RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXX	CASE:  PD-2017-04236
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070912

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Wheeled Vehicle Mechanic, medically separated for “rheumatoid arthritis of the left elbow” with a  disability rating of 10%.  

CI CONTENTION:  Review all conditions.  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 - 20070529	VARD - 20080812	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Rheumatoid Arthritis of the Right Elbow	5002	10%	Inflammatory Monoarthritis of the Right (Major) Elbow with Contracture	5002-5206	30%	20080109	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

Rheumatoid Arthritis of the Right Elbow.  According to the service treatment record and MEB narrative summary (NARSUM), the CI’s right (dominant) elbow condition began in 2001 during advanced individual training with no trauma or injury.  She gradually developed swelling and flexion contracture of the elbow, but laboratory and radiology studies did not reveal the etiology of the inflammatory process.  In 2005, she was placed on systemic immunotherapy (Enbrel) which stayed on until approximately March 2006.  Repeat laboratory studies were normal and she was subsequently treated with systemic and local anti-inflammatory medications, with improvement, but a mild elbow flexion contracture remaining.  

At the 2 February 2007 MEB examination (recorded on DD Forms 2807-1 and 2808), 7 months prior to separation, the CI reported a very painful, warm and inflamed right elbow with arthritis and loss of motion.  Physical examination (PE) showed mild tenderness and trace swelling of the right olecranon (elbow).  Physical therapy (PT) measured elbow range of motion (ROM) with a goniometer on 23 March 2007, 6 months before separation, which showed flexion to 135 degrees (normal 145) and extension lacking 10 degrees (normal 0) after repetition and with painful motion.  There was normal forearm pronation (normal 80) and supination (normal 85).  

At the 26 March 2007 rheumatology examination, the CI was not taking a systemic medication for rheumatoid arthritis.  She reported some depression and hair loss, but no history of skin or oral lesions or systemic symptoms involving the heart, lungs, gastrointestinal or neurologic systems.  Her elbow was doing well, but she had some right knee discomfort.  The PE showed general hair thinning without focal alopecia (hair loss), and normal skin and nails.  There was full ROM of the spine, shoulders, wrists, hands, left elbow, hips and left knee, and a slight flexion contracture of the right elbow without synovitis (no warmth, redness).  There was right knee tenderness without synovitis and no synovitis of the ankle or feet.  The rheumatologist noted that although the CI had been stable with no current inflammatory process or required systemic therapy at that time, she might eventually require systemic treatment again.  

The 20 April 2007 MEB NARSUM examination, 5 months prior to separation, noted complaints of right elbow pain.  The PE cited the MEB Form 2808, PT and rheumatology examinations, and there was a picture of the CI’s elbow in the record with lack of approximately 30 degrees of extension.  The MEB NARSUM examiner noted the limitation was due to pain and soft tissue restriction, and at the PT examination, the CI was able to flex and extend the elbow more, likely  due to warm-up activity.

At the 9 January 2008 VA Compensation and Pension (C&P) examination, 4 months after separation, the CI reported constant right elbow pain, which improved somewhat with moving the joint, as well as swelling, warmth, redness, instability or giving way, locking, fatigability, and lack of endurance.  She had flare-ups 2-3 times a month with reduced ROM and the inability to use the arm.  She was taking flaxseed oil and daily oral anti-inflammatory medication to treat the elbow, and stated that since being off the oral steroids and/or Enbrel, the pain had returned “with a vengeance.”  The PE showed tenderness and guarding of the elbow and a fixed deformity without nodules, but no swelling, effusion, instability or weakness.  Elbow flexion was to 90 degrees, with pain, and extension lacked 20 degrees.  Forearm supination was 85 degrees and pronation was 70 degrees with pain.  The examiner noted there was additional functional loss and limitation after repetitive use due to pain, fatigue, weakness, or lack of endurance, without documenting loss of motion in degrees.  Laboratory testing for inflammation was normal.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right elbow condition 10%, coded 5002 (rheumatoid (atrophic) arthritis), citing ROM limited by mechanical block.  The VA rated the right elbow condition 30%, dual coded 5002-5206 (rheumatoid arthritis-limitation of forearm), based on the C&P examination, citing flexion limited to 70 degrees, although “flexion of 90 degrees, significant additional loss of motion with repetitive use and flare-ups” was cited.  Panel members agreed there was no evidence prior to separation to support a rating for limited elbow flexion or extension (5206 or 5207), or forearm supination or pronation (5213); and insufficient elbow limitation due to flexion contracture to warrant a rating analogously coded as elbow ankylosis (5205).  There was, however, evidence of painful motion of the elbow to support a 10% rating (based on §4.59, §4.40 and §4.45).  The elbow flexion of 90 degrees documented at the post-separation VA examination supported a 20% rating and may have reflected post-separation worsening of the CI’s inflammatory condition, but there was no evidence of such limitation of motion in record prior to separation.  The service PT ROM examination included documentation of three repetitions, and the VA examination provided a single measurement without recording ROM after repetition or with flare-ups.  The panel therefore placed greater probative value on the PT examination and concluded there was no higher rating supported than that adjudicated by the PEB.  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 right elbow condition.  

BOARD FINDINGS:  In the matter of the right elbow 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:

	PD-2017-04236

AR20190012133, XXXXXXXXXXXXXXXXXX 

Dear XXXXXXXXXXXXXXX

	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.