RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  xxxxxxxx	CASE:  PD-2020-00119
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20061010

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was a National Guard E6, Observation Scout Helicopter Repairman, medically separated from the Temporary Disability Retired List (TDRL) for “history of chronic pancreatitis” and “history of chronic multiple joint pains, diagnosed as seronegative spondyloarthropathy,” rated 0% each, with a combined disability rating of 0%.   

CI CONTENTION:  His legal counsel wrote an 11-page brief in support of his application.  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 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 - 20060814	VARD – 20060805	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Pancreatitis	7347	0%	Chronic Pancreatitis	7347	30%	20060209	
Chronic Multiple Joint Pains, Diagnosed as Seronegative Spondyloarthropathy (SS)	5099-5002	0%	Rotator Cuff Syndrome, Right Shoulder Associated with Osteoporosis and SS, Left Hip	5201	20%	20060210	
			Osteoporosis and SS, Lumbar Spine	5013-5242	20%	20060210	
			Osteoporosis and SS of Left Hip	5013-5003	10%	20060210	
			Osteoporosis and SS of Right Hip	5013-5003	10%	20060210	
			Osteoporosis and SS, Right Knee	5257-5003	0%	20060210	
			Osteoporosis and SS of Left Knee	5013-5003	0%	20060210	
			Rotator Cuff Syndrome, Left Shoulder Associated with Osteoporosis and SS Left Hip	5201	0%	20060210	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  70% 	

ANALYSIS SUMMARY:  

According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s pancreatitis and seronegative spondyloarthropathy began in 1999.  He was separated and placed on the TDRL on 31 March 2005.

Chronic Pancreatitis.  At the 9 February 2006 VA Compensation and Pension (C&P) general medical examination, 8 months prior to TDRL removal, the CI reported his arthritis medication incidentally helped his pancreatitis and that he had no current complaints.  Physical examination showed medium build and good state of nutrition.  The abdomen was soft, with tenderness in the right upper quadrant and subxiphoid area.  There was some guarding, but peritoneal signs were absent.

During the 10 February 2006 gastrointestinal TDRL NARSUM examination, the CI reported a weight gain of 20 pounds in the past year and that he generally felt better, with pain rated at 1/10.  Review of systems notes documented recent weight gain and normal appetite, but no fever, chills, vomiting, abdominal pain, or stool changes.  The examiner noted direct epigastric tenderness and that the abdomen was not soft; however, bowel sounds were normal, with no abdominal muscle guarding or rebound tenderness.  The assessment noted the pancreatitis was stable and that the CI reported decreased flare-ups, no severe abdominal pain in the past year, and no dependence on narcotic medication for abdominal pain.

The 16 February 2006 rheumatology TDRL NARSUM noted the CI’s weight at 148 pounds and reports of chronic epigastric abdominal pain which had improved considerably with medication.  The examiner referred to the 10 February 2006 GI examination and noted the CI had been diagnosed with chronic pancreatitis.  

The panel directed attention to its rating recommendation based on the above evidence.  The CI was removed from the TDRL with a permanent disability disposition of separation with severance pay at 0%.  The PEB coded the pancreatitis 7347 (pancreatitis), citing “no history of any acute episodes in the past year,” some tenderness, and no guarding.  The VA rated the pancreatitis 30%, coded 7347, based on the C&P examination, citing “persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain productive of considerable impairment of health.”  The STR, as well as the VA C&P and TDRL NARSUM examinations did not record a single attack of typical severe abdominal pain in the year prior to TDRL removal, and thus a 10% rating under code 7347 was not warranted.  The CI reported decreased flare-ups, no longer required narcotic medication for severe abdominal pain, and did not seek emergency room (ER) care or require physician prescribed bedrest.  At the time of the C&P and TDRL examinations, the most recent lab studies and clinical evidence supported the absence of active disease, and the CI reported significant improvement with the addition of medication for the treatment of his arthritis.  He had also regained the weight he lost in 2005.  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 pancreatitis.  

Seronegative Spondyloarthropathy.  At an ER visit for a finger injury on 26 April 2005, the provider documented full range of motion (ROM) of the CI’s bilateral upper and lower extremities.  On 19 December 2005 at an outpatient visit, the examiner noted slight stiffness with shoulder ROM and cervical spine extension and “excellent” lower extremity ROM.

