RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXX	CASE:  PD-2013-00068
BRANCH OF SERVICE:  AIR FORCE	BOARD DATE:  20131119
SEPARATION DATE:  20040820

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SrA/E-4 (3E052/Electric Power Production Journeyman) medically separated for a multiple finger amputations.  The CI sustained crush injuries to his left hand in 2003 during a deployment to Iraq that required surgeries and occupational therapy.  During his post-deployment period, the CI was diagnosed with adjustment disorder and posttraumatic stress disorder (PTSD), which was treated with counseling.  The CI’s physical profile could not be elevated to meet the physical requirements of his Air Force Specialty (AFS) or satisfy physical fitness standards.  He was issued a permanent U3 profile and referred for a Medical Evaluation Board (MEB).  Finger amputations, PTSD and bilateral compartment syndrome (legs) conditions were forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123.  No other conditions were submitted by the MEB.  The PEB adjudicated finger amputation left 3rd and 4th digits associated with PTSD as unfitting, rated 20%.  The remaining conditions were determined to be not unfitting.  The CI made no appeals and was medically separated.

CI CONTENTION:  “PTSD was diagnosed on the narrative summary and listed on the medical board, but I was never evaluated for this condition prior to being medically discharged.  If you review my VA rating, it shows that my PTSD rating of 30% is back dated to date of discharge.  This condition, if properly evaluated in conjunction with my hand injuries, would have entitled me to a medical retirement. Bilateral Leg Compartment Syndrome was diagnosed on the narrative summary and listed on the medical board, but I was never evaluated for this condition prior to being medically discharged.  If you review my VA rating, it shows that my Bilateral Leg Compartment Syndrome rating of 20% is back dated to date of discharge. This condition, if properly evaluated in conjunction with my hand injuries, would have entitled me to a medical retirement.”

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e.(2).  It is limited to those conditions determined by the PEB to be unfitting for continued military service and those conditions identified, but not determined to be unfitting by the PEB when specifically requested by the CI.  The rating for the multiple finger amputations, PTSD and bilateral leg compartment syndrome are addressed below.  Any other condition or contention not requested in this application, remain eligible for future consideration by the Board for Correction of Military Records.  

RATING COMPARISON:

Service IPEB – Dated 20040605	VA1 - based on Service Treatment Records (STR)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Finger Amputation Left 3rd and 4th digits w/associated PTSD	5149	20%	Left Hand Amputation of Middle & Ring Finger...	5141	30%2	STR	
			PTSD	Deferred3	--3	--3	
Hx of Bilateral Leg Compartment Syndrome	Category II	Bilateral Leg Condition4	Deferred4	--4	--4	
No Additional MEB/PEB Entries	Other x 5	--5	
Combined:  20%	Combined:  30%	
1. Derived from VA Rating Decision (VARD) dated 20041001 (most proximate to date of separation [DOS])
2. No change to rating derived from C&P x exam subsequent C&P exams
3. Initially rated 10% effective 20040821 day after DOS, based on C&P PTSD exam 20041129, then increased to 30% also effective 20040821, based on Board of Veterans’ Appeals 20080904
4. Initially not service connected for “bilateral leg compartment syndrome” then rated 10% each for left and right leg compartment syndrome effective 20040821 day after DOS, based on C&P joints exam 20090918
5. C&P General exam 20041130

ANALYSIS SUMMARY:  The Board acknowledges the CI’s contention that suggests a higher rating should have been granted at the time of separation.  IAW DoDI 6040.44, the Board’s authority is limited to making recommendations on correcting disability determinations.  The Board’s role is thus confined to the review of medical records and all evidence at hand to assess the fairness of PEB rating determinations, compared to Veterans Affairs Schedule for Rating Disabilities (VASRD) standards, based on ratable severity at the time of separation and, to review those fitness determinations within its scope (as elaborated above) consistent with performance-based criteria in evidence at separation.  The Board also acknowledges the CI’s contention for ratings of his bilateral leg compartment syndrome condition which was determined to be not unfitting by the PEB.  Disability compensation may only be offered for those conditions that cut short the member’s career.  Should the Board judge that this contested condition was most likely incompatible with military service, a disability rating IAW the VASRD, based on the degree of disability evidenced at separation, will be recommended.  

