DEPARTMENT  OF THE NAVY
SECRETARY OF THE NAVY COUNCIL OF REVIEW BOARDS
·	720 KENNON STREET SE STE 309 WASHINGTON NAVY YARD DC 20374-5023

IN REPLY REFER TO

1850
CORB:003
12 Feb 20

From: To:

Director, Secretary of the Navy Council of Review Boards 
PD-2017-00582

Subj:	PHYSICAL DISABILITY BOARD OF REVIEW (PDBR)

Ref:	(a) DoDI 6040.44
(b) PDBR ltr dtd 4 Feb 19

1.	Pursuant to reference (a), the_ PDBR reviewed your case and forwarded its recommendation (reference (b)) to the Department of the Navy of 15 October 2019 for appropriate action.

2.	On 31 January 2020, the Assistant S cretary of the Navy (Manpower & Reserve Affairs) accepted the recommendation of the PDBR of no change to your characterization of separation or disability rating assigned by the Department of the Navy's Physical Evaluation Board.

3.	The Secretary's decision on your PDBR application is final and is not subject to appeal or additional review by the Board for Correction of Naval Records.

RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXXX		CASE: PD-2017-00582 BRANCH OF SERVICE: MARINE CORPS	SEPARATION DATE: 20080630

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E3, Rifleman, medically separated for “reactive arthritis” with a disability rating of 20%.

CI CONTENTION: No specific contention was made.  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 PEB to be unfitting for continued military service, and when specifically requested by the CI, those conditions identified by the Medical Evaluation Board (MEB), but determined by the Physical Evaluation Board (PEB) 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. The panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections when appropriate. The panel’s assessment of the PEB rating determination is based on review of medical records and all available evidence relevant to application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards for 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, which operates 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 disability at the time of separation.

RATING COMPARISON:

SERVICE PEB - 20080429	VARD - 20080421	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Reactive Arthritis	5009-5242	20%	Reactive Arthritis Conditions Below	
[Bilateral] Foot Pain	
Cat II	Right Foot Reactive Arthritis	5009-5284	10%	
20080303	
		Left Foot Reactive Arthritis	5009-5284	10%		
[Bilateral] Ankle Pain		Right Ankle Reactive Arthritis	5009-5271	10%		
		Left Ankle Reactive Arthritis	5009-5271	10%		
Lumbago		Lumbar Spine Reactive Arthritis	5009-5242	20%		
COMBINED RATING: 20%	COMBINED RATING OF ALL VA CONDITIONS: 50%	

ANALYSIS SUMMARY:

Reactive Arthritis. According to the service treatment record and MEB narrative summary (NARSUM), the CI’s reactive arthritis began in November 2006 as left knee pain and swelling, which came on fairly quickly over 2-3 days. There was no prior injury, illness, travel, insect or tick exposures, no contacts with any ill person, no blood transfusions, and no tattoos, and the CI

denied any skin rash or new nodules. An MRI in December 2006 demonstrated a large effusion and chondromalacia of the lateral femoral condyle as well as the medial patellar facet. An aspiration of the knee in January 2007 revealed no growth on culture and no crystals. The right knee became painful and swollen in early January 2007 with less prominent symptoms than the left knee. He did note that his hands and forearms had been tender for a few weeks, but the symptoms resolved thereafter. Nonsteroidal anti-inflammatory drugs (NSAIDs) did not provide relief and a short course of prednisone in February 2007 was not tolerated.

A chest X-ray on 22 February 2007 showed punctate dense nodules in the upper lungs, which likely represented old calcified granulomatous disease. Treatment with penicillin for 10 days was carried out based on a positive ASO titer and throat culture for non-group-A beta hemolytic streptococcus. At a rheumatology clinic visit in March 2007 there were moderate to large effusions present, left greater than right with tenderness along the medial joint line. The rheumatologist favored a reactive arthritis as the most likely etiology, but could not rule out an unusual rheumatoid arthritis presentation or an early manifestation of a yet undifferentiated connective tissue disease.

