RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-02211
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20070625

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Motor Transport Operator, medically separated for “spondyloarthropathy” 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 Physical Evaluation Board (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 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 - 20070604	VARD - 20070904	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Joint Pain in the Ankles, Toes, Fingers, Wrists, Elbows, Knees and Back Secondary to HLA-B27 Positive Undifferentiated Spondyloarthropathy	5099-5002	20%	Polyarthropathy from Rheumatoid Arthritis Lumbosacral Spine	5002	10%	20070802	
			Uveitis Left Eye Associated with Polyarthropathy 	6000-6079	10%	20070802	
			Polyarthropathy Bilateral Knees	5002	0%	20070802	
			Polyarthropathy Fingers	5260-5002	0%	20070802	
			Polyarthropathy Bilateral Ankles 	5271-5002	0%	20070802	
			Polyarthropathy Bilateral Wrists	5215-5002	0%	20070802	
			Polyarthropathy Bilateral Elbows	5206-5002	0%	20070802	
			Polyarthropathy Bilateral Toes	5002	NSC	20070802	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Bilateral Joint Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI sprained his left ankle in 2003 and was evaluated for a recurrent iritis in 2005.  He was found to be HLA B-27 positive (increases likelihood of inflammatory arthritis) and was referred to rheumatology, but deployed prior to his appointment.  Due to ongoing arthritic symptoms, he was evacuated from theater and returned to his home station to complete his evaluation.  He was subsequently diagnosed with an undifferentiated spondyloarthropathy (inflammatory process primarily involving the spine).  

Ankle X-rays on 21 February 2007 were normal on the left and showed an old fracture on the right.  At a rheumatology evaluation on 23 February 2007, the CI reported discomfort in his back, knees, ankles and feet, with initial difficulty walking in the morning.  The examination showed decreased neck rotation and flexion and possible dactylitis (sausage digit) of the right fourth toe.  A test for lumbar spine ankylosis was negative, and the provider assessed an inflammatory spondylopathy and recommend systemic treatment.  The CI was seen in optometry on 8 March 2007 for an evaluation of possible uveitis (inflammation of part of the lining of the eye which includes the iris).  He was asymptomatic, but used steroid drops, and near and distant vision were corrected to 20/20 bilaterally.  Pigmentation of the lens was present from a prior inflammation, and tapering of the steroid drops was recommended along with discontinuation of another medication.  A lumbar spine MRI on 27 March 2007 was normal, but ankle MRIs the same day showed inflammation and evidence of old trauma on the right, and tenosynovitis on the left.  

During the 2 April 2007 MEB examination (recorded on DD Forms 2807-1 and 2808), 2 months prior to separation, the CI reported back and right foot pain, headaches with the uveitis during flares, swelling of the ankles and feet, and tingling and osteoarthritis of the feet.  Physical examination revealed reduced lower extremity strength recorded as 2/5 (which implies that movement is possible, but not against gravity).  The MEB NARSUM examination, on the same day, noted CI complaints of bilateral ankle pain aggravated by activity, but no morning stiffness.   The provider documented a normal gait (inconsistent with a 2/5 limitation in function) and full range of motion (ROM) of all joints and tenderness only along the ankle joint line.  Chest expansion was normal and dactylitis was absent, as was inflammation of the fascia and other tendons.  An eye examination showed vision correctable to 20/20 bilaterally.  The CI was thought to have an undifferentiated spondyloarthropathy and continued used of Methotrexate (immune modulator) was recommended.  

In physical therapy (PT) on 20 April 2007, ankle dorsiflexion was 11 degrees on the right (normal 20) and 14 degrees on the left.  Plantar flexion was 31 degrees on the right (normal 45) and 29 degrees on the left; all limitations were due to pain.  In orthopedics on 30 April 2007, the CI reported an atraumatic history of left and right ankle pain as well as low back pain, aggravated by activity and improved with medications including Methotrexate.  On examination, back and ankle motion was painful, but limitation, if any, was not recorded.  There was ankle and bilateral foot tenderness, with gait was recorded as “normal foot and ankle.”  Osteoarthritis of both ankles was diagnosed.  An X-ray showed mild sclerosis of the right sacroiliac joint.  An orthopedic addendum to the NARSUM on 1 May 2007 showed decreased ROM of the spine (not quantified), but full ROM of the extremities including the ankles.  

