RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXX	BRANCH OF SERVICE: navy
CASE NUMBER:  PD0900294	BOARD DATE: 20090909
SEPARATION DATE: 20071217
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SUMMARY OF CASE:  This covered individual (CI) was a First Class Petty Officer who was medically separated from the Navy in 2005 after more than 14 years of service.  The medical basis for the separation was right wrist synovitis.  She was separated 20071217 with 10% disability.

MEDICAL HISTORY:
CI initially injured her right wrist in 2001 in a motor vehicle accident and did not respond to conservative treatment.  She had arthroscopy in April 2002 with repair of lunotriquetral ligament and pinning.  She then had surgery to remove the pins in July 2002.  She injured her wrist again while exercising on a cross trainer and had arthroscopy in 2003.  Her condition failed to respond to casting and injections only transiently relieved her symptoms.  An MRI revealed a torn TFCC (triangular fibrocartilage complex) and she had arthroscopic debridement of the central TFCC tear.  She injured her wrist a third time in 2005 with a mild twisting type injury that resulted in persistent ulnar sided and central wrist pain.  Arthroscopy showed additional fraying of the TFCC tear and this was debrided.  Radial volar synovitis and a full thickness central volar lunate fossa defect measuring 3x4mm were also noted.  The defect was treated with microfracture and drilling with limited local debridement.  She also had right wrist synovitis in the volar ganglion and luno-hamate arthrosis, grade 2.  She was referred to the Navy Physical Evaluation Board (PEB) and was placed on the Temporary Disabled Retirement List (TDRL) in 2005 with a 30% disability rating for 5299-5214 Right Wrist with Grade II Lunotriquetral Ligament Insufficiency status post Arthroscopic Debridement and Pinning.  She then fell while roller skating in September 2006 (while on TDRL) and fractured her distal radius.  She had open reduction and internal fixation (ORIF) and the plate and screws were still in place at the TDRL periodic exam in 2007.  She also had a flare of pain after her hand was hit by another person at the Strawberry Festival.  X-rays were noted to have disuse osteopenia and mild degenerative changes by the VA hand surgeon at a visit 20060530.  Since the time of placement on TDRL, the CI was working at a desk job using a computer.  She worked as a civilian Intelligence Specialist at Central Command.

Appropriate therapy failed to alleviate her symptoms and she was referred to the PEB in 2005.  CI was placed on the TDRL on 20051031 and had her first TDRL periodic evaluation in June 2007.  The Navy Informal PEB determined she was fit for duty on 20070713. She then demanded a Formal PEB, was found unfit, and was separated with a 10% disability for 8712 Right Wrist Synovitis using the Veterans Affairs Schedule for Ratings Disabilities (VASRD) and applicable Navy and Department of Defense regulations.
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CI CONTENTION:  The CI states:  “I was in a car accident 18 August 2001 while stationed in Ankara. Turkey, I injured my (R) wrist and was initially diagnosed as a bad sprain.  After about a week of occupational therapy, the pain got worse.  The doctor performed surgery in April 2002 and found a torn ligament and inserted three pins. This was the first of five surgeries.  Twelve weeks later, July 2002, the pins were removed.  I then completed around five months of occupational therapy.  In 2004 I injured my (R) wrist again.  The doctor performed surgery in February to fix a torn cartilage.  I completed approximately five months of Occupational therapy.  In 2005 I injured my (R) wrist a third time.  I tore my ligament again. In March the doctor put in three pins for twelve weeks.  The pins were removed in June.  As I was working on occupational therapy, my board was submitted and I was rated 30%, and placed on the TDRL.  In September 2006 I fell (wearing a wrist brace) and broke two bones in my (R) wrist.  The doctor performed surgery and put in plate and four screws.  I completed about another five months or occupational therapy.  I had my 18 month evaluation in 2007.  The doctor said I was unfit for duty, but the board came back with a finding of fit.  I requested a formal board and in September 2007, the board gave me 10% for chronic pain.  I was separated from the Navy in December 2007.  I am right hand dominant.  This injury has caused a significant change in my quality of life.  I have chronic pain for which I take Tylenol 3 with codeine and wear a brace.  I have difficulty doing everyday things: I have pain when I iron clothes, use a can opener, brush my teeth, blow dry my hair, drive for long periods.  I have pain after about five minutes of typing or writing.  I start having pain when holding a book to read, lean on my hand, lifting items.  And I even wake up with pain.  I worked hard as a First Class Petty Officer in the Navy and was looking forward to earning my khakis as a Chief Petty Officer and retiring at my 20 year mark.  I did approximately 14.5 years, received good evaluations and held leadership positions.  I strongly believe my rating should be at least 30%.  My VA rating for my (R) wrist is 30%.”
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RATING COMPARISON:

Previous Determinations 	
Service	VA	
PEB Condition	Code	Rating	Date	Condition	Code	Rating	Exam Date	Effective date	
Right Wrist with Grade II Lunotriquetral Ligament
Insufficiency Status Post Arthroscopic Debridement and Pinning	5299-5214	30%	TDRL July 2005