An MRI of the left knee dated 27 April 2007 demonstrated thickening and enhancement of the knee joint capsule consistent with synovitis, which could be seen with reactive arthritis as well as inflammatory arthropathies or chronic infection. There was also fissuring of the articular cartilage of the medial and lateral patellar facets. Indomethacin (an NSAID) was not tolerated nor helpful. Treatment with DMARD (disease modifying antirheumatic drug) therapy was instituted with methotrexate and folic acid in May 2007 and the dose was titrated up to 17.5 mg daily, which the CI tolerated without apparent adverse drug effects and he had reasonable control of his symptoms. He additionally underwent physical therapy. X-rays of the pelvis dated 31 October 2007 were suggestive, but not diagnostic of sacroiliac sclerosis on the left. Weight bearing X-rays of the knees on the same day showed a large right knee effusion and a small left knee effusion. In late 2007/early 2008, he noted mild to moderate lower back pain and had tenderness over the sacroiliac joints bilaterally. An MRI of the pelvis dated 18 January 2008 revealed no evidence of sacroiliitis and minimal heterogeneity of the superior fibrous portion of the sacroiliac joints bilaterally. In February 2008 he denied significant swelling or warmth in his knees and his range of motion (ROM) was full. Nevertheless, he noted mild to moderate discomfort in his knee joints, right greater than left.

The 4 February 2008 MEB NARSUM examination, 5 months prior to separation, noted complaints of reactive arthritis. Physical examination showed a well-developed CI in no acute distress, who was alert and oriented. The upper extremities demonstrated full ROM without swelling, tenderness, or warmth throughout. The lower extremities were remarkable for a minimal effusion at the right knee, which was slightly warm to the touch and tender along the medial joint line. The left knee was unremarkable as were the hips, ankles and feet, all of which demonstrated full ROM without swelling, tenderness, or warmth. Painful motion was not addressed. There was no enthesitis (inflammation at the sites where tendons or ligaments insert into the bone) and no dactylitis (inflammation of digits (fingers or toes)). There was normal ROM of the back without painful motion being addressed, but with mild bilateral sacroiliac joint tenderness. There was no skin rash, lesions, or nodules. Laboratory studies including a complete blood count, rheumatoid factor, HLA-B27, CCP-IgG (cyclic citrullinated peptide antibodies IgG), Lyme titer, RPR (rapid plasma regain), ANA (antinuclear antibody) screen, hepatitis B and C, and ACE (angiotensin converting enzyme) were all within normal limits; however, parvovirus B19 IgG titer was elevated. The examiner indicated the CI’s course of reactive arthritis was more consistent with  a chronic persistent arthritis since it lasted more than 6 months, was geographically limited, and his medication required frequent monitoring due to side effects.

The non-medical assessment (NMA) dated 15 February 2008 did not mention the back, knees or feet, but instead noted the service member’s “injury makes him ineligible to carry out the duties

required of him by both his MOS and  general duties as  a Marine.”   X-rays of both ankles on     3 March 2008 were normal.

