disability Retired List (TDRL) for “psoriatic arthritis” with a disability rating of 0%.

CI CONTENTION:  “Please review all conditions.”  The CI’s 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 - 20041110	VARD - 20030305	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Psoriatic Arthritis	7899-7816	0%	Psoriatic Arthritis, Lumbar Spine	5002-5292	20%	20030211	
			Psoriatic Arthritis, Left Hand 	5221-5002	10%		
			Psoriatic Arthritis, Right Hand		10%		
			Psoriatic Arthritis, Right Wrist	5215-5002	10%		
			Psoriatic Arthritis, Left Wrist		10%		
			Psoriatic Arthritis, Right Foot	5271-5002	10%		
			Psoriatic Arthritis, Left Foot	5215-5002	10%		
			Psoriatic Arthritis, Right Knee	5260-5002	0%		
			Psoriatic Arthritis, Left Knee		0%		
Obstructive Sleep Apnea	Not Unfitting	Sleep Apnea	6847	50%		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  80%	

ANALYSIS SUMMARY:  

Psoriatic Arthritis.  According to the service treatment record (STR) and the TDRL placement Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s arthritis condition began in 1986, but the psoriatic arthritis diagnosis was first considered in 1999.  In May 2001, the CI was diagnosed with psoriatic arthritis and osteoarthritis by a rheumatologist.  The CI was treated by a rheumatologist with methotrexate (a disease modifying drug) and oral steroids but continued with daily pain and swelling of the hands and feet with occasional pain of the elbows and knees as well.  The CI was found unfit and placed on the TDRL in June 2002.  

A 30 July 2002 rheumatology examination, 28 months before separation, noted that the CI was seeking to establish care to continue the Remicade treatments (an additional disease modifying drug) which had been recently added to the CI’s treatment regime.  He reported his wrists were his worst joints with pain graded 2/10 and morning stiffness that lasted one hour.  Physical examination showed no skin rash.  There was no lymphadenopathy.  Examination of the heart, lungs, and abdomen was normal.  There was diffuse puffiness of the hands bilaterally.  Wrists were affected bilaterally.  With right wrist flexion 60 degrees and extension 40 degrees and left wrist flexion 55 degrees and extension 40 degrees.  Elbows were “good” and shoulders “fine”, hips “moved well,” knees showed “no fluid.”  Ankles were “modestly warm” and there was tenderness with squeezing of the metatarsophalangeal joints bilaterally.  The rheumatologist noted that the most recent X-rays were consistent with inflammatory arthritis with erosive changes of the small joints of the hand.  

At a 3 September 2002 rheumatology visit, 27 months before permanent separation the CI reported a recent treatment with Remicade went well.  He reported increased foot and hand pain recently but was unsure if related to a recent change in geography and weather.  He graded his pain level 2/10 and was feeling better overall.  He had been exercising more and had lost some weight which he had gained while on steroids.  Physical examination showed the right index finger was “quite swollen.”  The CI was unable to touch the palm of his hand, but the examiner noted the CI was much improved from his previous examination.  

At the 11 February 2003 VA Compensation and Pension (C&P) evaluation, performed 22 months before separation, the CI was on methotrexate and Remicade.  The CI reported his hands, wrists, and feet were his worst joints with a pain scale of 4/10 and morning stiffness lasting 2 hours.  Physical examination showed no skin rash.  There was good ROM of the cervical spine and shoulders.  There was full elbow extension with “limited full flexion”, with arthralgia and full extension 140 degrees limited.  Diffuse puffiness of both wrists and dorsum of the hand.  Right wrist flexion 60 degrees and extension 45 degrees.  Left wrist limited to 40 degrees flexion and 35 degrees extension.  There was 1+ swelling and tenderness of the second and third metacarpal joints bilaterally.  The CI could not “make full grip due to involvement of the MCP joint and his synovitis in his second, third, and fourth PIP joints and first IP joints bilaterally.   There was full ROM of the hips.  There was full extension of the knees of 135 degrees flexion with arthralgia.  There was no warmth, but there was tenderness to palpation and a question of left knee effusion.  The ankle showed no active synovitis with 10 degrees dorsiflexion.  The CI had hammertoe deformities of the fourth MTP joints.  There were no psoriatic skin lesions or nail changes.  There was limited lumbar flexion of 45 degrees (normal lumbar flexion 60 degrees/normal thoracolumbar flexion 90 degrees) with bilateral sacroiliac tenderness.  Radiographs of the wrists, hands and feet were interpreted by the radiologist as showing evidence of degenerative arthritis, but no definitive evidence of inflammatory arthritis.  Sacroiliac joint X-rays were normal and the visualized part of the lower lumbar spine was normal.  

