RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2013-01223
BRANCH OF SERVICE:  Army	BOARD DATE:  20150415
SEPARATION DATE:  20030811

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reserve O-3 (Medical-Surgical Nurse) medically separated for a left knee and left upper extremity reflex sympathetic dystrophy (RSD) conditions.  These conditions could not be adequately rehabilitated to meet the physical requirements of the Military Occupational Specialty or satisfy physical fitness standards.  A permanent P3/U3/L3 profile was issued and the CI referred for a Medical Evaluation Board (MEB).  Left knee pain and bilateral carpal tunnel syndrome (CTS) left greater than right, status post surgery on the left with RSD syndrome were forward to the Physical Evaluation Board (PEB) as medically unacceptable IAW AR 40-501.  The MEB also identified and forwarded depression and posttraumatic stress disorder (PTSD), childhood asthma, left shoulder pain, and rectal abscess for PEB adjudication as medically acceptable.  The Informal PEB (IPEB) adjudicated chronic pain, left knee as unfitting, rated 10% with application of the US Army Physical Disability Agency (USAPDA) pain policy.  The IPEB also adjudicated RSD, left upper extremity (LUE) following surgery for CTS as existing prior to service (EPTS) and not permanently service aggravated.  The remaining conditions were not adjudicated and therefore considered not unfitting.  The CI made no appeals and was medically separated.

CI CONTENTION:  “Presently I am a 50% with my disability when I feel it should be more.  I didn’t get anything for depression, my General Anxiety Disorder, and had my left leg decreased from 20% to 10%.  I was treated for oval-pharyngeal cancer in 2011 and feel that this cancer related to asbestus exposure when I was assigned at Fort Ord, California – 1972, here at Fort Sam Houston, Texas in 1973 & 1974, and when I was stationed in Aeshepehenburg, Germany in 1975.”

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 Veterans Affairs Schedule for Rating Disabilities (VASRD) / 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:

IPEB – Dated 20041108	VA* - (~9 Mos. Pre-Separation and Service Treatment Records (STR))	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Pain, Left Knee	5009-5003	10%	Left Knee Arthritis	5010-5261	10%	20040406	
Reflex Sympathetic Dystrophy, Left Upper Extremity following Carpal Tunnel Syndrome Surgery	8599-8513	---	Reflex Sympathetic Dystrophy Syndrome	5099-5025	NSC	STR	
			Left Arm Carpal Tunnel Syndrome…	8515	NSC	STR	
Depression and PTSD	Not adjudicated
Not Unfitting	Depressive Neurosis	9499-9410	NSC	STR	
		Dysthymic DO	9499-9433	NSC	STR	
Other x 4 (Not In Scope)	Other x 4	
RATING:  10%	RATING:  10%	
*Derived from VA Rating Decision (VARD) dated 20050629 (most proximate to date of separation (DOS))

ANALYSIS SUMMARY:

Left Knee.  The narrative summary (NARSUM) noted the knee was injured during training and left knee surgery was performed in 1994 and a second surgery in December 1995 for meniscal tear repair.  Notes in the STR indicated that the CI reported continued knee pain with limited ability to run at a primary care (PC) evaluation on 7 April 2003.  On exam there was a normal gait with full range-of-motion (ROM).  Left knee X-rays on 11 April 2003 were normal.  The next PC visit on 19 May 2003 indicated the CI reported for renewal of a profile and reported doing well; no pain, could walk, and do “PT.”  A physical fitness (PT) test was scheduled soon.  A duty status report on 25 October 2004 indicated that the CI reported chronic knee pain on 19 May 2003.  During a primary care telephone consult on 21 May 2003 the CI reported recent flare-up of the chronic knee pain during a PT test.  Orthopedic evaluation on 11 July 2003 indicated “L knee pain s/p menisectomy X 2” and recommended anti-inflammatory medication and initiation of an MEB.

At the MEB NARSUM Orthopedic evaluation on 13 April 2004, approximately 9 months prior to separation, the CI reported left knee pain and use of a cane with flares.  The exam noted use of a cane and an antalgic gait.  There was tenderness to palpation (TTP) of the joint line without swelling or effusion.  Knee ROM was extension-flexion of 0-125 degrees (normal 0-140), limited by pain.  There was no evidence of instability or acute meniscal injury.  There was full strength of the surrounding muscles.  The examiner noted knee X-rays showed no evidence of degenerative joint disease (DJD).  At the MEB NARSUM examination on 19 April 2004, 9 months prior to separation, the CI reported constant knee pain with intermittent use of a cane.  The MEB physical exam noted “decreased” ROM limited by pain without effusion.

