RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2013-01077
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060903

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (Petroleum Heavy Vehicle Operator) medically separated for a right upper extremity neurologic condition and bilateral patellofemoral syndrome.  These conditions could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty (MOS).  She was issued a permanent U3L2 profile and referred for a Medical Evaluation Board (MEB).  “Bilateral patellofemoral syndrome” and “reflex sympathetic dystrophy r/upper extremity” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded migraines as meeting retention standards.  The Informal PEB (IPEB) adjudicated “reflex sympathetic dystrophy right (dominant) upper extremity” and “bilateral patellofemoral syndrome” as unfitting rated 20% and 0%, respectively, with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The migraines were determined to be not unfitting.  The CI non-concurred with the IPEB findings but waived a Formal PEB (FPEB).  The USAPDA reviewed the case and affirmed the IPEB findings and recommendations, but completed an Administrative Correction to change the VA code and description.    

CI CONTENTION:  She was given a higher rating for her conditions by the VA.  Her complete submission is at Exhibit A.

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 when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting.  Any conditions outside the Board’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/Naval Records.  Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the VASRD standards to the unfitting medical condition at the time of separation.  The Board has neither the role nor the authority to compensate for post-separation progression or complications of service-connected conditions.  That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws.  The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation. 

RATING COMPARISON:  

PDA Admin Corr - Dated 20060718	VA* - (~1 Mos. Pre-Separation) 	
Condition	Code	Rating	Condition	Code	Rating	Exam	
RUE Neurologic Condition Mainly Affecting her Hand…	8799-8713	20%	RUE Reflex Sympathetic Dystrophy 		20%	20060821	
Bilateral Patellofemoral Syndrome	5099-5003	0%	Left Knee Patellofemoral Syndrome		10%	20060821	
Migraines	Not Unfitting	Migraines		30%	20060821	
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 5 	
COMBINED RATING:  20%	COMBINED RATING:  70%	
*Derived from VA Rating Decision (VARD) dated 20070312 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY:  