The CI was again seen in rheumatology on 8 May 2007 and reported improvement on Methotrexate with resolution of swelling, but persistent morning stiffness of the ankles.  Examination of the fingers, wrists, elbows, knees, ankles, and toes was unremarkable other than tenderness of the left great toe joint; the Methotrexate dosage was increased.  During a PT evaluation on 24 May 2007, back flexion was 80 degrees (normal 90) and combined thoracolumbar ROM was 165 degrees (normal 240), limited by pain.  
At the 2 August 2007 VA Compensation and Pension (C&P) examination, 6 weeks after separation, the CI reported low back pain for the prior 2 years, as well as knee, elbow, wrist and finger pain; he denied pain in his toes.  He noted a diagnosis of rheumatoid arthritis (not the actual diagnosis), but denied that this caused any incapacitation.  Physical examination revealed a normal posture and gait, normal skin, and no signs of uveitis.  Lumbar spine flexion was limited to 80 degrees (normal 90) by pain, but ROM was otherwise normal.  Bilateral knee, ankle, elbow, wrist, and finger ROM was full and pain-free.  Strength and sensation were normal and atrophy absent.  Multiple joint X-rays showed traumatic changes of the right ankle and mild arthritic changes of the right great toe (opposite the side which had been tender previously), but normal lumbar spine, elbows, wrists and fingers.  The provider estimated that there would be no additional limitation in function in a flare of any of these joints.  The C&P eye examination on 24 August 2007, 2 months after separation noted corrected distant visual acuity was 20/20 on the right and 20/50 on the left.  The pigmentary changes of the left lens were noted, but the evaluation was otherwise unremarkable.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the spondyloarthropathy 20%, analogously coded 5099-5002 (rheumatoid arthritis), citing joint pain in the ankles, toes, fingers, wrists, elbows, knees and back secondary to the undifferentiated spondyloarthropathy.  The PEB also noted “several episodes of uveitis,” and while there was no significant loss of joint motion, “…synovitis of the ankles, back, and upper extremity…are unfitting…” Osteoarthritis of the right ankle was not specifically commented upon.  The VA rated the spondyloarthropathy 10%, coded 5002, and the uveitis 10%, dual coded 6000-6079 (choroidopathy, including uveitis-impaired vision) for a combined rating of 20%, based on the C&P examination, citing limited back flexion and 20/50 vision.  Members noted that there is no specific VASRD code for spondyloarthropathy, but code 5002 allows rating for either systemic manifestations or for residuals.  Systemic manifestations include health impairment demonstrated by weight loss, anemia, or severe incapacitation, however, the CI was actually gaining weight the last year of active service, was not anemic and was not incapacitated.  Systemic signs of inflammation, including erythrocyte sedimentation rate and C-reactive protein, were also absent.  Thus, a rating higher than 20% is not supported by the records in evidence.  The panel then considered all joints and individual residuals for separately unfitting conditions.  

Multiple ocular examinations prior to separation documented visual acuity of 20/20 in both eyes.  The VA examination noted a distant visual acuity of 20/50 on the left, however, this is not compensable when coupled with normal vision on the right.  While the PEB cited uveitis, the last recorded flare was in May 2005, 2 years prior to separation.  Under code 6000, a 10% rating is warranted for the presence of incapacitation; however, this was not documented.  A 20% rating under code 5002 stipulates 1-2 flares a year, but STR documented 2 flares just over 2 years apart.  Therefore, a separate compensable rating for the eye condition is not supported by the evidence.  

Bilateral ankle MRIs showed evidence of synovitis, and X-rays revealed an old fracture on the right, but no evidence of arthritis of either ankle.  All but one examination showed full ROM, and painful motion was mentioned during some tests; incapacitation was not present.  Members agreed that a 10% rating for both ankles is supported under code 5003 (degenerative arthritis) as a residual condition, and next considered whether the ankle osteoarthritis was separately unfitting from the undifferentiated spondyloarthropathy.  The PEB subsumed the ankle condition under the unfitting undifferentiated spondyloarthropathy, and while the NARSUM indicated that the CI was referred into the MEB system (by the rheumatologist) due to the use of Methotrexate, the ankle osteoarthritis was noted to be medically unacceptable by the MEB, profiled, and implicated by the commander as impairing duty.  The panel majority determined that the evidence supported a finding that the ankles were separately unfitting at separation.  Because ROM was normal other than during one PT evaluation, and tenderness was present, a 10% rating is supported for the ankles (combined, not each) under code 5003 as a separately unfitting condition.  
Right sacroiliac joint X-rays showed pathology and flexion limited to 80 degrees, supporting a 10% rating as a separate residual.  The panel then considered whether the back was separately unfitting, noting it was found to be medically unacceptable by the MEB and profiled, although not commented upon by the commander.  Analogous to the reasoning for the ankles, the panel majority determined that the back was separately unfitting at separation and that the limitation in flexion supported a 10% rating, coded 5236 (sacroiliac injury or weakness).  

Left great toe tenderness was present on one examination, but X-rays showed pathology on the right side; other examinations were unremarkable.  Additionally ROM and X-rays of the knees, elbows, wrists, and fingers were normal.  Therefore, members agreed that there was no compensable rating under codes specific for any of these joints.

The panel noted that the 10% ratings for the back and bilateral ankle conditions combined to 20%, whether rated as residuals under the 5002 code or as separately unfitting conditions.  However, if rated separately, the remaining conditions of the unfitting spondyloarthropathy did not demonstrate 1-2 flares a year and a non-compensable rating is supported, providing no rating advantage to the CI.  After due deliberation, considering all of 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 spondyloarthropathy.  

BOARD FINDINGS:  In the matter of the bilateral joint pain due to spondyloarthropathy 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 20170404, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20180010724, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found your separation disability rating and your separation from the Army for disability with severance pay to be accurate.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed), and I accept its recommendation.  I regret to inform you that your application to the DoD PDBR is denied.  

	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.

Sincerely,					      
Enclosure