>>Fit July 2007	Right Wrist with Grade II  Lunotriquetral Ligament
Insufficiency Status Post Arthroscopic Debridement and Pinning  [Predischarge Exam]	5299-5214	30%	20050824	20051031	
Right Wrist Synovitis	8712	10%	FPEB
October 2007	Anxiety Disorder with Depressive Disorder also Claimed
as Adjustment Disorder [Predischarge Exam]	9400	30%	20050824	20051031	
				Lumbar Strain [Predischarge Exam]	5237	10%	20050824	20051031	
				Right Knee Patellofemoral Pain Syndrome [Predischarge
Exam]	5260	10%	20050824	20051031	
				Left Foot Plantar Fasciitis [Predischarge Exam]	5284	10%	20050824	20051031	
				Tinnitus [Predischarge Exam]	6260	10%	20050824	20051031	
				Hypertension [Predischarge Exam]	7101	10%	20050824	20051031	
				Migraine Headaches [Predischarge Exam]	8100	10%	20050824	20051031	
				Degenerative Changes, Left Shoulder [Predischarge Exam]	5010-5203	0%	20050824	20051031	
				4 other conditions 	NSC				
TOTAL Combined:  10%	TOTAL Combined (incl non-PEB Dxs):   
80% from 20051031 (Bilateral factor 1.9 for 5284, 5260)                                                                 

ANALYSIS SUMMARY:
Multiple Injuries and Surgeries to Right Wrist
Navy:
At TDRL evaluation in June 2007: CI complained of pain and stiffness and pain with lifting and opening jars.  She is right hand dominant and has to use her left hand more than normal, including to use the computer mouse.  She cannot lift weights with her right upper extremity.  She uses NSAIDS for pain. Physical examination documented decreased range of motion (ROM) with 50 degrees of dorsiflexion (extension) and 40 degrees of palmarflexion (flexion), symmetric grip strength, intact sensory examination, pain with motion and tenderness to palpation. Radiologic studies were interpreted by examiner to show advanced radiocarpal arthritis and hardware with screws.  Assessment was post-traumatic wrist arthritis on the right.  There is no mention of when pain occurred with ROM exam or the effect of repeated motion on examination.  She had previously been prescribed a splint to support and protect her wrist and she appears to have been wearing it most of the time.

VA:
Using an evaluation completed 20050824 near the time the CI entered the TDRL, the Veterans Administration (VA) rated this disability as 5299-5214 Right Wrist with Grade II Lunotriquetral Ligament Insufficiency status post Arthroscopic Debridement and Pinning at 30% based on decreased ROM, significant pain with ROM, and significant weakness with motor strength recorded as 3/5.  Although the decreased ROM did not reach the level for a compensable rating by itself, the totality of the CI’s functional limitations warranted a 30% rating.  This rating was done approximately two years before the CI separated from the Navy.
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BOARD FINDINGS 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.  After careful consideration of all available information, the Board unanimously concluded that the CI’s condition is appropriately rated at 20% for 5010-8712 Right Wrist Synovitis.  
 
While the CI continued to have functional limitations in 2007, her condition had improved when compared to her condition at the time of TDRL placement in 2005.  This is true even though she fractured her distal radius and underwent ORIF while on the TDRL.  In 2005 she had somewhat decreased range of motion of her wrist, significant pain with motion, decreased strength, and extremely limited endurance due to pain and weakness.  There was no evidence of weakness in her 2007 TDRL evaluation, 20060530 progress note from a VA Hand Surgeon, 20061128 note from Occupational Therapy, or 20061211 and 20070102 notes from an Orthopedic Surgeon in Florida.  She did have continued pain and pain with motion and increased use in 2007. Her pain was not constant.  By history she continued to have decreased endurance as evidenced by increased pain with increased typing and other activities.  However, this does not appear to be at the level documented in her 2005 VA evaluation.  She did require the use of a protective splint that had been prescribed prior to 2005.  And, although she was successfully employed, her computer work was less efficient because of her limitations and she was unable to perform some assigned tasks, such as emptying the shredder trash bag.  The Board determined that this level of functional limitation was appropriately rated analogous to mild incomplete paralysis of the lower radicular group on the dominant side. 

The Board also examined Adjustment Disorder, Lumbar Strain, Right Knee Patellofemoral Pain Syndrome, Left Foot Plantar Fasciitis, Tinnitus, Hypertension, Migraine Headaches, and Left Shoulder Degenerative Changes and did not find any of these conditions to be unfitting. 
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RECOMMENDATION:  The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of the CI’s prior medical separation.

Unfitting Condition	VASRD Code	Rating	
trauamtic arthritis/right wrist synovitis	5010-8712	20%	
Combined	20%	
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The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20090404, w/atchs.
Exhibit B.  Service Treatment Record.
Exhibit C.  Department of Veterans' Affairs Treatment Record.

	

MEMORANDUM FOR DEPUTY COMMANDANT, MANPOWER & RESERVE 
                                        AFFAIRS

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR)
          RECOMMENDATION ICO XXXXXX

Ref:   (a) DoDI 6040.44

Encl:  (1) PDBR ltr dtd 17 Sep 09 

1.  I have reviewed subject case pursuant to reference (a) and accept the recommendation of the Physical Disability Board of Review (enclosure (1)).

2.  Ms. XXXXX’s official records are to be corrected to reflect the following disposition:

	a. Separation from the naval service due to physical disability rated at 20% with entitlement to disability severance pay effective 17 Dec 2007.

3.  Please ensure all necessary actions are taken to implement this decision, including the recoupment of previously paid funds if appropriate, and that Ms. XXXX is notified once those actions are completed.