Right Upper Extremity Condition.  The service treatment record (STR) documents onset of hand symptoms beginning in 2004.  A nerve conduction study (NCS) demonstrated bilateral radial, and right median nerve neuropathies (injury or irritation of a peripheral nerves).  The CI underwent a right carpal tunnel release (CTR) for carpal tunnel syndrome ([CTS] compression of the median nerve in the wrist carpal tunnel causing numbness and tingling of the palm side of the thumb and fingers [sparing little finger]).  In the MEB history and physical (H&P) exam the CI reported onset of right hand pain in 2004.  The pain was intermittent and dull to sharp in nature.  The pain radiated to the elbow and towards the neck and was associated with finger paresthesias (abnormal sensation, tingling, burning and prickling).  Pain was exacerbated by lifting, gripping, grasping, repetitive motions and push-ups and symptoms worsened during her Iraq deployment (March 2004 to March 2005).  The diagnoses listed right CTS, right cubital tunnel syndrome (compression of the ulnar nerve in the elbow cubital tunnel causing numbness and tingling of the ulnar [little finger side] aspect of the forearm and hand), and bilateral radial tunnel syndrome (compression of the radial nerve in the radial tunnel causing lateral forearm pain without motor or sensory deficits).  The narrative summary (NARSUM) by an orthopedic hand surgeon, 4 months before separation, recounted the history and interventions.  The right-hand dominant CI reported a history of right hand pain, numbness and weakness.  The upper extremity evaluation was consistent with a right CTS and bilateral radial tunnel syndrome, without left-sided symptoms.  A right CTR was performed and the CI experienced some relief.  Postoperatively she developed reflex sympathetic dystrophy ([RSD] chronic extremity pain, swelling, limited range-of-motion [ROM], vasomotor instability, skin changes, and patchy bone demineralization following injury).  The CI was subsequently referred to occupational therapy (OT) and experienced some improvement.  The focused right upper extremity exam revealed a healed scar on palm with mild hypersensitivity.  The ROM of the fingers, hand, wrist, elbow, and shoulder was full except that the wrist lacked 20 degrees of extension.  The right upper extremity pain was listed as moderate in severity and constant in frequency per the American Medical Association (AMA) pain rating.  The diagnosis listed right upper extremity RSD.  The surgeon opined that no further orthopedic intervention was necessary and the CI’s condition was fair.  The functional status recorded decreased functionality of her right upper extremity with limited capacity for repetitive manual tasks.  The prognosis was characterized as marginal for full recovery and good for no further worsening.  The PEB proceedings were discontinued to gather additional information.  In a memorandum, the orthopedic surgeon responded to the PEB question "Are there any physical findings in the right upper extremity confirming RSD?" as follows:  “Her right upper extremity had a mild hypersensitivity.  Reflex Sympathetic Dystrophy (RSD, more recently called Complex Regional Pain Syndrome - CRPS) is characterized principally by neurogenic pain and hyperesthesias [abnormal increased sensitivity to stimulation]; it is a continuum from mild (probably often undiagnosed) to severe.  While advanced or severe cases may also have smooth, shiny skin as well, this Soldier did not exhibit these signs.  The absence of specific comment on this reasonably asserts that the only symptom SGT Bell has is the complaint of constant burning (neurogenic) pain without anatomic basis and the hyperesthesias.”  The VA pre-discharge exam documented the CI reported recurrent sharp shooting pain, from the right hand into the right elbow.  The symptoms prevented the CI from opening lids, lifting greater than 20 pounds, turning doorknobs or performing push-ups.  The exam recorded that tests for peripheral neuropathy and wrist flexion were both positive.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB, 2 months before separation, rated the right upper extremity condition 20% coded 8799-8713 (rating by analogy-all radicular groups neuralgia).  Neuralgia, cranial or peripheral, characterized usually by a dull and intermittent pain, of typical distribution so as to identify the nerve, is to be rated on the same scale, with a maximum equal to moderate incomplete paralysis.  The PEB cited right (dominant) upper extremity neurologic condition, areas supplied by both median and radial nerves, mainly affecting hand, diagnosed as RSD and right radial tunnel syndrome, predominant disability due to RSD, rated for neuralgia (all radicular groups).  The VA rating decision (VARD), 6 months after separation, rated the right upper extremity condition at 20% (mild incomplete paralysis of hand movements).  The VARD evidence included service medical records and VA treatment records.  The VARD cited right wrist pain and numbness, CTS, status post CTR, RSD, recurrent sharp hand pain shooting into the elbow, peripheral neuropathy, wrist flexion and functional limitations.  The NARSUM documented the CI realized modest benefit (some relief) from the corrective CTR surgery, but postoperatively developed RSD.  She subsequently experienced some symptom improvement with OT.  The exam revealed she lacked 20 degrees of wrist extension and had mild right upper extremity hypersensitivity.  The pain remained moderate in severity and constant in frequency.  Her right upper extremity functionality was decreased, but no further orthopedic intervention was necessary.  The CI’s condition was fair and the prognosis for no further worsening was good.  Per the memorandum, the CI’s only symptoms were constant burning pain, without anatomic basis and hyperesthesias.  Following an appropriate period of convalescence, the CI experienced incomplete resolution of her preoperative CTS symptoms, and developed mild RSD symptoms.  Board members agreed there was functional loss consistent with mild incomplete paralysis, rated 20%.  There was no evidence of disability for consideration of rating under 5214 (wrist, anklylosis of) or 5215 (wrist, limitation of motion of).  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the right upper extremity condition.

