RECORD OF PROCEEDINGS
AIR FORCE BOARD FOR CORRECTION OF MILITARY RECORDS

IN THE MATTER OF:	DOCKET NUMBER:  01-03671
		INDEX CODE:  108.01
		COUNSEL:  

		HEARING DESIRED:  YES

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APPLICANT REQUESTS THAT:

Her records be corrected to show that she was found to be unfit for military duty and that she was assigned a minimum rating of 20% or more appropriately that her name was placed on the Temporary Disability Retired List (TDRL) with a 40% rating under VASRD Diagnostic codes 8599-8515 for her Reflex Sympathetic Dystrophy (RSD).

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APPLICANT CONTENDS THAT:

While on duty in the Surgical Intensive Care Unit she injured her left hand while attempting to lift a patient.  The nature and extent of her injury was listed as "left index finger sagittal band rupture" and her injury was determined to be in-line-of-duty by the appropriate authority.  On 8 Sep 99, she underwent a surgical procedure that consisted of partial release of her ulnar sagittal band with repair of the radial sagittal band and realignment of her extensor mechanism over her index finger.  When her cast was removed on 30 Sep 99, she experienced severe hypersensitivity over her incision and along the dorsal forearm as well as pain.  There was poor metacarpal motion, wrist motion and elbow motion.  She could not tolerate even a slight touch to her left hand all the way to her elbow.  Her physician suspected RSD and referred her to the occupational therapy clinic.  

On 4 Oct 99, her therapy began which included desensitization, scar massage and, passive and active range of motion exercises.  The therapy was very painful, especially when she attempted to extend her finger.  During follow-up, on 14 Oct 99, it was noted that she was experiencing numbness, pain, and tingling along the right side of the left index finger.  Beginning 15 Oct 99, she was seen twice a day, five days a week in occupational therapy for desensitization and active range of motion exercises.  During a follow-up visit on 21 Oct 99, she reported some progress with desensitization, but the numbness and tingling sensation along the left index finger continued and the pain remained the same.  On 18 Nov 99, she reported pain along the side of the left finger while doing active range of motion exercises and informed the therapist that if she did not exercise the finger within 3 hours it would become very stiff.  Occupational therapy was decreased to once per day to decrease the pain.  
On 22 Nov 99, she reported that she had developed hard and painful nodules on the left index finger.  The pain was excruciating with flexion and the skin had become very red.  It was determined that she was experiencing some synovitis and was provided with a figure eight splint.  By 16 Dec 99, her numbness and tingling was unchanged yet her finger was stiffer as a result of being placed in the splint.  She requested tests to determine whether or not she had suffered nerve damage or injury.  She asked for nerve conduction velocity tests to be performed as well as tests for bone density.  Since her physician did not see the need for these tests, she sought a second opinion.  During her second opinion examination a decrease in flexion was noted.  The physician suspected that the dysesthesia was mild and declined to recommend surgery at least for a period of one year.  On 31 Jan 00, in a follow-up appointment, she reported improvement in pain during flexion and after fluid therapy.  However, the physician did note continued mild swelling, redness and nodules.  No changes in therapy were made.  During the month of February 2000, it was noted that her therapy had plateaued.  Her left index finger remained stiff and difficult to bend beyond a certain point.  Her numbness and tingling were unchanged and her left hand was weaker than the right.  On 6 Mar 00, she was discharged from occupational therapy.  Since that time she continued to experience pain and stiffness.  On 13 Mar 00, she was told that her finger might not improve much more, if at all and that she would not be able to do patient care as she had done before, but as a nurse had other options.  

A Medical Evaluation Board (MEB) convened on 6 Apr 00 and recommended return to duty.  On 12 Apr 00, she submitted her letter of exception to the MEB results.  Her case was referred to an Informal Physical Evaluation Board (IPEB) which met on 21 Apr 00.  The IPEB determined that there was no category I unfitting condition which was compensable and ratable.  However, the IPEB did find that she suffered from a category II condition that could be unfitting but was not currently compensable or ratable, namely chronic pain in the left second digit.  The VA diagnostic code utilized by the IPEB was 8715, which is designated as neuralgia of the median curve.  The IPEB stated that her medical condition did not prevent her from performing less strenuous duties.  The IPEB found her fit and recommended that she be returned to duty.  

