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

Dear XXXXXXXXXX:

		Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2017-05682.

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.

RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXX	CASE:  PD-2017-05682
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20090929

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E6, Security Forces Craftsman, medically separated for “reactive arthritis” with a disability rating of 20%.  

CI CONTENTION:  “Joint damage in numerous extremities noted in VA physical immediately preceding separation from active duty.  Current VA rating 60%.”  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 - 20090626	VARD - 20100219	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Reactive Arthritis	5009	20%	Reactive Arthritis with Residual Limitation of Motion of the Right Knee	5002-5260	10%	20091007	
			Reactive Arthritis with Residual Limitation of Motion of the Left Knee	5002-5260	10%	20091007	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

Reactive Arthritis (Designated as Bilateral Knee).  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI developed bilateral knee pain as a component of reactive arthritis (suspected diagnosis of Reiter’s syndrome complicating salmonella enteritis) in 2008 while deployed to Iraq.  She was medically evacuated and subsequently diagnosed and followed by rheumatology after redeployment.  Her symptoms were controlled by oral corticosteroids which were successfully withdrawn, and she was stabilized on medication (sulfasalazine and Relafen), but did not recover sufficiently to resume full duties.  

A rheumatology entry of 18 November 2008 documented “an increase in range of motion [ROM], decrease in swelling, morning stiffness for only 10-15 minutes … back to running 3 miles … responding right now to sulfasalazine … off of the prednisone.”  The final outpatient STR entry by rheumatology on 6 February 2009 noted that the condition was “80% better” and that the CI “has been more active as far as running.”  The physical examination showed “good extension of the legs,” benign joints, and a normal gait.  These findings were corroborated by other STR provider notes.  There was no STR documentation of formal ROM measurements for the knees, although there were no entries that implicated significant ROM limitation.  There was no STR evidence of gait disturbance, persistent effusion, locking, or other VASRD-ratable findings for the knee.  There was no STR documentation of weight loss, anemia, significant health impairment, or incapacitating exacerbations associated with reactive arthritis (criteria for ratings higher than 20% under code 5002 as below).

The 29 March 2009 MEB NARSUM examination, 6 months prior to separation, noted nonspecific pain that limited load bearing, high impact activities, and prolonged standing.  The L2 profile permitted exercise at own pace with no specific prohibition of running.  There was no documentation of any manifestations of reactive arthritis other than arthralgias, or of incapacitating episodes.  The physical examination recorded a normal gait and full strength “with only slight increase in pain with squatting which she notes in her knees.”  There was no note of limited ROM, painful motion, or any abnormal joint finding for either knee.

At the 7 October 2009 VA Compensation and Pension (C&P) examination, 9 days after separation, the CI reported “constant” pain and “severe” morning stiffness forcing her to alter her wake schedule.  Specific functional limitations were not elaborated other than “mild” limitations on sports and recreation.  The reactive arthritis was judged to be stable and the medications were unchanged with no resumption of steroids (discontinued for a year at this point).  There was no documentation of any associated symptoms other than arthralgias, or of incapacitating episodes.  The physical examination (all findings bilateral) recorded an antalgic gait, tenderness, no swelling or effusion, no signs of inflammation, and no signs of meniscal impingement.  Measured ROM was flexion to 110 degrees left and 100 degrees right (normal 140, 45 for minimum 10%) with 0 degrees extension (normal) bilaterally, specifying the absence of objective signs of painful motion and no ROM degradation with repetition.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB conferred a 20% rating for reactive arthritis (specifying only “bilateral knee pain” as unfitting) under code 5009 (arthritis, other types) which defaults to rating criteria of code 5002 (rheumatoid arthritis).  The PEB’s AF Form 356 decision did not specify whether this represented separate 10% joint ratings or the 20% criterion of code 5002, “one or two exacerbations a year in a well-established diagnosis.”  The VA conferred separate 10% ratings for each knee under code 5002-5260 (5260 for limitation of flexion), citing painful motion for each knee (contrary to the C&P documentation as above).  

The panel agreed that there was no evidence to support a rating higher than 20% under criteria of code 5002 as quoted above.  It was incumbent on the panel, however, to assure that more favorable rating could not be achieved by separate joint ratings; i.e., whether a rating higher than 10% for either or both joints was supported under alternate codes.  There was no compensable limitation of motion under codes 5260 and 5261 for limitation of flexion or extension, no evidence of dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258), or history of surgery to remove a meniscus (5259) to support a rating under those codes.  There was no fracture, nonunion or malunion of the femur or tibia to support consideration under the respective codes for knee impairment related to long bone conditions (5255, 5262).  There was thus no VASRD §4.71a rating higher than the 10% for either knee that would be more advantageous than the PEB’s rating.  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 (bilateral knee) condition.  

BOARD FINDINGS:  In the matter of the reactive arthritis (designated bilateral knee) 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.