RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXX	CASE:  PD-2017-04281
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20070104

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E6, Cannon Crewmember, medically separated for “psoriatic arthritis” with a disability rating of 0%.

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 - 20061204	VARD - 20070620	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Psoriatic Arthritis	5009	0%	Psoriatic Arthritis, Right Knee	5003-5260	10%	20070425	
			Psoriatic Arthritis, Left Knee	5003-5260	10%	20070425	
Adjustment Disorder	Not Unfitting	Anxiety Disorder	9400	30%	20070425	
Hypertension	Not Unfitting	Hypertension	7101	0%	20070425	
High-Frequency Hearing Loss	Not Unfitting	Bilateral Hearing Loss	6100	NSC	20070425	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  70%	

ANALYSIS SUMMARY:

Psoriatic Arthritis.  According to the service treatment record and MEB narrative summary (NARSUM), the CI’s psoriatic arthritis condition began in 1998 with psoriasis of the face, knees and elbows and was treated with topical steroids and ultraviolet therapy.  During a deployment he began to have finger and knee joint pain and swelling; psoriatic arthritis was diagnosed in 2004 based on those symptoms.  Treatment with Humira (medication to treat rheumatoid and psoriatic arthritis) was self-administered biweekly from April 2004 through January 2005.  It provided decent control of his joint pain and rash.  X-rays of the right hand dated 6 October 2005 were normal.  

At a dermatology clinic visit in August 2006 the CI reported problems with his hands and knees, and had difficulty lifting weights, turning wrenches and walking.  Physical examination revealed numerous hyperpigmented macular (flat) patches of the torso and upper extremities with nail pitting of the digits of the hands and knuckle swelling.  The thumbs and metacarpal phalangeal joints were tender; gripping caused pain.  

During a rheumatology clinic visit on 18 August 2006 the examiner noted the CI was clinically stable on Humira with no evidence of hand, foot or knee synovitis (joint lining inflammation).  The fourth left and right great toe had minimal nail changes.  The commander’s statement dated 22 August 2006 indicated the CI’s condition was exacerbated by field conditions, stress and deployment.

During the 23 August 2006 MEB examination (recorded on DD Forms 2807-1 and 2808), 5 months prior to separation, the CI reported hand, knee, wrist, elbow and foot pain.  Physical examination revealed shoulder and wrist tenderness.  Bilateral wrist and knee range of motion (ROM) was normal, but knee pain was present with deep squatting.  Bilateral grip strength was 4/5 which decreased due to pain not weakness.  Upper and lower extremity strength was normal.  

The 8 November 2006 MEB NARSUM examination, 2 months prior to separation, noted complaints of morning hand pain and stiffness.  Joint pain was fairly well-controlled with Humira.  The CI continued to receive topical steroids and ultraviolet light treatment.  The physical examination incorporated the MEB and dermatology examination findings.  There was no bilateral hand, elbow, knee or foot pain, and ROM was “full” for all joints.

At a VA clinic visit on 2 March 2007, 2 months after separation, the examiner noted the CI had excellent psoriasis control while using Humira, but liver enzymes were elevated.  Physical examination revealed no extremity synovitis and the skin did not have significant plaques or nail pitting.  There was some hyperpigmented skin from previous plaques. 

At the 25 April 2007 VA Compensation and Pension (C&P) examination, 3 months after separation, the CI reported psoriatic arthritis.  Physical examination showed a normal gait.  There were a few white plaques on the abdomen and trunk, but none on the elbows or knees.  Bilateral knee, shoulder and wrist ROMs were normal, and upper and lower extremity strength was normal.  Shoulder, wrist and left hand X-rays were normal, but bilateral knee X-rays showed osteoarthritis. 

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the psoriatic arthritis condition 0%, coded 5009 (arthritis other types), citing no loss of motion and controlled with medication IAW DoDI 1332.39 6.10.1.  The VA rated the right and left knee psoriatic arthritis conditions 10% each, dual coded 5003-5260 (arthritis, degenerative-leg, limitation of flexion), based on the C&P examination, citing degenerative joint disease.

Panel members noted psoriatic arthritis involves multiple joints and has many clinical features similar to rheumatoid arthritis; therefore, the PEB’s use of code 5009 was appropriate.  The CI’s psoriatic arthritis condition was controlled with Humira, but became exacerbated when the medication was unavailable.  A 20% rating, which requires “one or two exacerbations a year in a well-established diagnosis” is reasonable.  However, evidence to support a 40% rating, which requires “symptom combinations productive of definite impairment of health objectively supported by examination findings or incapacitating exacerbations occurring 3 or more times a year” was not documented.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 20% for the psoriatic arthritis condition, coded 5009.

Contended PEB Conditions:  Adjustment Disorder, Hypertension and High-Frequency Hearing Loss, Bilaterally.  The panel’s main charge is to assess the fairness of the PEB determination that the contended conditions were not unfitting.  None of the conditions were profiled, implicated in the commander’s statement or judged to fail retention standards.  

Adjustment Disorder.  Adjustment disorder is a condition not constituting a physical disability, IAW DoDI 1332.38.  Therefore, the panel has no basis for recommending it as unfitting.  

Hypertension.  On 7 August 2006 the CI’s blood pressure measured 163/104 and 139/90 with an adult cuff.  The CI was diagnosed with hypertension which was treated with hydrochlorothiazide (a diuretic).  The 8 November 2006 NARSUM indicated the hypertension was under control with hydrochlorothiazide.  

High-Frequency Hearing Loss, Bilaterally.  An audiogram baseline on 1 December 1999 revealed an average hearing loss of 1.25 dB on the left and no loss on the right.  Audiology evaluation on 28 September 2006 noted mild bilateral high frequency sensorineural hearing loss.  A bilateral ear test for the eighth nerve pathology was negative and eardrum movement was within normal limits.

The panel agreed there was no performance-based evidence from the record that any of the above contended conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded there was insufficient cause to recommend a change in the PEB fitness determination for any of the contended conditions, so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the psoriatic arthritis condition, the panel recommends a disability rating of 20%, coded 5009 IAW VASRD §4.71a.  In the matter of the contended adjustment disorder, hypertension, and high-frequency bilateral hearing loss, the panel recommends no change from the PEB determinations as not unfitting.  There are no other conditions within the panel’s scope of review for consideration.  

The panel recommends the CI’s prior determination be modified as follows, effective the date of medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Psoriatic Arthritis	5009	20%	

The following documentary evidence was considered:

[AR Number], XXXXXXXXXX

Dear XXXXXXXXXX:

The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found that your disability rating should be modified but not to the degree that would justify changing your separation for disability with severance pay to a permanent retirement with disability.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed) and I accept its recommendation.  This will not result in any change to your separation document or the amount of severance pay.  A copy of this decision will be filed with your Physical Evaluation Board records.  I regret that the facts of the case did not provide you with the outcome you may have desired.
  
	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. 

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