What the IPEB overlooked in this case is that her condition is not simply "chronic pain in the left second digit (index finger)" but rather a serious neurological condition known as Reflex Sympathetic Dystrophy (RSD).  This condition is an excruciatingly painful condition, which is both extremely debilitating and has one of the highest rates for suicide among the afflicted of any known medical condition.  Subsequent to her release from active duty she was evaluated by the Department of Veterans Affairs (DVA).  A rating decision was issued to her which assigned her 20% disability for her left index finger radial sagittal rupture.  The decision stated that "Service records and other evidence shows hospitalization for a prolonged period of treatment of wound, with record of consistent complaint of loss of power, weakness, lowered threshold of fatigue, fatigue-pain, impairment of coordination, and uncertainty of movement, and if present, evidence of inability to keep up with work requirements.  The DVA found her disability to be "moderately severe".  The DVA assigned its percentage for moderately severe muscle disability whereas the IPEB chose to focus more upon the damage to the nerves, utilizing VA diagnostic code 8715 for neuralgia of the median nerve.  Based on the verbiage of the VA rating decision it is obvious that the DVA evaluated her on the basis of the impairment she experienced in the muscles of the hand.  It is a well-established principle that the Air Force need not rate an evaluee in the same manner as the DVA.  Nevertheless, it is well known to practitioners before the Formal Physical Evaluation Board (FPEB) that, upon TDRL re-evaluation, the FPEB always inquires as to the evaluee's rating with the DVA and the rationale for that rating.  The FPEB in particular is always concerned as to whether or not the DVA rating decision was based upon only a records review or upon a medical examination.  Although not binding on the FPEB or IPEB, DVA determinations often carry great weight with these boards.  In her case the DVA rating decision is definitely relevant to a determination of whether the Air Force disability system made the appropriate determination in finding her fit for duty.  The DVA by contrast considered her condition to be that of a moderately severe muscle disability.  The DVA gave her condition the careful, thoughtful consideration it deserved.  However, the more pertinent of the two evaluations would be to rate her RSD under the appropriate code for incomplete paralysis of the median nerve as at least "moderate" for the non-dominant hand at 20%.  An argument could be made for rating her condition as incomplete paralysis of the median nerve as severe as 40%.  Such a rating would of course direct a determination that she be placed on the TDRL.  A rating of 20% would at a minimum recognize her medical condition as not only service connected but as one which rendered her, in fact, unfit for military service and which constituted a debilitating condition much greater than merely "chronic pain."  

In support of her request, applicant provided her counsel's brief, a personal statement, documents associated with her Line-of-Duty (LOD) determination, extracts from her medical records, documents associated with her Disability Evaluation System (DES) processing, documents associated with her DVA claim processing and rating decision, a magazine article, a local newspaper article, and medical journal excerpts.  Her complete submission, with attachments, is at Exhibit A.

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STATEMENT OF FACTS:

Applicant, a prior service Army Reserve officer, was appointed a captain, Reserve of the Air Force, on 3 Sep 96.  She was voluntarily ordered to extended active duty on 12 Nov 96.  While working as a critical care nurse the applicant injured her left hand on 22 May 99 while moving a very heavy patient.  She was subsequently referred to orthopedic surgery and was diagnosed with partial rupture of the stabilizing radial sagittal band of the left index finger metacarpal phalangeal joint.  She underwent surgical repair on 8 Sep 99.  Upon removal of her cast on 30 Sep 99 she was found to have hypersensitivity that generalized to the forearm.  The orthopedic surgeon referred her to occupational therapy using the RSD protocol.  She was subsequently seen by occupational therapy 68 times.  In December 1999 and January 2000 orthopedics reported her RSD symptoms and symptoms of dysesthesias improving.  In February 2000, she reported decreased pain and improved range of motion.  

An MEB was convened on 6 Apr 00 and returned the applicant to duty.  The applicant did not concur with the findings of the MEB.  Her case was consequently referred to an IPEB which determined her injury did not prevent her from performing less strenuous duties commensurate with her office, rank, grade, or rating, or from completing her current tour of duty, and returned her to duty.  Her request for extension of service (Specified Period of Time Contract) was denied based on her ineligibility for military retirement due to her age.  On 26 Apr 99, she requested separation from the Air Force.  On 30 Jun 00, she was released from active duty and transferred to the Ready Reserve.  She served 3 years, 7 months, and 19 days on active duty.