At the VA Compensation and Pension (C&P) examination on 6 April 2004, also approximately 9 months prior to separation, the CI reported constant pain and stiffness that did not cause incapacitation or lost time from work.  The CI reported no treatment for the condition at the time.  The exam noted a normal gait.  There was no sign of abnormal weight bearing on the feet and the CI was not using a cane or crutches.  There was full ROM of the left knee with crepitus noted, without evidence of instability or symptomatic meniscal injury (semilunar cartilage).  Lower extremity strength, sensation, and reflexes were normal.  Left knee x-rays showed minimal evidence of DJD.

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB rated the left knee condition 10%, coded 5099-5003 and cited the USAPDA pain policy and the VA rated it 10%, coded as 5010-5261 (limited leg extension with traumatic arthritis).  The Board agreed that the evidence in record supports a 10% rating with multiple applicable §4.71a codes, including 5003 for painful, limited motion of a single major joint with evidence of degenerative changes; 5259 (symptomatic semilunar cartilage, removal); or, with a ROM code for painful motion IAW VASRD §4.59 (painful motion).  The Board reviewed to see if any higher evaluation was achieved with any code, but there was no evidence of compensable limitation of ROM based on ROM alone, frequent episodes of “locking”, pain, and effusion into the joint, instability, or impairment of the femur, tibia, or fibula resulting in knee disability, or evidence of any other ratable impairment of the knee.  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 left knee condition.

Reflex Sympathetic Dystrophy, Left Upper Extremity and associated Left Carpal Tunnel Syndrome.  The LUE reflex sympathetic dystrophy (RSD – also known as complex regional pain syndrome) condition occurred due to an injury sustained in 1999 while the CI was not on active duty (AD).  The PEB, adjudicated the LUE RSD condition as unfitting, but EPTS (existed prior to service), without evidence of service aggravation.  During this period of AD, the CI reported that the left shoulder began to ache while walking during physical fitness testing and at physical therapy visits the LUE pain was referred to alternately as RSD or shoulder impingement.  On a Post-Deployment Health Assessment, the CI reported aggravation of the RSD condition during deployment.  The Board noted that IAW DoDI 1332.38 that there is a presumption of service aggravation of any EPTS condition, which can only be overcome with clear and unmistakable evidence based upon well-established medical principles, and the source of the well-established medical principles upon which the determination is based must be cited.  In this case there was no evidence cited for the PEB’s determination that there was “compelling evidence” that the condition was not service aggravated during active duty.  Additionally three temporary profiles were written between 22 May 2003 and 21 July 2003; all noted left arm and shoulder pain and the final profile listed left shoulder pain and RSD of the LUE.  The Board concluded that the evidence in record supports the unfitting LUE condition was service aggravated and is therefore eligible for disability rating.  Thus, the Board reviewed the evidence in record regarding the LUE RSD condition for a rating recommendation.

The MEB NARSUM examination, 9 months prior to separation, noted that the CI had a past medical history of bilateral CTS with a diagnosis of RSD of the LUE following CTS surgery.  The NARSUM noted that these conditions were EPTS, diagnosed in February 2000.

An orthopedic evaluation on 19 June 2000 recounted that the CI had injured the left wrist while working as a civilian as private duty nurse on 13 September 1999 and underwent complicated hand/wrist surgery that included carpal tunnel release.  Following rehabilitation the CI was released to modified work duty.  A comprehensive orthopedic exam on 19 June 2000 noted the CI was right hand dominant and the exam of the LUE was normal except for tenderness of the top of the wrist and positive evidence of median nerve compression (Tinel’s) of the left wrist.  The examiner noted “mild evidence of recurrent CTS” and “no evidence of RSD at this time.”  A “history of mild RSD” was noted and the orthopedic specialist recommended prophylactic avoidance of lifting, pushing, pulling, or repetitive use of the LUE to avoid recurrence of the CTS and concluded that the CI was unable to lift and move patients.