Bilateral Knee Condition.  The PEB combined the left and right knee conditions under a single disability rating and rated by analogy to degenerative arthritis (5099-5003).  Not uncommonly this approach by the PEB 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 PEB’s bilateral rating of 0% analogously to 5003 does not comport with the VASRD §4.71a stipulation for a 10% rating under 5003 for “2 or more major joints,” the latter without regard to ROM limitation or other factors.  Although VASRD §4.71a permits combined ratings of two or more joints under 5003, it allows separate ratings for separately compensable joints.  The Board must follow suit (IAW DoDI 6040.44) if the PEB combined adjudication is not compliant with the latter stipulation, provided that each ‘unbundled’ condition can be reasonably justified as separately unfitting in order to remain eligible for rating.  If the members judge that separately ratable conditions are justified by performance based fitness criteria and indicated IAW VASRD §4.7 (higher of two evaluations), separate ratings are recommended; with the stipulation that the result may not be lower than the overall combined rating from the PEB.  The Board’s initial charge in this case was directed at determining if the PEB’s combined adjudication was justified in lieu of separate ratings.
Left Knee Condition.  The service treatment record (STR) documents that the CI sustained knee injuries beginning in 1997.  A nuclear medicine bone scan was normal and showed no evidence of lower extremity stress fracture.  In the MEB H&P exam the CI complained of intermittent, throbbing knee pain.  It followed exertion and was associated with swelling and occasional giving way.  Pain was exacerbated by prolonged impact activities, running, and climbing stairs.  It was relieved by rest, ice, compression elevation (RICE), medications (NSAIDs and muscle relaxants), heat and knee braces.  The NARSUM recounted the history and interventions.  The CI complained of increasing bilateral knee pain on her yearlong deployment to Iraq and sought definitive treatment on return.  She reported that with constant load bearing, walking on uneven ground and rocks, her right knee would "give out".  The CI was told it was “just a sprain” and given Motrin, which did not help.  On redeployment, she was referred to physical therapy (PT) and given a brace.  At the time of the NARSUM, the CI had improved and only had symptoms with stairs and other climbing.  The focused lower extremity exam revealed full and symmetric ROM with normal strength (5/5).  The patellar grind (assesses abnormal patellar movement and painful crepitation) and patellar compression (apprehension or pain on quadriceps contraction with patella displaced) tests were positive.  The knee pain was listed as moderate in severity and occasional in frequency per the AMA pain rating.  The diagnosis listed bilateral patellofemoral syndrome ([PFS] symptom complex of anterior knee pain involving the patella).  The surgeon opined that no further orthopedic intervention was necessary and the CI’s condition was fair.  The functional status recorded the CI was unable to climb stairs or bear loads without risk of dropping them due to her knees.  The PEB proceedings were discontinued to gather additional information.  The orthopedic surgeon memorandum reported that bilateral knee ROM was full (0 to 140 degrees) and symmetric.  There was no pain associated with the motion but tests related to the patella were positive.  The VA pre-discharge exam documented the CI reported intermittent left knee pain.  A test of flexion and rotation of the left knee joint revealed painful motion.  There were no objective findings of limitation of motion present.  

Right Knee Condition.  With the exception of the right knee being implicated in the profile and a right knee sprain cited in the NARSUM, the overwhelming majority of STR evidence concerned bilateral knee complaints.  Specific details concerning the right knee condition are contained above under the left knee condition.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral knee condition 0%, coded 5099-5003 (rating by analogy-degenerative arthritis).  The PEB cited bilateral PFS without limitation of motion.  The VARD rated the left knee condition at 10%.  The VARD cited intermittent left knee pain, painful motion, and no objective findings of limitation of motion.  While the profile implicated right knee pain, the VA pre-discharge exam documented left knee pain.  The commander’s statement, orthopedic surgery NARSUM, MEB, PEB, and memorandum for the PEB all documented bilateral knee pain.  The orthopedic surgery NARSUM and PEB memorandum recorded full, symmetric, and pain-free ROM.  The VA pre-discharge exam documented no objective findings of limitation of motion, but painful motion.  The Board assigned more probative value to the NARSUM exam as it represented a comprehensive exam, by an orthopedic surgeon, and was in evidence.  The Board agreed the preponderance of the medical records involved evaluation and treatment of both knees.  The Board was unable to ascertain a differential in severity or impact on function.  Given this evidence, it agreed that both knees were unfitting.  The Board undertook to rate the individual right and left knee conditions.  There was no evidence of arthritis by X-ray to support a minimum rating under the degenerative arthritis (5003) or traumatic arthritis (5010) codes.  The NARSUM and VA pre-discharge exams showed no limitation of motion to support a minimum rating under the limitation of flexion (5260) or extension (5261) codes.  There was no ankylosis (5256), instability (5257), or dislocated meniscus (5258) to support a minimum rating under the respective codes.  The Board noted the presence of positive patellar grind and patellar compression tests, but these finding caused no functional impairment.  The Board agreed that neither knee was compensable IAW §4.71a, functional loss (§4.40) or painful motion (§4.59) given ROM findings and absence of pain on the probative (NARSUM and PEB memorandum) exams.  The Board found that the record in evidence supported a 0% rating for each knee and was unable to find any pathway to higher rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the bilateral knee condition 