On 24 Feb 01, the DVA rated her medical condition for the left index finger radial sagittal rupture, as 20 percent disabling.  

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AIR FORCE EVALUATION:

The BCMR Medical Consultant recommends denial.  The Medical Consultant states that the applicant contends that her disability should have been based on a diagnosis of RSD using VASRD Code 8713, neuralgia of all ridiculer groups (i.e. the entire arm) rather than a diagnosis of pain limited to the index finger using VASRD Code 8715, neuralgia of the median nerve (localized portion of the hand innervated by the median nerve that includes the thumb, index, middle and ring fingers).  Her DVA disability rating is based on loss of muscle function using VASRD 5307, loss of flexion of the hand and wrist, at a moderately severe level, rather than on the basis of pain neuralgia.

A diagnosis of RSD was suspected based on her abnormal painful response to her surgery.  RSD is a pain syndrome that affects an entire extremity and often occurs as an abnormal response to an injury of surgery affecting only a part of that extremity.  Although she initially showed some symptoms that were concerning to her orthopedic surgeon for RSD, that of pain and hyperesthesia that generalized to the forearm, the generalized symptoms appeared to resolve quickly with therapy and her subsequent problems affected only the left (non-dominant) index finger.  Using the VASRD code for neuralgia that affects the entire extremity as claimed by the applicant is not appropriate since her disability at the time of separation from the Air Force was limited to the left index finger.  Using the median nerve code for neuralgia or the muscle disability codes, both of which characterize the disability to the region affected, are more appropriate in this case.  The Medical Consultant evaluation is at Exhibit C.

AFPC/DPPD reviewed applicant's request and recommends denial.  DPPD states that IPEB decisions that result in return to duty recommendations are not given rebuttal rights to the individual.  This decision is determined on the condition that fit for duty findings do not cause involuntary separation for physical disability.  One question comes to mind when evaluating this case is that it has been 21 months since she was released from active duty; however, nothing in her military records medically disqualifies her from her Ready Reserve status, a strong indication that she is still qualified for military service.  The main purpose for the MEB was to determine the status of her injured left index finger.  Although the MEB medical narrative summary states that she was started on the RSD protocol, a final diagnosis was not determined during this timeframe.  The DVA rating decision rates her medical condition for the left index finger sagittal rupture and does not evaluate her for RSD.  The applicant was treated fairly during the DES process and she was properly rated under federal disability guidelines based on her condition at the time of her assessment.  The DPPD evaluation is at Exhibit D.

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APPLICANT'S REVIEW OF AIR FORCE EVALUATION:

Applicant responded and states that the Air Force evaluations neglected to mention that her duties that she was returned to were as a "gofer."  She was not able to return to her duties as a Critical Care Nurse as she had done for the previous 15 years.  She is left with pain, discomfort and hypersensitivity on her left hand and not only her left finger as is so frequently stated in the evaluation.   She has been forced to make a career change that has left her with a salary a lot lower than she would earn if she were able to work in Critical Care Units.  