At the 27 January 2004 rheumatology examination, 10 months before separation, the CI reported feeling well for 2 to 3 weeks, followed by feeling “achy” for 2 to 3 weeks “not pain, but just more crummy” and questioned if it was the timing of his medications.  He graded his pain level as 3/10.  Physical examination showed “excellent range of motion of the fingers.”  Wrist ROM was right wrist flexion 50 degrees and extension 35 degrees and left wrist flexion 35 degrees and extension 30 degrees.  Laboratory studies including bone marrow, liver and kidney function were normal.  The examiner’s assessment was that the CI was doing well on his medications “but still some achy six [symptoms].”  
The 3 September 2004 TDRL NARSUM examination, 3 months before separation, the CI reported morning stiffness involving the wrists, hands, ankles, and knee joints that lasted 2 to 3 hours.  He remained on methotrexate and Remicade for disease management, and anti-inflammatory medication for pain.  He reported increased joint pain since his methotrexate dose was reduced and the Remicade added.  He experienced nausea with methotrexate treatments (once every 2 weeks).  He was attending school full time.  He reported that he used to be very active with sports, but decreased his activities due to the arthritis.  Physical examination showed a normal gait.  Examination of the skin, heart, lungs and abdomen was normal.  The CI was right-handed.  The bilateral wrist joints were “slightly swollen” without limitation of motion noted.  There was no limitation of motion of the elbow, shoulders, hips, knees, or ankles.  Radiographs in February 2003 of the spine, wrists and bilateral feet reportedly showed no evidence of rheumatoid or psoriatic arthritis.  Rheumatologic blood work including rheumatoid factor and anti-nuclear antibody (ANA) tests were negative.  The TDRL examiner indicated that the CI “has no restrictions on his level of activity at this point,” but that the side effects with methotrexate treatment were limiting 

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the psoriatic condition 0%, analogously coded 7899-7816 (psoriasis), citing no radiographic evidence of psoriatic arthritis at the TDRL removal.  The VA rated the psoriatic arthritis condition of the lumbar spine 20% coded 5002-5292 (limitation of lumbar spine motion and rheumatoid arthritis); right and left wrists 10% each, coded 5215-5002 (limitation of wrist motion-rheumatoid arthritis); right and left hands at 10% each, coded 5221-5002 (favorable ankylosis of four digits of one hand-rheumatoid arthritis); right and left feet 10% each, coded 5271-5002 (limited ankle motion-rheumatoid arthritis) on the right and 5215-5002 on the left; and right and left knees 0% each, coded 5260-5002 (limitation of leg motion-rheumatoid arthritis) based on the C&P examination 22 months before separation.  Based on the evidence in record in the year before permanent separation, the CI was doing well since his original psoriatic arthritis diagnosis by a rheumatologist, approximately 4.5 years before permanent separation.  The CI experienced relative waxing and waning of symptoms which he and his treating physicians thought was related to the timing of the cyclic administration of his disease modifying medications, which continued to be adjusted and refined to improve symptom reduction and minimize side effects.  However, there was no evidence of disease flares in the year before separation with symptoms such as marked increase in pain levels, diffusely swollen joints, rash, fatigue, anemia, organ involvement or periods of incapacitation.  The panel therefore considered its rating recommendation for the psoriatic arthritis based on chronic residuals as specified under 5002.  