Contended PEB Condition.  The Board’s main charge is to assess the fairness of the PEB’s determination that the migraine condition 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.  

Contended Migraine Condition.  The STR documents complaints of having headaches for about 3 years in a neurology encounter.  Headaches usually started in the left temple, or over the left eye, and spread to involve both temples.  Pain was characterized as a severe pounding sensation.  Headaches were associated with nausea, vomiting, photophobia (light sensitivity), dizziness, difficulty keeping balanced, and muscle weakness.  The CI denied diplopia (double vision), convulsions, fainting, memory lapses or loss, lost periods of time, abnormal sense of smell, speech difficulties, difficulty understanding speech, involuntary movements, poor coordination, tingling, numbness, or dysphagia (difficulty swallowing).  She reported no history of physical trauma or trauma to the head.  Headaches lasted 1-2 hours and occurred five times per month.  An abortive medication (Zomig) was effective for headaches, but was associated with adverse effects.  An antiemetic medication (Phenergan) was effective for nausea.  The neurological exam revealed normal gait, stance, balance, coordination, language, and level of consciousness.  Cranial nerves, sensation, muscle tone, strength, and deep tendon reflexes were normal.  The diagnosis listed common migraine (without aura).  The neurologist documented it was medically acceptable as the CI had not exhausted therapeutic treatments.  The MEB addendum by neurology recounted a three year history of migraines.  The migraines were significantly exacerbated when she deployed to Iraq, but worsened when she returned.  The headaches responded to Zomig, but it caused “a very unpleasant sensation of bilateral facial burning,” and took approximately 1-2 hours to work.  During the time the CI was in pain, she could not do anything.  She experienced approximately five headaches per month, and was therefore incapacitated for approximately 5-7 hours per month.  The neurologist started headache prophylaxis (Pamelor) and abortive (Phenergan, Indocin, and Midrin) medications and ordered a head CT.  The neurologist documented “At this time, her headaches are medically acceptable to the extent that we have no means whatsoever exhausted all treatment modalities, but her pain should be characterized as severe and occasional.”  Head/brain and sinus CTs were unremarkable except for minimal mucosal thickening in the right maxillary sinus.  The headache condition was not profiled or implicated in the commander’s statement.  It was not judged to fail retention standards by the MEB and was considered not unfitting and therefore not ratable by the PEB.  There was no indication 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 the headache condition; and, therefore, no additional disability ratings can be 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.  The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised.  In the matter of the right upper extremity condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the bilateral knee condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended migraine condition, the Board unanimously recommends no change from the PEB determination as not unfitting.  There were no other conditions within the Board’s scope of review for consideration.  

RECOMMENDATION:  The Board, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination. 

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20130729, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB						

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXXXXX, AR20150018443 (PD201301077)

I have reviewed the enclosed Department of Defense Physical Disability Board of Review (DoD PDBR) recommendation and record of proceedings pertaining to the subject individual.  Under the authority of Title 10, United States Code, section 1554a,   I accept the Board’s recommendation and hereby deny the individual’s application.  
This decision is final.  The individual concerned, counsel (if any), and any Members of Congress who have shown interest in this application have been notified of this decision by mail.

 BY ORDER OF THE SECRETARY OF THE ARMY:

Enclosure

CF: 
(  ) DoD PDBR
(  ) DVA