RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01076
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20041105

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a National Guard 05, Field Artillery Generalist, medically separated for rheumatoid arthritis with a disability rating of 20%.  

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 - 20040526	VARD - 20050223	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Rheumatoid Arthritis	5002	20%	Rheumatoid Arthritis of the Cervical Spine, Bilateral Hands and Wrists	5002	20%	20041019 	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

Rheumatoid Arthritis.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s rheumatoid arthritis (RA) condition (a disease characterized by inflammation of the joints with swelling, pain, and limitation of motion which can cause permanent joint damage if not successfully treated) began in 1998 when he was having trouble sleeping due to neck, shoulder, and knee pain as well as left wrist and other joint pain in a random pattern.  In August 1999, a rheumatoid factor was done and tested positive confirming the diagnosis.  A C-spine X-ray series done 30 September 2003, revealed narrowing posteriorly at several levels in the mid-cervical region.  Right shoulder and left shoulder X-rays in September 2003 were normal.  Despite treatment, the RA condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for MEB.  The 12 November 2003 MEB Internal Medicine (IM) consult examination, 12 months prior to separation, noted complaints of morning stiffness.  His worst symptoms appeared to be in his neck, but occasionally also in his knees.  The examiner noted that the CI had a history of migratory polyarthralgia and polyarthritis over the last several years and had been seeing a Rheumatologist from 1999 to 2003.  He also stated that the RA had involved his bilateral wrists, bilateral knees, both great toes and his and neck.  He also was being treated for suspected unrelated bilateral shoulder rotator cuff problems.  Physical examination in his neck showed some mild decreased range of motion (ROM) with mild right sided spasm.  His shoulders showed a moderate ROM with internal and external rotation.  He was able to raise his arms above his head, but with some difficulty.  His joint examination showed no current hotspots or synovitis. His elbows showed bilateral subcutaneous nodule or densities in the olecranon areas.  His knees showed bilateral Baker's cyst, left greater than right, but no synovitis, and no decreased ROM.  His feet showed varus deformities of both great toes, the left being more so than the right. 

During the 29 April 2004 MEB examination, 6 months prior to separation, the CI reported arthritis with neck, wrists, shoulders, knees and feet pain.  Physical examination showed the CI had tenderness to palpation over his right occipital condyle.  He had mild tenderness to palpation over both shoulders, near the biceps tendons.  Forward elevation was 180 degrees (normal 180) bilaterally; lateral abduction was 0 to 150 degrees (normal 180) bilaterally, with pain at 120 degrees.  Internal rotation was 90 degrees bilateral and external rotation of 75 degrees bilaterally, limited by pain.  There was also mild tenderness to palpation about the right elbow at the lateral epicondyle.  Elbow flexion was 140 degrees (normal 145), pronation/supination was 90 degrees bilaterally.  The right wrist exhibited mild tenderness to palpation over the extensor carpi ulnaris tendon.  Right wrist dorsiflexion was 78 degrees (normal 70), palmar flexion was 65 degrees (normal 80), radial deviation was 30 degrees (normal 20), and an ulnar deviation of 50 degrees (normal 45).  There was a slight decrease in sensation along the ulnar nerve distribution of the right hand and Tinel's test was positive (test for carpel tunnel), right hand, along the median nerve distribution.  Left wrist ROM revealed dorsiflexion of 66 degrees, palmar flexion of 63 degrees, radial deviation of 25 degrees and ulnar deviation of 50 degrees.  Left knee had a mild effusion.  Both knees had ROM of 0 to 140 degrees (140 normal), no tenderness, no warmth and no laxity.  Both feet little toes showed hypertrophy of at the metatarsal phalangeal joints and both great toes had valgus deviation at the interphalangeal joints, left greater than left.  

