RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXX		BRANCH OF SERVICE: Army
CASE NUMBER:  PD0900212		COMPONENT: Active
BOARD DATE:  20090730   		SEPARATION DATE: 20051108
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SUMMARY OF CASE:  This covered individual (CI) was SPC/E-4 44B Machinist, medically separated from the Army in 2005 after 2.5 years of service.  The medical basis for the separation was Left elbow pain and limited motion.  The CI suffered a traumatic fracture of his left elbow (radial head) while deployed to OIF.  He was medically evacuated out of theater and had surgeries on his left elbow which led to removal of his left radial head.  The CI had pain and limited use of his left upper extremity despite additional surgeries and rehabilitation.  Further surgery was not recommended.  As the CI could not perform the duties of his MOS, he was referred to the PEB, found unfit, and separated at 20% disability.  
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CI CONTENTION:  'My Left elbow injury limits me in my physical abilities extremely. My left elbow effects my left arm so that it does not function normally. My left elbow limits my employment capabilities drastically.  I cannot perform the machinist duties which I have did prior to my enlistment in the Army, as well I cannot perform my regular physical activity that requires the use of my left arm. Due to the result of my injury, I have had to settle for lower paying jobs than what I would get if I was still physically capable of functioning normally. As a result of me settling for lower paying jobs due to my injury I have had trouble financially, and that has cause problems and stress on my marriage and affected my whole family.  I do not even lift anything with my left arm due to the discomfort of pain, which now I find myself relying on prescription drugs to help ease the pain.  By only using my right hand to lift things I have developed constant pain in it.  I cannot play with my children normally nor can I pick my children up due to the pain.  When I am in pain I tend to get agitated very easily and this causes family issues.'
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RATING COMPARISON:

Previous Determinations 	
Service	VA ~3 months post discharge	
PEB Condition	Code	Rating	Date	Condition	Code	Rating	Exam Date	Effective date	
Chronic left elbow pain with limited motion following traumatic injury  (fracture / dislocation of the radial head).	5213	20%	20050922	STATUS POST LEFT ELBOW FRACTURE (ALSO CLAIMED AS
RESIDUAL SCARS)
	5213

5206	10%

40%	20060201

Above from Decision Review Officer (DRO)	20051109

20051109	
				LEFT WRIST  STRAIN
	5215	0%
10%	20060201
From DRO	20051109
20051109	
				SURGICAL SCARS, LEFT ELBOW	7805	0%	20060201	20051109	
				CORNEAL OPACITY, RIGHT EYE	6099-6027	0%	20091229	20080711	
				POSTTRAUMATIC STRESS DISORDER	9411	NSC			
				GASTROESOPH-AGEAL REFLUX DISEASE	7346	NSC			
TOTAL Combined:  20%	TOTAL Combined (incl non-PEB Dxs):   10%
                                                    From DRO  50%	

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ANALYSIS SUMMARY:   

Left Elbow.  This right-handed CI was a Machinist injured in Kuwait in April 2004.  His left elbow was struck by a gate or guard stand and he sustained a fracture of his left radial head. He was evacuated out of theater.  He was initially thought to have had radial head dislocation (actual radial head fracture) and an attempted reduction was performed.  When he returned to Fort Irwin the radial head fracture had healed in malunion.  Conservative rehabilitation to regain range of motion (ROM--principally loss of supination) was unsuccessful.  The CI underwent an attempted reconstruction of his radial head that was not successful and radial head excision was performed.  Despite multiple release surgeries and rehabilitation, the CI's ROM was not regained and he had constant left arm pain exacerbated with motion.  An upper extremity specialist did not recommend any further treatment.  The CI was noted to be significantly limited with activity due to his loss of supination and pain.  The CI was noted in the NARSUM to have developed wrist pain, 'which sometimes goes along with a radial head excision with potential migration of his distal radioulnar joint (DRUJ).'  CI's left upper extremity was neurovascularly intact with ROM from 0 degrees of supination (normal 85), to 45 degrees of pronation (normal 80).  Flexion and extension was from 0-130 degrees (normal 0-145).  He could reach 15 degrees of supination passively.  The orthopedic surgeon started 'He is unable to supinate past neutral.  This makes it very difficult for him to perform his duties as a machinist and many of the activities of daily living.  He cannot perform push·ups.'  The PEB used the 15 degrees supination in their rating description:  'Chronic left elbow pain with limited motion following traumatic injury (fracture / dislocation of the radial head). Status post open reduction and internal fixation procedure. Joint arthrosis limits supination to 15°, pronation to 45°. Chronic pain prevents full function in PMOS.  Your functional limitations in maintaining the appropriate level of left elbow function caused by the physical impairments recorded above make you medically unfit to perform the duties required of a Soldier of your rank and primary specialty.'     

The VA examination of 20060201 (3 months post discharge), originally rated at 10%, had repeat rating of the same exam by a VA Decision Review Officer (DRO) that corrected the rating to 40% based on limited elbow flexion.  The DRO started:  'We have increased the evaluation of your left elbow disability to 40 percent based on your recent VA medical examination (20060201) which reported severely decreased range of motion in the joint (flexion to 10 degrees, supination to 10 degrees, pronation to 40 degrees) with evidence of painful motion but no additional limitation of function due to fatigue, weakness, lack of endurance or incoordination.  An evaluation of 40 percent is assigned for limitation of forearm flexion to 45 degrees or less.' 