At the 21 April 2008 VA Compensation and Pension (C&P) examination, 4 months before separation, the CI noted complaints of persistent pain in the bilaterally in the knees, ankles and sacroiliac joint areas with a diagnosis of reactive arthritis. He also had persistent pain in the mid plantar and mid dorsum of the foot, but had no complaints referable to the arms or hips. The condition was not incapacitating and he was able to function and perform his daily activities as well as remain employed. Physical examination showed a well-developed man in no distress with a normal gait without the use of any support device. No skin lesions were present. There was no tenderness over the lower back or sacroiliac areas and no muscular spasm. Flexion was 50 degrees (normal 90) and the combined ROM was 170 degrees (normal 240). There was no pain with repetition or weakness, fatigability, decreased endurance, or incoordination. No motor or sensory abnormalities were noted. There was no tenderness of the knees or deformities, but there was slight swelling in the right, but not the left knee. Flexion was 110 degrees (normal 140) and extension 0 degrees (normal); there was no pain with repetition. The CI had bilateral shallow arches of the feet with tenderness over the mid plantar foot area bilaterally and there was no pain with repetition. There was no tenderness, swelling, or deformities of the ankles. Dorsiflexion of the ankles was 20 degrees (normal) and plantar flexion 40 degrees (normal 45), inversion 5 degrees, and eversion 0 degrees. No painful motion was reported. There was no tenderness, swelling or deformities of the arms and hips. Both femurs rotated freely. There was no pain with repetition. X-rays of the knees showed joint space narrowing; X-rays of the ankles and feet were normal.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the reactive arthritis condition 20%, analogously coded 5009-5242 (arthritis, other types-degenerative arthritis of the spine). The PEB listed foot pain, ankle pain, and lumbago as related Category II conditions as related diagnoses to the unfitting reactive arthritis, which contributed to the disability in this case. The panel agreed that all of these conditions were diagnoses related to the reactive arthritis and were not separate conditions which could be separately rated IAW §4.14 (avoidance of pyramiding; more than one rating based on the same impairment is prohibited). The VA rated the right and left foot reactive arthritis conditions 10% each, both analogously coded 5009-5284 (arthritis, other types-foot injuries, other), based on the C&P examination, citing tenderness to palpation, which most approximated the rating criteria or for moderate symptoms. The VA also rated the right and left ankle reactive arthritis conditions 10% each, both analogously coded 5009-5271 (arthritis, other types-ankle, limited motion), based on the C&P examination, citing limited plantar flexion motion. The VA rated the lumbar spine reactive arthritis conditions 20%, analogously coded 5009-5242 (degenerative arthritis of the spine), based on the C&P examination, citing forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees.

Panel members noted first and foremost that the CI’s working diagnosis was a reactive arthritis, although despite extensive laboratory studies, the etiology was not determined. Panel members then reviewed the PEB’s JDETS document where the coding for the reactive arthritis was listed as 5099-5002. However there was a penciled note that indicated the “VA to rate.” On reconsideration the PEB rated 20% using code 5009-5242 as noted above. According to the VASRD code 5009 (arthritis, other types (specify)), which in this case is reactive arthritis, the disability is to be rated as rheumatoid arthritis (code 5002). A 20% rating requires “one or two exacerbations a year in a well-established diagnosis,” while a 40% rating requires “symptom combinations productive of definite impairment of health objectively supported by examination findings or incapacitating exacerbations occurring 3 or more times a year.”

A 20% rating using code 5002 offers no benefit to the CI; therefore the panel members discussed whether his disability warranted  a 40% rating.           The question that the panel pondered was

whether proximate to separation the CI’s symptoms related to his back, ankles and feet taken together rise to the level of definite impairment of health objectively supported by examination findings. The facts are that the CI had decreased ROMs of the back and knees with slight swelling of the right knee, which was not specifically in the scope of review, but still a finding of the reactive arthritis, along with a very slight decrease in plantar flexion of the ankles and tenderness of the plantar aspects of the feet while on methotrexate and folic acid. However, there were insufficient symptoms relating to the back, ankles, and feet taken together to rise to the level of definite impairment of health objectively supported by examination findings since the methotrexate and folic acid reasonably controlled the symptoms, albeit he still had some pain.

Panel members also considered rating the residuals of the reactive arthritis as did the VA. However, the panel has to determine whether the back, each ankle, and each foot was separately unfitting, but the NMA does not offer sufficient guidance to separate out the foot pain, ankle pain, or the lumbago. Therefore, each of the aforementioned conditions cannot be objectively determined to be separately unfitting or not, but all are in actuality Category II conditions that are components of and contributed to the all-encompassing diagnosis of reactive arthritis. The panel noted that the correct code should be 5009-5002 IAW with the VASRD; however, the PDBR does not alter the rating code unless there is a change of rating, which in this case warrants the PEB’s already adjudicated 20% rating, and no higher. After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded there was insufficient cause to recommend a change in the PEB adjudication for the reactive arthritis condition.

BOARD FINDINGS: In the matter of the reactive arthritis condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication. There are no other conditions within the panel’s scope of review for consideration. Therefore, the panel recommends 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 20170214, w/atchs Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record