At the 19 Oct 2004 VA Compensation and Pension (C&P) evaluation, 2 weeks before separation, the CI reported the ongoing issues from RA arthritis with his neck, shoulders, wrists, knees, feet, and shoulders.  Physical examination showed cervical spine normal posture with mild reversal.  Initial pain 2/10 scale reached 4/10 scale of a diffuse type pain.  No spams were detected.  Neck ROM after Deluca repetitions: forward flexion was 0-35 degrees, extension was 0-30 degrees, lateral bending was 0-35 degrees, and rotation was 0-75 degrees.  Bilateral shoulders ROM revealed after repetition, a flexion of 0-180 degrees and an abduction of 0-155 degrees.  Bilateral shoulder strength was decreased at 4/5.  No mention of pain or swelling.  Bilateral elbow flexion was 0-145 degrees, supination was 0-85 degrees and pronation was 0-80 degrees.  On the right elbow, evidence of likely epicondylitis was noted with mild 2/10 pain.  At the posterior aspect of the elbows bilaterally were palpable nodules likely rheumatoid related.  Bilateral wrist movements did cause pain affecting the CI’s ROM with repetition resulting in an extension of 0-50 degrees, flexion of 0-60 degrees, ulnar deviation of 0-35 degrees, and radial deviation of 0-20 degrees.  There was no Tinel sign or de Quervain tenosynovitis bilaterally.  Bilateral knees revealed after repetition a right knee flexion of 0-140 degrees, and the left decreased to 0-130 degrees.  There was no active swelling, no inflammation. ·Medial and lateral cruciate ligaments were stable.  Drawer signs and Lachman and McMurray tests were negative bilaterally.  Feet: big toe and small toe had no evidence of a claw toe or hammertoe.  There was evidence of hallux valgus, especially on the left with a mild 15 degrees and distally the big toe had left lateral deviation by 20 degrees.  No active swelling.  No inflammation, but there was swelling present more likely secondary to the rheumatic condition.  Toe joint area pain was noted.  Big toe extension was 0-20 degrees, flexion was 0-10 degrees.  With repetition ROM decreased in extension to 0-15 degrees and in flexion to 0-5 degrees bilaterally.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the RA condition 20%, coded 5002 (arthritis rheumatoid), citing neck involvement and shoulder pain that prevented wearing Kevlar, backpack and LBE.  Physical profile limitations were extensive and unfitting.  The VA also rated the RA condition 20%, coded 5002, based on the C&P examination 1 month before separation, citing one or two exacerbations a year in a well-established diagnosis.  The panel agreed that a 20% rating was justified based on one or two exacerbations a year in a well-established diagnosis coded 5002.  A higher rating of 40% was not justified in this case based on symptom combinations productive of definite impairment of health objectively supported by examination findings or incapacitating exacerbations occurring 3 or more times a year.  Per the VASRD 4.71a, chronic residuals such as limitation of motion or ankylosis, favorable or unfavorable, rate under the appropriate diagnostic codes for the specific joints involved.  Where, however, the limitation of motion of the specific joint or joints involved is non-compensable under the codes a rating of 10% is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under diagnostic code 5002.  Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion.  Therefore the panel considered separately rating the involved joints based on this criteria.  All panel members agreed that the C-spine and bilateral shoulders were separately unfitting, with unfitting limitations implicated by the PEB as well as the profile.  Panel members further agreed there was a limitation of motion of the C-spine based on both the IM and C&P examinations with muscle spasm and pain respectively supporting a 10% rating coded 5002-5242 (degenerative arthritis of the spine).  The panel also agreed that both the left and right shoulders had a demonstrated limitation of motion on both the IM and C&P examinations with pain clearly shown on the former for a 10% rating each coded 5002-5201 (arm, limitation of motion).  The panel majority concluded that the right elbow, right wrist, left knee, left foot, and right foot were not in scope and therefore not considered for rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the C-spine, coded 5002-5242; 10% for the left shoulder coded 5002-5201; 10% for the right shoulder coded 5002-5201.  

BOARD FINDINGS:  In the matter of the C-spine RA condition, the panel unanimously recommends a disability rating of 10%, coded 5002-5242 IAW VASRD §4.71a.  In the matter of the left shoulder RA condition, the panel unanimously recommends a disability rating of 10%, coded 5002-5201 IAW VASRD §4.71a.  In the matter of the right shoulder RA condition, the panel unanimously recommends a disability rating of 10%, coded 5002-5201 IAW VASRD §4.71a.  The single voter for dissent submitted the appended minority opinion.  There are no other conditions within the panel’s scope of review for consideration.  

panel 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	
Rheumatoid Arthritis, C-spine	5002-5242	10%	
Rheumatoid Arthritis, Left  Shoulder	5002-5201	10%	
Rheumatoid Arthritis, Right Shoulder	5002-5201	10%	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160928, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

MINORITY OPINION:  