The service treatment records (STR) consistently demonstrated limited left forearm supination and pronation to similar degrees as the VA exam.  However, the VA left elbow limited flexion ROM was significantly more limited than any flexion limit documented in numerous notes and exams in the STR.  It is exceptionally unlikely that the CI had such severely limited flexion at the time of discharge.  Post-discharge progression of disease with adhesions might explain this difference in ROMs, despite approximately 6 months between exams.  

Left Elbow and Forearm
Movement	Normal	20060201 
VA C&P exam	20050728
NARSUM	20040414 PT Note; Tender. Lack 10 Ext after mobilization 	
		ROM	W/ Pain limit	Passive ROM	W/ Pain limit	ROM	W/ Pain limit	
Flexion	145	10	10	130			135	
Extension	0	0		0		-25	-5	
Supination	85	10	10	15	0	15	15	
Pronation	80	40	40	45		60	60	

Left Wrist.  The NARSUM, written by an orthopedic surgeon, states that the CI 'is beginning to develop some wrist pain, which sometimes goes along with a radial head excision with potential migration of his distal radioulnar joint (DRUJ).'  There are STR notes to indicate that wrist pain was part of the CI's decreased full use of his left upper extremity and that loss of use of his left upper extremity was found to be unfitting.  There were no formal left wrist ROMs performed.  The anatomy and pathophysiology of radial head resection can be clearly linked to development of wrist overuse, strain, and painful motion.  The VA exam 3 months post discharge demonstrated mild left wrist limited ROMs with painful motion.  Although wrist pain at the level that CI demonstrated would not be a stand-alone unfitting condition, it is almost certainly subsequent to, or a residual of, the Left radial read resection.  In combination with the elbow/forearm disability, the wrist contributed to decreased functional use of the CI's left upper extremity.  As the CI was discharged in 2005 when the Army pain rule was in effect, it would not have been likely that non-mechanical limitation of wrist ROM, or painful wrist motion would have been ratable by the PEB.  In the absence of the Army pain rule and IAW §4.59 Painful motion, the left wrist should be added as an unfitting condition and be rated at 10% for painful motion. 

Left Elbow Surgical Scars.  Surgical scars were not noted to be additionally limiting within the STR due to pain, breakdown, or other ratable criteria.  There was no linkage of the scar to being unfitting such as interference with wearing body armor, etc.  The detailed VA exam noted no basis for a compensable rating.  There was no tenderness, disfigurement, ulceration, adherence, instability, tissue loss, Keloid formation or hyperpigmentation.  Left elbow scars should not be added as a new unfitting diagnosis.
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BOARD FINDINGS:  IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the PDBR to the extent they were inconsistent with the VASRD in effect at the time of the adjudication.  The Board had robust discussion concerning the most appropriate left elbow ROMs to use as a basis for rating, as well as whether or not painful motion of the left wrist should be added as a new unfitting diagnosis.  The CI's elbow exam clearly worsened regarding limited flexion between the military exam (20050728, 4 months pre-discharge) and the VA exam (20060201, 3 months post-discharge) with service discharge of 20051108 between the two dates.  The multiple STR ROMs demonstrating stability and lack of recent surgical intervention made it difficult to reconcile the magnitude of the changed elbow flexion limits aside from progression.  The military ROMs specifically addressed painful endpoints, so it was unlikely to be due to application of the Army pain rule.  The VA exam also demonstrated a non pain-limited flexion of 10 degrees.  The Board could not determine what the left elbow flexion would have been at separation and opined that the NARSUM exam had greater probative value for rating.  Discharge flexion limits would have had to be limited at 55 degrees for a 30% rating, or 45 degrees for a 40% rating.  Post-discharge worsening of the CI's condition cannot be rated by the Board.  The Board unanimously voted that the left elbow should remain rated at 20% as the PEB did not exercise any prerogative outside of the VASRD for their elbow rating.   

The orthopedic surgeon noted in the NARSUM that left wrist pain was linked to the CI's elbow surgery and STR notes agree with wrist pain due to overuse.  The broader unfitting issue was decrease in function of the left upper extremity and the painful wrist adversely affected the CI's use of his left arm.  The wrist pain was noted in the disability evaluation package, although not listed as a separate MEB/PEB diagnosis.  Given the Army pain rule in place at the time and reliance on mechanical limitations of motion, the provider and MEB/PEB were unlikely to consider painful motion of the left wrist as ratable or separately unfitting.  There was no specific left wrist ROM accomplished by the military, and the post-discharge VA ROM does not meet the compensable wrist ROM limits aside from §4.59 painful motion.  The Board opined that the left wrist painful motion was linked to the CI's elbow injury and surgery and that in combination with the elbow condition limits the CI's use of his non-dominant upper extremity, and should therefore be added as a new unfitting condition.  The Board voted by simple majority to add 5215, Left Wrist Strain, Due to elbow condition, Painful motion as a new unfitting condition rated at 10% IAW §4.59 painful motion.  The single voter for dissent (who recommended rejecting adding the left wrist painful motion as a new unfitting condition, 5215 at 10%) elected not to submit a minority opinion.  
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RECOMMENDATION:  The Board recommends that the CI’s prior determination be modified as follows and that the discharge with severance pay be recharacterized to reflect permanent disability retirement, effective as of the date of the CI’s prior medical separation.

Unfitting Condition	VASRD Code	Rating	
Chronic left elbow pain with limited motion following traumatic injury and radial head removal	5213	20%	
LEFT WRIST  STRAIN, Due to elbow condition, Painful motion	5215	10%	
Combined	30%	
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The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20090210, w/atchs.
Exhibit B.  Service Treatment Record.
Exhibit C.  Department of Veterans' Affairs Treatment Record.