During the 10 February 2006 VA C&P joint examination, the CI reported pain in the lower back and in most joints “at any given time,” but that medication improved his condition significantly, with pain levels rated at 3-4/10.  During flare-ups, back, hip, knee, and shoulder pain sometimes reached 9-10/10, but did not require physician-prescribed bed rest.  Physical examination showed normal gait and station, and the ability to heel-toe walk and squat/rise.  Lumbosacral range of motion (ROM) was initially to 50 degrees and then to 60 degrees (normal) after repetition, with painful motion [normal thoracolumbar ROM is to 90 degrees but was not measured].  Tenderness was noted about the right sacroiliac joint, but not over the hips, and muscle strength, sensory function and deep tendon reflexes were normal.  Bilateral hip abduction was to 50 degrees (normal 45), adduction to 30 degrees (normal 25), extension to 10 degrees (normal 20), and flexion to 110 degrees (normal 125); painful motion was not present.  Neither knee showed tenderness, swelling, or signs of inflammation, and tests for instability were negative.  Bilateral knee ROM was from 0-140 degrees (normal), with no painful motion.  Muscle strength was normal with no signs of atrophy.  Right shoulder examination revealed mild acromioclavicular (AC) joint tenderness with abduction to 95 degrees (normal 180) and forward flexion to 130 degree (normal 180), and painful motion in both planes.  Muscle strength was normal with no atrophy.  Left shoulder flexion and abduction were both to 130 degrees, with painful motion.  Bilateral shoulder, sacroiliac joint, and hip as well as lumbosacral spine X-rays were unremarkable without any joint or bony abnormalities.  The examiner assessed bilateral rotator cuff syndrome (related to spondyloarthropathy, seronegative spondyloarthropathy affecting multiple joints, and osteoporosis). 

The 16 February 2006 TDRL NARSUM noted CI complaints of right arm and bilateral hip pain, but that his arthralgia/arthritis had dramatically improved since being treated with an infusion medication a year prior.  His low back pain had also improved with stiffness only lasting for an hour in the morning.  He no longer required opioid analgesia and was fully able to undertake activities of daily living to include caring for his three children.  Past medical history included an osteoporosis diagnosis, and review of systems notes documented the absence of fever or chills and transient oral ulcers in the past from methotrexate use, but none recently.  Upon examination, the CI was in no acute distress.  There was pain and crepitus with shoulder abduction, which was full, and mild bilateral AC joint tenderness without signs of synovitis.  Back forward flexion was noted be slightly decreased, and there was no sacroiliac joint tenderness.  Bilateral hip ROM was full with painful motion, and bilateral knee ROM was also full without swelling or tenderness.  There was mild ankle tenderness with no evidence of synovitis.  Painful motion was not addressed for the back, knees or ankles. Pelvic and knee X-rays were normal.  The examiner assessed that the seronegative spondyloarthropathy appeared to be stable on medication “with no evidence of current disease activity demonstrated by laboratory or radiographic clinical data.”  The CI’s prognosis was noted to be “good with continued therapy.”

The 14 June 2006 TDRL NARSUM addendum, 4 months prior to TDRL removal, noted the diagnosis of inflammatory spondyloarthropathy was confirmed by a combination of military and civilian physicians, and the condition was a disease process that had stabilized and was not expected to worsen or improve.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the seronegative spondyloarthropathy 0%, analogously coded 5099-5002 (arthritis rheumatoid), citing “the condition is now considered stable by WRAMC [Walter Reed Army Medical Center] standards” and an “essentially normal” extremity examination.  The VA rated each joint, as well as the spine, for both osteoporosis and seronegative spondyloarthropathy, noting that a separate rating for the same condition was not warranted (see rating comparison chart above).  The VA also rated a condition that was not identified by the PEB (rotator cuff syndrome), and thus not in scope for PDBR review.  Panel members placed more probative value on the TDRL examination, which was closest to TDRL removal and corroborated by the STR.  A 20% rating under 5002 code requires demonstration of one or two exacerbations a year and was not supported by the evidence, with the TDRL examiner noting the condition had been stable over the previous year due to a new medication regimen.  However, panel members agreed that based on code 5002 for chronic residuals, a 10% rating was justified for slightly decreased back ROM noted at the 16 February 2006 TDRL NARSUM examination.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the seronegative spondyloarthropathy, coded 5099-5002.   

BOARD FINDINGS:  In the matter of the pancreatitis and IAW VASRD §4.114, the panel recommends no change in the PEB adjudication.  In the matter of the seronegative spondyloarthropathy, the panel recommends a disability rating of 10%, coded 5099-5002 IAW VASRD §4.71a.  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 removal from TDRL:  

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic Pancreatitis	7347	0%	
Chronic Multiple Joint Pains, Diagnosed as Seronegative Spondyloarthropathy	5099-5002	10%	
COMBINED	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20200602, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record

AR20210013426,XXXXXXXX

Dear XXXXXXXX:

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 and to the counsel you listed on your application, XXXXXXXXXXX

Sincerely,