Counsel states that her contention continues to be that the IPEB ignored relevant and competent evidence of the applicant's diagnosed medical condition, RSD, now renamed Complex Regional Pain Syndrome I, and as a result mischaracterized her medical condition as simply "chronic pain of the left second digit (index finger)."  As a result, the IPEB failed to find her medical condition unfitting for further military service.  Her physician immediately started her on an RSD protocol.  Thus, as early as this first post-operative visit, Air Force physicians recognized that she was suffering from RSD and not just a sagittal band rupture.  
In the medical advisory the Medical Consultant acknowledges the possible existence of RSD as a diagnosis in the applicant's case.  He noted that on 30 Sep 99 upon removal of her cast, she was found to have hypersensitivity over the surgical incision and the dorsal forearm and had poor range of motion of the elbow, wrist, and index finger joints.  The Medical Consultant also noted that her RSD-like symptoms improved from October 1999 to March 2000.  He also observed that as of 15 Jun 00 a hand surgery note indicated "resolving RDS..."  Thus he located many of the same entries in the applicant's medical records that counsel had noticed, which referred to RSD as possibly the appropriate diagnosis in her case.  The applicant was obviously suffering from something more significant than chronic pain and the IPEB should have been more precise in its characterization of her medical condition.  It is apparent that the Medical Consultant is skeptical of this diagnosis, since he says that her problem affected "only the left (non-dominant) index finger."  He has reluctantly admitted that RSD may be appropriately diagnosed in one affected upper or lower extremity.  There are many cases in the medical literature provided which reflect diagnoses of RSD in a leg, an arm, a hand, or a foot.  The medical Consultant's statement to the effect that "RSD is a pain syndrome currently termed Complex Regional Pain Syndrome that affects an entire extremity..." is not exactly correct.  RSD need not affect the entire extremity, but may affect some portion of the extremity i.e. the fingers of a hand.  The Medical Consultant inaccurately states the applicant's position with regard to the appropriate VASRD code to be applied and misquotes the Brief of Counsel.  He is incorrect stating that "The applicant contends that her disability should have been rated based on a diagnosis of RSD using the VASRD code of 8713, neuralgia of all radicular groups (i.e. the entire arm), rather that a diagnosis of pain limited to the index finger using VASRD code 8715, neuralgia of the median nerve..."  Counsel contends that the appropriate code to be utilized for her RSD was VASRD code 8515 for incomplete paralysis of the median nerve.  

The applicant recognizes that 8713 is in fact a VASRD code for neuralgia for all radicular groups.  She was merely suggesting the analogous code 8799-8713 as a possibility.  By misquoting the Counsel's Brief, the Medical Consultant would imply to the Board that the applicant is somehow requesting more than is appropriate for her medical condition.  She is not claiming that she suffers neuralgia in all radicular groups of the peripheral nerves; she is not claiming that she suffers RSD in her entire forearm or arm' she is merely claiming that the appropriate code would be VASRD 8515, incomplete paralysis of the median nerve and that this should be rated at least 20% "moderate" for the non-dominant hand.  The VASRD does not go into detail such that dysfunctions of the digital nerves are rated separately from the larger nerves (such and the median) which intervate them. 

The Medical Consultant states that "Her subsequent VA Disability rating of 20% is based on loss of muscle function using VASRD 5307, loss of flexion of the hand and wrist as a moderately severe level, rather than on the basis of pain (neuralgia)."  He is only partially correct in this assertion.  The VA's rating was on the impairment of the applicant's muscles to flex and/or extend the left finger rather than the entire wrist.  VASRD code 5307 refers to group VII of the muscles of the forearm and the hand, the specific functions of which are flexion of the wrist and fingers.  VASRD code 5308 refers to group Viii of the muscles of the forearm and hand, the functions of which are extension of the wrist and fingers.  It is clear from the VA medical examination that range of motion was measured with regard to the fingers of the left hand, i.e. the interphalangeal joints, not the radiocarpal joint which is responsible for flexion of the wrist.  Te approach used of analyzing the condition of a muscle disability is certainly an acceptable method of rating the applicant's physical disability.  Her contention is that the preferable method is to rate her condition as RSD, under VASRD code 8515.  

In additional support of her request, applicant provided her counsel's brief, a personal statement, and extracts from her post-service medical records.  Her complete response, with attachments is at Exhibit F.

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APPLICANT'S ADDITIONAL REVIEW OF AIR FORCE EVALUATION: 

Counsel states that as early as her initial post-operative visit she complained of burning in the radial aspect of the left index finger and her physician immediately started her on an RSD protocol.  The Air Force physician recognized that she was suffering from RSD and not just a sagittal band rupture.  The IPEB rated her condition under VASRD code 8715, which is designated as neuralgia of the median nerve.  Neuralgia is simply a synonym for pain. The IPEB should have rated her RSD under appropriate code for incomplete paralysis of the median nerve, VASRD code 8515 as at least moderate for the non-dominant hand at 20 percent.  An argument could be made for rating her as "severe" at 40 percent.  The Medical Consultant acknowledges the possible existence of RSD as a diagnosis of her case.  He noted that upon removal of her cast, she was found to have hypersensitivity over the surgical incision and the dorsal forearm and had poor range of motion of the elbow, wrist, and index finger joints.  He also notes that her RSD like symptoms improved from October 1999 through March 2000.  He also observed a hand surgery note indicates "resolving RSD..."  Thus he located many of the same entries as counsel noted which referred to RSD.  The applicant was obviously suffering from something more significant that chronic pain. 