The PEB combined finger amputation of left 3rd and 4th digits with associated PTSD as the single unfitting and solely rated condition, coded 5149.  The Board must apply separate codes and ratings in its recommendations, if compensable ratings for each condition are achieved IAW VASRD §4.71a.  If the Board judges that two or more separate ratings are warranted in such cases; however, it must satisfy the requirement that each “unbundled” condition was unfitting in and of itself.  The approach by the PEB not uncommonly reflected its judgment that the constellation of conditions was unfitting and there was no need for separate fitness adjudications or implied adjudication that each condition was separately unfitting.  The Board's initial charge in this case was therefore directed at determining if the PEB's approach of combining conditions under a single rating was justified in lieu of separate ratings.  When considering a separate rating for each condition, the Board considers whether each condition was separately unfitting.  When the Board recommends separate fitness recommendations in this circumstance, its recommendations may not produce a lower combined rating than that of the PEB.

PTSD Condition.  Soon after being medically evacuated from his deployed location for a non-combat related left hand injury, the CI presented with complaints of difficulty sleeping and concentrating, decreased interest, upsetting memories and recurrent nightmares about his injury.  He also avoided things related to his injury.  The CI was followed in the Behavioral Health clinic from July 2003 until March 2004.  He was involved in individual and group therapy.  Multiple notes by the same social worker written between 11 July 2003 and 3 March 2004 reported completely normal mental status exams.  Mood was consistently noted to be unremarkable, affect normal and suicidal ideation not present.  At a 3 March 2004 visit, a Global Assessment of Functioning (GAF) score of 75 (transient symptoms, no more than slight impairment) was assigned.  At the MEB psychological evaluation performed on 15 April 2004, 4 months prior to separation, the CI reported persistence of recurrent and intrusive recollections of his traumatic event.  He endorsed ongoing distressing dreams, intense distress when exposed to stimuli that remind him of the event, avoidance and markedly diminished interest in activities.  He also complained of sleeping difficulty, hypervigilance and exaggerated startle.  Treatment was considered to be helpful.  The author, in referring to the psychologically traumatizing hand injury, implied that there were other traumatizing events but did not specify any.  A mental status exam (MSE) was not performed.  An Axis I diagnosis of chronic PTSD was given.  A GAF of 60 (moderate symptoms or impairment) was assigned, but it was opined that symptoms would have a mild impact on social and occupational functioning.  On 22 April 2004 an outpatient summary, by a social worker who had provided continuous care for the CI’s mental condition, reported that the CI was currently receiving weekly individual or group therapy.  “War experiences” in addition to the injury were implicated in the genesis of his symptoms, but such experiences were not described.  An entry by a psychiatrist on 18 May 2004 noted a diagnosis of PTSD and that no medications were prescribed.  The commander’s letter noted an inability to satisfy duty requirements based on a profile that limited lifting, wear of chemical gear and performing physical training.  He missed 13 hours per week for medical appointments.  A termination of care note written on 9 June 2004 indicated the prognosis was considered “Good” and an S1 profile was assigned.  The enlisted performance report written on 16 July 2004 and covering the period from 16 July 2003 to 15 July 2004 indicated that during a winter storm, the CI “expediently troubleshot and repaired a faulty sand spreader…(and) provided roadside service to stranded motorists.”  He “aided in repair of base Auto Hobby shop… (and) installed a 50 kilowatt commercial Oman generator.”  He also “volunteered time and efforts to local community church – reroofed and renovated out-of-date facilities.”  A Report of Medical Assessment on 19 July 2004, a month prior to separation, stated that the CI had been followed “by Life Skills and psychiatry x 1 year.”  It indicated that PTSD was due to the hand injury and that he felt better after being on medication for the previous 2 months.  A VA Compensation and Pension (C&P) exam for PTSD was performed on 29 November 2004, 3 months after separation, but was not in evidence.  However, an evaluation by a psychiatrist for “medication management” was also performed that day and noted “similar findings of a current depression and PTSD.”  The CI stated that he had experienced “substantial improvement” when treated with medications in the service, but he ran out of medications three months prior.  Prior to taking those past medications, he reported drinking alcohol to calm himself.  More recently, he was drinking most nights until 3 weeks prior when he got into a fight and realized he needed to stop.  This incident caused him to reduce drinking to two beers every other night to help sleep.  He also reported working 70 hours per week as a courier, and recently went through a divorce.  He endorsed irritability, insomnia, hyperarousal, depression and loss of pleasure.  Other than a depressed mood and congruent affect, the MSE was normal.  The Axis I diagnosis was PTSD and recurrent major depressive disorder (mild to moderate severity).  GAF was 50 (serious symptoms or impairment).  Two psychotropic medications were prescribed.  At another C&P exam on 30 November 2004, it was reported that the CI was working 60 hours per week as a courier and noted that he had one drink per day.  Review of the record showed no evidence of emergency room visits or hospitalizations for psychiatric illness.

