RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-02640
BRANCH OF SERVICE:  AIR FORCE	SEPARATION DATE:  20060905

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Communications Computer System Programmer Journeyman, medically separated for “rheumatoid arthritis” with a disability rating of 20%.   

CI CONTENTION:  No specific contention 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 - 20060721	VARD - 20070505	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Rheumatoid Arthritis	5002	20%	Rheumatoid Arthritis with Bilateral Knee Degenerative Changes	5002	60%	20061229	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  80%	

ANALYSIS SUMMARY:  

Rheumatoid Arthritis (RA).  According to service treatment record (STR) and MEB narrative summary (NARSUM), the CI first sought medical care for global arthralgia in the spring of 2003.  The symptoms resolved after 1 week, however her knee pain remained until May 2005 when global arthralgia symptoms also returned.  Lab tests showed an elevated rheumatoid factor and a rheumatologist initiated treatment with Plaquenil and a non-steroidal medication along with periodic corticosteroids for flares.  

The 2 August 2005 rheumatology examination occurred during a flare-up with the CI complaining of pain that started in the joints and then “moved all over” with an overall rating of 9/10.  She had new right arm and hand pain that significantly limited movement, and described the flare-up as “typical.”  The examiner noted tenderness at the first through fifth metacarpophalangeal joints and second through fifth proximal interphalangeal joints on the right hand, as well as at the radiocarpal and ulnocarpal joints of the right wrist.  The elbows had full range of motion (FROM) without pain, warmth or swelling.  Both shoulders were normal in appearance with moderate trapezius muscle tenderness, but no acromioclavicular joint tenderness.  Bilateral hip and knee ROM was normal and there was no knee effusion, warmth or erythema.  Ankles and foot ROMs were full with no synovitis or pain upon palpation.  Overall muscle tone was normal as was gait, and spinal examination revealed FROM with no deformities or tenderness.  

The 9 August 2005 rheumatology follow-up, 13 months prior to separation, noted CI complaints of joint pain in the right wrist and in both knees and ankles.  Physical examination of the hands revealed FROM with no synovitis, but right wrist tenderness and swelling (1+).  The elbows had FROM without pain, warmth or swelling, and the shoulders appeared normal with no tenderness and a negative impingement test.  Bilateral hip ROM was full with no pain.  The right knee had a small effusion along the anterior aspect of the right thigh and there was right ankle tenderness.  Both feet had full ROM with no synovitis.  The spine examination was within normal limits with no paraspinal tenderness and cervical ROM showed full flexion, extension and rotation.  The CI was assessed with palindromic rheumatism at multiple sites and right knee pain and effusion.  

At the 17 November 2005 rheumatology visit, 10 months before separation, the CI was doing well with no pain or morning stiffness and no flare-ups noted since August 2005.  Physical examination showed spinal ROM within normal limits with no paraspinal tenderness.  Hand and wrist ROM was full with no synovitis, and the elbows had FROM without pain, warmth, or swelling.  Shoulder, hip, knee and ankle ROMs were also all within normal limits and unremarkable with regards to pain, tenderness or effusion.  The examiner concluded the CI had RA functional status Class I, and was completely able to perform usual activities of daily living.

On 2 May 2006, a letter from the CI’s treating rheumatologist, 4 months prior to separation, noted that her symptoms included significant joint pain located primarily in the small joints of the hands, feet, and in the lower back.  July 2005 hand and foot X-rays were referenced and did not show any evidence of erosive disease, while March 2006 X-rays indicated some mild degenerative changes of both knees, right greater than left, but showed a normal spine.  The specialist also noted that the knees had osteoarthritis, but not rheumatoid arthritis, and concluded that the CI’s prognosis was fair based upon continued inflammation and flare-ups involving peripheral joints and her lower back.  The 11 May 2006 MEB NARSUM examination, 4 months before separation, noted no specific complaints. The physical examination did not address any affected joints and primarily referenced the 2 May 2006 rheumatology consult.  
 
The commander’s statement dated 15 May 2006, indicated the CI had been released early from work 6-8 times that year due to pain and fatigue, but had routinely worked 8-hour days with her present physical condition slightly impacting her duty.  A performance evaluation report for the period from 16 July 2005 through 15 July 2006 documented “absolutely superior in all areas,” “consistently exceeds all training requirements,” “one of our best airman,” and the CI was recommended for immediate promotion. 

On 20 July 2006, the day before the Formal PEB, the Director of Communications and Information sent an email to the CI’s legal representative stating that while she worked hard and did her best, the CI’s arthritis was too debilitating to allow retention.  She reportedly had missed 6 days over the previous 2 months because she had to leave work due to pain, and could not sit at her desk for more than 1 hour due to the arthritis.  An 8 August 2006 primary care examination, 1 month before separation, noted complaints of monthly RA flare-ups with more constant pain, but specific findings were not recorded.

At the 29 December 2006 VA Compensation and Pension (C&P) evaluation, 3 months after separation, the CI described weakness and fatigue “at times” due to her RA and reported monthly “incapacitating episodes” that would typically last 2-3 days with ongoing morning pain and stiffness.  Flares included increased pain and stiffness as well as fatigue.  Physical examination showed full active and passive ROM of all four extremities as well as the entire spinal column.  No specific deformities were identified.   The CI reported since becoming pregnant in September 2006, the flares-ups had dramatically reduced and she was no longer taking Plaquenil.   

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the RA condition 20%, coded 5002 (arthritis rheumatoid).  The VA rated the RA with bilateral knee degenerative changes condition 60%, coded 5002, based on the C&P evaluation, citing more than four incapacitating episodes per year.  Members noted that at the time of separation, the CI’s RA was moderately controlled by medication, with minimal symptoms and objective findings.  In the year prior to separation, she experienced monthly exacerbations but did have at least a 3-month asymptomatic period.  The panel agreed that a 20% rating was justified based on one or two exacerbations a year in a well-established diagnosis.  Per the VASRD, the definition of “incapacitating” requires the CI to have sought medical care and required bed rest.  The panel concluded that there was insufficient evidence in the STR of incapacitating exacerbations occurring 3 or more times a year to support a 40% rating.  There was no weight loss and anemia productive of severe impairment of health, or severely incapacitating exacerbations occurring four or more times a year, or a lesser number over prolonged periods to support the higher 60% rating.  There also were no chronic residuals such as limitation of motion or ankylosis of any joints to warrant consideration for rating joints separately.  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 RA condition.

BOARD FINDINGS:  In the matter of the RA 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 20170316, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

SAF/MRB
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD  20762

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

		Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2017-02640.

After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was appropriate.  Accordingly, the Board recommended no re-characterization or modification of your separation.

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding and their conclusion that re-characterization of your separation is not warranted.  Accordingly, I accept their recommendation that your application be denied.

						Sincerely,

	

								XXXXXXXXXXXXXXXXXX
								Director
								Air Force Review Boards Agency

Attachment:
Record of Proceedings