In his diagnosis he has reluctantly admitted that RSD may be appropriately diagnosed in one affected upper or lower extremity.  There are many cases in medical literature which reflect diagnoses of RSD in a leg, an arm, a hand, or a foot.  His statement to the effect that RSD is a pain syndrome currently termed Complex Regional Pain Syndrome that affects an entire extremity, is not exactly correct.  RSD need not affect an entire extremity, but may affect some portion of the extremity, i.e. the fingers of a hand.  The Medical Consultant inaccurately states her position stating that she contends that her disability should have been rated using VASRD code 8713 when in actuality she contends that it should have been 8715.  She was merely suggesting the analogous code 8713 as a possibility.  She is not claiming that she suffers neuralgia in all radicular groups of the peripheral nerves; she is not claiming that she suffers RSD in her entire forearm of arm; she is merely claiming that the appropriate code would be VASRD 8515.  

The Consultant comments that a note reflected "a digital nerve dysfunction, not a median nerve dysfunction."  The VASRD does not go into detail such that dysfunctions of the digital nerves are rated separately from the larger nerves (such as the median) which intervate them.  Counsel believes that the consultant is only partially correct in his assertion that her DVA disability rating is based loss of muscle function using VASRD 5307, loss of flexion of the hand and wrist at a moderately severe level, rather that on the basis of pain.  It is true that the DVA rating was focused on impairment of the muscles rather than on pain; however, counsel believes the DVA rating was on the impairment of her muscles to flex and/or extend the left finger rather than the entire wrist.  VASRD code 5307 refers to group VII of the muscles of the forearm and hand, the specific functions of which are flexion of the wrist and fingers.  VASRD code 5308 refers to group VIII of the muscles of the forearm and hand, the functions of which are extension of the wrist and fingers.  It is not clear which of these two VASRD codes the DVA used.  It is clear that range of motion was measured with regard to the fingers of the left hand.  

DPPD acknowledges that the applicant was started on the RSD protocol as well.  The DPPD advisory fails to effectively refute the applicant's contention as set forth in counsel's brief in the fact that the only diagnosis commented on frequently in the medical records, other than the sagittal band rupture, is RSD.  

This is not a case where the Board is asked to second-guess a percentage of disability which was assigned by the PEB.  Rather, this is a case of fundamental issues.  The first is the nature of the medical condition itself and the second is whether or not the applicant was fit or unfit as a result of the medical condition.  The applicant's complete submission is at Exhibit G.

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ADDITIONAL AIR FORCE ADVISORY:

The BCMR Medical Consultant states that the nature of the applicant's condition, that of pain of neurologic origin is not at issue.  There is evidence to support that her pain was more than that expected from a normal post-operative course for the type of surgery that had undergone and was considered to be RSD.  She was treated with improvement but with residual discomfort documented to have been limited to the left index finger (radial side).  At the time of her MEB there was no weakness or instability of the finger.  She did have variable limitation of motion related to pain and attendant stiffness that was overcome with stretching and use. Within a year following separation, the DVA evaluation documented pain and limitation of motion and rated her at 20 percent.  At issue is whether she was unfit for continued duty.  The orthopedic surgeon did not find any "mechanical deficit in her hand that would necessitate her to be removed from clinical care," yet she contends that her painful left index finger completely disabled her from working as a nurse in any capacity.  Thus, there was no objective finding that her condition was unfitting for continued service but her pain limited her ability to perform her duties as a critical care nurse.  The index finger in unique in function to the hand as a whole and that impairments involving the index finger alone do affect function of the hand as a whole requiring therapy to compensate.  At the time of her separation, she had not returned to clinical care nursing.  The consultant concurs with the opinion of the orthopedic surgeon and the IPEB that her condition at that time was not unfitting as defined by the ability to perform as a clinical nurse in a more generic way.  Had her contract been extended she could have continued to function effectively, albeit in a different capacity.  If the IPEB had instead reached the conclusion that her finger pain was unfitting and compensable, then the VASRD code for neuralgia of the median nerve (8715) is the most appropriate.  Since the nature of her condition is predominantly pain of a neurogenic basis, the neuralgia code is the most appropriate.  The reason she could be fit for duty despite the presence of a medical problem and later granted a service-connected disability by the DVA lies in understanding the differences between Title 10 U.S.C., and Title 38, U.S.C.  Title 10 charges the service Secretaries with maintaining a fit and vital force.  For an individual to be considered unfit for service there must be a medical condition so severe that if prevents the performance of any work commensurate with rank and experience.  In this instance, her condition did not appear to have rendered her unfit for continued military service and she proceeded with planned separation from the Air Force.  Title 38, which governs the DVA compensation system was written to allow awarding compensation ratings for conditions that are not unfitting for military service.  This is the reason why an individual can be found fit for service and yet soon thereafter receive compensation rating from the DVA.  The Medical Consultant evaluation is at Exhibit H.