As noted above, the Board first considered if the PTSD condition, having been de-coupled from the combined PEB adjudication, remained itself unfitting as established above.  Members agreed that, based on the above evidence and mindful of VASRD §4.3 (reasonable doubt), there was a questionable basis for arguing that it was separately unfitting.  The well-established principle for fitness determinations is that they are performance-based.  The enlisted performance report, completed a month prior to separation, was not consistent with a significant degree of functional impairment from psychiatric symptoms.  The Board could not find evidence in the commander’s statement or elsewhere in the STR that documented any significant interference of the PTSD condition with the performance of duties at the time of separation.  There was no history of emergency treatment for psychiatric issues and no psychiatric hospitalization.  At no time was a profile other than S1 assigned and after separation, the CI worked 70 hours per week.  After due deliberation, members agreed that the evidence does not support a conclusion that the functional impairment from the PTSD condition was integral to the CI’s inability to perform his AFS requirements and, accordingly cannot recommend a separate rating for it.

Finger Amputation Left Third And Fourth Digits.  The right-handed CI sustained an injury to his left hand in April 2003 when his hand fell into the fan of a generator.  He underwent multiple surgeries over the next 2 months that resulted in amputations of the middle and ring fingers.  At an outpatient clinic visit on 23 February 2004 the CI complained of “occasional pain in his fingers.”  Dexterity issues prevented his use of small tools.  He complained of easy hand fatigue and some finger numbness and hypersensitivity.  An occupational therapy (OT) note on 26 February 2004 (8 months after surgery and 6 months prior to separation) indicated that grip strength testing was limited to one trial due to pain of residual digits.  At the narrative summary exam on 29 March 2004 (approximately 5 months prior to separation), the CI reported that OT had resulted in gradual improvement in left hand grip strength and digit range-of-motion, but recently he noted increased pain during OT, subjective decreased hand strength and easy hand fatigue.  He could not hold small tools for any length of time and lacked dexterity to use them appropriately.  Pain was limited to OT exercises or when the hand was accidentally struck.  Physical exam noted scarring of the index finger with a moderate mallet finger.  The middle finger was disarticulated at the proximal interphalangeal level (PIP; middle knuckle), with a desensate but irritable tip.  The ring finger was amputated beyond the PIP joint, which was fixed in flexion and hypersensitive.  The little finger was supple (but was reported to have an unstable nonunion of the distal phalanx).  Some muscle wasting was present on the dorsum of the hand between the index, middle and ring fingers.  An OT visit on 5 April 2004 indicated the CI was having no hand pain.  At a C&P evaluation on 30 November 2004 (3 months after separation) physical exam noted a good hand grip and normal muscle function.  At another C&P exam on 2 December 2004 (3 months after separation) hand or finger pain and hand fatigue were not reported.  Physical examination noted that weakness of hand grip was present “because of the absence of the long and ring fingers beyond the PIP joints.”  Repetition of hand grip was not performed.  The little finger had some limitation of motion of the distal interphalangeal joint (DIP; knuckle nearest fingernail).  The DIP joint of the index finger attained a position of neutrality, but flexion of the distal phalanx was “limited to 30 rather than 45 degrees.”