At the TDRL examination, the examiner noted no limitation of motion of any joint, but indicated the wrists were “slightly swollen.”  The ROM of both wrists were noted to be significantly reduced (even if not ratable greater than 0%) at every other examination in record that addressed wrist ROM.  Even if wrist ROM was within functional limits at TDRL examination, it seems implausible to the panel that it was in fact fully normal given the noted swelling.  The panel recommends there is sufficient support for 10% rating of each wrist.  The TDRL examiner noted no limitation of motion of any other joint, and lent additional support to this observation by indicating the CI had “no restriction on his activity level” at the time of the examination.  The CI required potent medications for control of his inflammatory arthritis condition.  However at the time of the TDRL examination, the arthritis condition was stable with minimal permanent impairment due to chronic residuals in evidence.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends disability ratings of 10% each for the right and left wrist conditions, coded 5215-5002

Contended PEB Conditions.  OSA.  The panel’s main charge is to assess the fairness of the PEB’s determination that the OSA condition was not unfitting at permanent separation.  During active duty the CI was diagnosed with mild to moderate OSA by sleep study and treated with a continuous positive airway pressure device (CPAP).  The OSA condition was determined to be unfitting by the PEB at the time of placement on the TDRL in June 2002.  The 11 February 2003 C&P Joints examination, 22 months before permanent separation, noted the CI was using CPAP for OSA.  At a 7 October 2003 outpatient VA pulmonary visit, 14 months before separation, the CI reported that his CPAP mask broke 6 weeks earlier.  Since he was not using CPAP he noted return of snoring, daytime sleepiness, and morning headaches.  At the evaluation his Epworth sleepiness scale was 4, which was normal (10 or more abnormal).  The examiner noted the CI had mild OSA according to his original sleep study.  The CI had gained weight since his initial diagnosis and the examiner concluded that it was likely that his OSA persisted.  The prescription for CPAP was continued and the CI was given a prescription for a new mask.  

At the 3 September 2004 TDRL evaluation the TDRL examiner noted the CI had not been using CPAP for the past 3 months.  The CI reported his machine was broken and he could not afford to buy a new one.  No current OSA related symptoms were recorded.  Under the diagnoses and plan section, the TDRL examiner indicated the CI needed to go back on CPAP.  In the year before separation there was no evidence that the CI was using CPAP or of impairment due to OSA related symptoms in the absence of using CPAP.  The panel concluded there was not a preponderance of evidence in record to overcome the PEB’s determination that the OSA condition was not unfitting at separation.  After due deliberation, the panel concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the OSA condition and so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the psoriatic arthritis condition, the panel unanimously recommends a disability rating as follows: a 10% rating for the right wrist and 10% rating for the left wrist, both coded 5215-5002 IAW VASRD §4.71a.  In the matter of the contended OSA condition, the panel unanimously recommends no change from the PEB determination as not unfitting.  There are no other conditions within the panel’s scope of review for consideration.  

The panel recommends that the CI’s prior determination be modified as follows, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Psoriatic Arthritis, Right Wrist	5215-5002	10%	
Psoriatic Arthritis, Left Wrist	5215-5002	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160913, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170016336, XXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found that your disability rating should be modified but not to the degree that would justify changing your separation for disability with severance pay to a permanent retirement with disability.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed) and I accept its recommendation.  This will not result in any change to your separation document or the amount of severance pay.  A copy of this decision will be filed with your Physical Evaluation Board records.  I regret that the facts of the case did not provide you with the outcome you may have desired.
  
	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. 

	A copy of this decision has also been provided to the Department of Veterans Affairs.

Sincerely,	
Enclosure