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APPLICANT'S REVIEW OF ADDITIONAL AIR FORCE EVALUATION:

A copy of the additional Air Force evaluation was forwarded to the applicant on 20 Dec 02 for review and comment within 30 days.  As of this date, this office has received no response.

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THE BOARD CONCLUDES THAT:

1.  The applicant has exhausted all remedies provided by existing law or regulations.

2.  The application was timely filed.

3.  Insufficient relevant evidence has been presented to demonstrate the existence of an error or injustice.  After a thorough review of the evidence of record and the documentation submitted in support of her appeal, we are not persuaded that she was unfit for continued military service at the time of her separation from the military.  Her records indicate that she suffered a partial rupture of the stabilizing radial sagittal band of the left index finger while lifting a patient in the performance of her military duties.  During her treatment process, it appears that her symptoms led the attending physician to suspect the existence of RSD and she was referred to a specialist for further evaluation and treatment.  Further review of her medical record reveals that those particular symptoms of RSD apparently improved and resolved after therapeutic treatments.  Contrary to her contentions, we are not persuaded that the decision of the IPEB was inappropriate at the time it was considered nor has evidence been provided that would lead us to believe that the IPEB decision was made without taking all of the appropriate factors into consideration.  Evidence has not been presented which would lead us to believe that her condition prevented her from completing her tour of duty with the Air Force or that her condition rendered her unable to perform other military duties commensurate with her grade and position.  The Air Force is required to rate an individual's disability at the time of evaluation.  The DVA operates under a totally separate system with a different statutory basis.  In this respect, we believe that the Air Force appropriately considered the applicant's condition and whether or not the condition rendered her unfit to perform the duties of her office and grade at that time.  The DVA rates for any and all service connected conditions to the degree in which they interfere with future employability, without consideration of fitness.  Therefore, in the absence of evidence that convincingly refutes the opinions and recommendations of the Air Force offices of primary responsibility, we are compelled to agree with their recommendation and adopt their rationale as the basis for our conclusion that she has not been the victim of an error of injustice and find no compelling basis to recommend granting the relief sought in this application.

4.  The applicant's case is adequately documented and it has not been shown that a personal appearance with or without counsel will materially add to our understanding of the issue involved.  Therefore, the request for a hearing is not favorably considered.

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THE BOARD DETERMINES THAT:

The applicant be notified that the evidence presented did not demonstrate the existence of material error or injustice; that the application was denied without a personal appearance; and that the application will only be reconsidered upon the submission of newly discovered relevant evidence not considered with this application.

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The following members of the Board considered Docket Number 01-03671 in Executive Session on 12 Mar 03, under the provisions of AFI 36-2603:

The following documentary evidence was considered:

    Exhibit A.  DD Form 149, dated 10 Dec 01, w/atchs.
    Exhibit B.  Applicant's Master Personnel Records.
    Exhibit C.  Letter, BCMR Medical Consultant, dated 4 Mar 02.
    Exhibit D.  Letter, AFPC/DPPD, dated 18 Apr 02.
    Exhibit E.  Letter, SAF/MRBR, dated 26 Apr 02.
    Exhibit F.  Letter, Applicant, dated 19 May 02.
    Exhibit G.  Letter, Applicant's Counsel, dated 23 Aug 02.
    Exhibit H.  Letter, BCMR Medical Consultant, dated 6 Dec 02.
    Exhibit I.  Letter, SAF/MRBC, dated 20 Dec 02.