The Board directs attention to its rating recommendation based on the above evidence.  Regarding the amputated fingers condition, there was a preponderance of evidence that it was unfitting.  The PEB assigned a rating under the 5149 code.  This code identifies the middle (long) finger and the ring finger as amputated (per VASRD 4.71a, the term “amputation” for multiple finger involvement applies to amputations at the proximal interphalangeal joints or through proximal phalanges); and justifies a 20% rating if the non-dominant hand is involved.  Based on the STR, the VA assigned a 30% rating under the 5141 code, which identifies amputations of the middle, ring and little fingers.  Notwithstanding the PEB’s determination that only the middle and ring finger amputations were unfitting.  Board members agreed that that identification of the little finger as amputated for rating purposes was not supported by the evidence, and a 20% rating under the 5149 code was appropriate.  The Board deliberated pathways to a rating higher than 20%.  “Limitation of motion of digits” (5229 code) and “unfavorable ankylosis of two digits” (5219 code) options offer no advantage to the CI.  Likewise, although a muscle coding pathway (5307; flexion of wrist and fingers) is a poor clinical fit for this case, a level of “severe” (justifying a 30% rating) would not be approached anyway.  Finally, the evidence did not support application of §4.40 or §4.45 as an avenue to the next higher 30% rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 20% for the left 3rd and 4th finger amputation condition.

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that bilateral leg compartment syndrome was not unfitting.  The Board’s threshold for countering fitness determinations is higher than the VASRD §4.3 (reasonable doubt) standard used for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  The CI first presented in September 2003 with complaints of a 10-month history of calf pain with activity.  Orthopedic evaluation in March 2004 noted a chief complaint of bilateral calf numbness with running, using a stairmaster and prolonged walking.  The numbness began 5-10 minutes after exercise.  Pressure measurements in April 2004 concluded that bilateral compartment syndrome was present.  The CI was considered to be a surgical candidate, but surgery was not performed.  A Report of Medical Assessment on 19 July 2004 noted that the CI was unable to exercise due to leg pain.  Examination findings showed no calf swelling or tenderness and a normal gait.  The undated commander’s letter referred to a profile restriction of no squadron physical training or ergometry testing.  A temporary L3 profile was written on 7 April 2004 that specified no marching greater than a half mile and no running, but a revised permanent profile on 13 April assigned an L1 profile.  The bilateral compartment syndrome condition was not judged to fail retention standards.  It was reviewed and considered by the Board.  There was no performance based evidence from the record that this condition significantly interfered with satisfactory duty performance.  After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for this contended condition and so no additional disability rating is recommended.

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 Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication.  PEB reliance on DoD guidelines for rating finger amputation with PTSD was operant in this case and the condition was adjudicated independently of that instruction by the Board.  In the matter of the finger amputation with PTSD condition, the Board unanimously recommends that it be adjudicated for two separate conditions.  In the matter of the finger amputation left 3rd and 4th digits non-dominant hand, the Board unanimously recommends a disability rating of 20%, coded 5149.  In the matter of the PTSD condition, the Board agrees that it cannot recommend a finding of unfit for additional disability rating.  In the matter of the contended bilateral leg compartment syndrome condition, the Board unanimously recommends no change from the PEB determination of not unfitting.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of his/her prior medical separation:

UNFITTING CONDITION	VASRD CODE	RATING	
Finger Amputation Left Third & Fourth Digits	5149	20%	
PTSD	Not Unfit	
RATING	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20130128, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

PDBR PD-2013-00068

MEMORANDUM FOR THE CHIEF OF STAFF

	Having received and considered the recommendation of the Physical Disability Board of Review and under the authority of Title 10, United States Code, Section 1554a (122 Stat. 466) and Title 10, United States Code, Section 1552 (70A Stat. 116) it is directed that:

	The pertinent military records of the Department of the Air Force relating to XXXXXXXXXXXXXX, be corrected to show that the diagnosis in his finding of unfitness was Finger Amputation Left Third & Fourth Digits, VASRD Code 5149, rated at 20% ; rather than Finger Amputation Left Third & Fourth Digits with associated PTSD, VASRD Code 5149 rated at 20%.