The minority dissent with the majority recommendation is based on the totality of the evidence from the STR as accurately portrayed in the above proceedings.  Based on a preponderance of this evidence, the minority member opines that the CI met the criteria for a 60% rating.  The majority vote favored a 30% rating for the RA condition with ratable manifestations in the neck and bilateral shoulders because these joints were directly or indirectly alluded to in the CI’s profile, commander’s letter, and specifically mentioned by the PEB.  The majority excluded the other RA involved joints solely because they were not specifically contended by the CI.  The minority member believes that the CI meets the criteria for 60% based on the following evidence.  The CI made no specific contention on his DD Form 294 to the Board.  He was separated by the PEB with the following statement as the basis for discharge:  “Rheumatoid arthritis, onset 1998, while on full time National Guard duty, manifested by migratory polyarthralgia and polyarthritis involving the neck and extremities with positive rheumatoid factor.  Neck involvement and shoulder pain prevent wearing Kevlar, backpack and LBE, physical profile limitations are extensive and unfitting (MEB Dx 1 & NARSUM).”  The MEB also listed, in addition to rheumatoid arthritis, the following: 2. Rotator cuff tendinitis of both shoulders; 3. Recurrent left knee synovitis; 4. DJD, feet; 5. Right elbow epicondylitis; 6. Mild carpal tunnel syndrome, right hand; and 7. Spondylosis, C-spine.  Each of these conditions was directly related to the underlying RA condition as enumerated throughout the STR and NARSUM.  Rheumatoid arthritis is an autoimmune disorder which occurs when an individual’s immune system mistakenly attacks their own body's tissues.  This chronic inflammatory disorder can affect the lining of joints on both sides of the body, such as both hands, both wrists, or both knees with swelling, pain, and limitation of motion, that can eventually result in bone erosion and joint deformity.  This symmetry helps to set it apart from other types of arthritis.  Thus, by definition, RA can and often does involve numerous joints in the patient’s body.  All members agreed that the 20% criteria was met in this case for 5002 Arthritis rheumatoid (atrophic) as an active process based on one or two exacerbations a year in a well-established diagnosis.  However, the VASRD goes on to state for RA that for residuals such as limitation of motion or ankylosis, favorable or unfavorable, rate under the appropriate diagnostic codes for the specific joints involved.  Where, however, the limitation of motion of the specific joint or joints involved is non-compensable under the codes a rating of 10% is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under diagnostic code 5002.  Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion.  Note: The ratings for the active process will not be combined with the residual ratings for limitation of motion or ankylosis.  Assign the higher evaluation.  Based on VASRD §4.7, Higher of two evaluations, where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating.  Otherwise, the lower rating will be assigned.  The panel unanimously believes that the PEB applied the first part of the VASRD definition for a 20% RA rating but failed to apply the second part for rating the residuals which were clearly listed by the MEB and discussed at length in the STR and NARSUM.  The majority then applied the appropriate limitation of motion rating to the CI’s shoulders and neck for an overall 30% rating.  The minority member understands that the CI did not specifically contend each involved joint to the PDBR but did so in his NARSUM examination.  To this member, this oversight is clearly understandable because each of the CI’s joint problems was directly related to the underlying diagnosis of RA.  Also, the PEB seems to concur by stating that the CI’s RA was “manifested by migratory polyarthralgia and polyarthritis involving the neck and extremities with positive rheumatoid factor” as the basis for their disability description.  Thus, the minority member believes that all joints that had a demonstrated limitation of motion with associated pain, swelling or muscle spasm should be rated.  The right elbow, right wrist, left foot, and right foot each met this criteria.  The minority member offers no dissent with the panel conclusion that the §4. 71a threshold for a minimum 30% rating was reasonably satisfied in this case; since, there was evidence from multiple providers and was specifically listed by the PEB as disqualifying.  However, the minority member believes that additionally the right elbow, right wrist, left foot, and right foot should be considered within the scope of the overall RA diagnosis and that each be rated as chronic residuals and added to the above overall calculations.  The minority member contends that there was a limitation of motion of the right elbow based on the C&P examination with pain supporting a 10% rating coded 5002-5209 (elbow, other impairment).  The minority member contends that the right wrist should be rated 10% for demonstrated limitation of motion on the C&P examination with pain coded 5002-5215 (wrist, limitation of motion).  Per the STR both feet had involvement of the MCP joints and the interphalangeal joints including X-ray evidence of degenerative changes of the great toes.  Each are considered groups of minor joints, ratable on a parity with major joints.  The minority member contends that both feet great toes demonstrated pain and swelling with demonstrated limitation of motion on the C&P examination to justify a rating of 10% as a group of minor joints for each foot coded 5002-5281 (hallux rigidus, unilateral, severe).  Consistent with the DoDI 6040.44 standard of recommendations that are fair and equitable to both the Service and the CI, the Secretary is respectfully requested to consider the minority recommendation that the CI’s discharge with severance pay be re-characterized to reflect an overall permanent 60% disability retirement per the table below.  

CONDITION	VASRD CODE	PERMANENT RATING	
Rheumatoid Arthritis, C-spine	5002-5242	10%	
Rheumatoid Arthritis, Left  Shoulder	5002-5201	10%	
Rheumatoid Arthritis, Right Shoulder	5002-5201	10%	
Rheumatoid Arthritis, Right Elbow	5002-5209	10%	
Rheumatoid Arthritis, Right Wrist	5002-5215	10%	
Rheumatoid Arthritis, Left Foot	5002-5281	10%	
Rheumatoid Arthritis, Right Foot	5002-5281	10%	
COMBINED	60%	

AR20170018536, XXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX

	I accept the recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) to recharacterize your separation as a disability retirement with the combined disability rating of 30% effective the date of your medical separation for disability with severance pay.  Enclosed is a copy of the Board’s recommendation and record of proceedings for your information.

	The recharacterization of your separation as a disability retirement will result in an adjustment to your pay providing retirement pay from the date of your original medical separation minus the amount of severance pay you were previously paid at separation.
 
	The accepted DoD PDBR recommendation has been forwarded to the Army Physical Disability Agency for required correction of records and then to the U.S. Defense Finance and Accounting Service to make the necessary adjustment to your pay and allowances.  These agencies will provide you with official notification by mail as soon as the directed corrections have been made and will provide information on your retirement benefits.  Due to the large number of cases in process, please be advised that it may be several months before you receive notification that the corrections are completed and pay adjusted.  Inquiry concerning your correction of records should be addressed to the U.S. Army Physical Disability Agency, (AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557.

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

Sincerely,	
Enclosure