The CI was mobilized on 20 March 2003 and reported an injury to the left shoulder during physical training on 21 May 2003.  Notes in the STR indicate that on 22 May 2003, the CI reported pain that radiated down the left arm with weakness during the training, but denied pain at the medical evaluation a day later, and reported the ability to work “for now.”  The past diagnosis of RSD was noted.  At a PT visit on 28 May 2003, the CI reported that during the PT test “noted achiness walking” and the arm symptoms persisted.  The exam noted full ROM of the LUE with pain with an assessment of shoulder impingement.  A PT note dated 25 June 2003 noted painful shoulder flexion and abduction, flexion and abduction decreased by approximately 15 degrees, and strength limited by pain.  The therapist provided the opinion that the CI still had RSD of the shoulder, which limited strength and ROM.  The therapist recommended the CI slowly return to weightlifting and swimming and return for care as needed.  Electrodiagnostic studies of the LUE on 25 June 2003 were normal, with no evidence of CTS.  A visit to discuss the MEB on 21 July 2003 noted left shoulder tenderness with ROM of flexion of 100 degrees and abduction of 100 degrees, with no skin abnormalities.

On a Post-Deployment Health Assessment, performed in August 2003, the CI reported that the “RSDS has been aggravated causing me constant pain.”  The commander’s statement dated 24 October 2004 referenced an Officer Evaluation Report (OER) completed in August 2003, which noted the CI was able to “complete her duties without limitations.”  The OER indicated the CI’s duty performance was outstanding as a clinical nurse in an intensive care unit, although unable to complete the sit-up event of the Army Physical Fitness Test.

On the MEB DD Form 2807, Report of Medical History, dated 5 April 2004, the CI reported that the RSD symptoms were now intermittent, but had been aggravated during training.  The CI was on no medications at the time, except as-needed over the counter anti-inflammatory medication.  The MEB DD Form 2808, Report of Medical Examination, dated 18 April 2003, noted pain, slight LUE weakness and full ROM of the elbow and wrist and full shoulder ROM with assistance.  The MEB NARSUM examiner, 9 months prior to separation, noted that knee symptoms impaired the performance of military duties and did not mention the LUE.  The MEB NARSUM orthopedic exam simply noted the diagnosis of RSD and that the CI reported being evaluated by another service, with no examination of the LUE documented.

At the VA C&P examination on 6 April 2004 9 months prior to separation, the CI reported left shoulder impingement and intermittent RSD symptoms as often as daily described as pain mainly of the LUE that traveled from the shoulder to the arm, with numbness and tingling, and weakness.  The current treatment was noted to be anti-inflammatory medication and there had been no lost work time due to the condition.  The CI also reported left CTS with the same symptoms noted for RSD and no lost time from work.  The exam noted the CI was right hand dominant and the appearance of the left side was normal.  Shoulder ROM was described as the “degrees that pain occurs” and reported as 30 degrees of flexion (normal 180) and 20 degrees of abduction (normal 180).  Wrist ROM was normal, with no pain noted.  There was normal strength, sensation, and reflexes of the upper extremities.  A positive test for carpal tunnel syndrome (Tinel’s sign) was noted on the left.  Shoulder, humerus, and forearm X-rays were normal.

The Board directed its attention to its rating recommendation based on the above evidence.  As elaborated above the PEB adjudicated the LUE RSD as EPTS and not permanently service aggravated.  A VARD on 7 May 2004 did not service-connect RSD and noted that there was no evidence of a clinical diagnosis of RSD.  The VARD on 29 June 2005 addressed additional medical evidence provided by the CI and did not service-connect any conditions of the LUE noting that carpal tunnel was due to an injury in 1999 and was not incurred or aggravated by military service, and there no evidence to support changing the denial of service-connection for RSD.

The Board determined that evidence in the record supports the CI had intermittent RSD symptoms at separation.  The MEB NARSUM exam noted slight weakness of the non-dominant LUE was noted and at the C&P exam normal strength, sensation, and reflexes of the LUE were noted, with tenderness over the median nerve.  The Board noted that the rating criteria for 8615 (incomplete paralysis of the median nerve) is the appropriate nerve code for CTS or analogous code for RSD related to median nerve injury, which are subjective and described as “mild” for 10%, “moderate” for 20% , and “severe” for 40% rating of the non-dominant upper extremity IAW VASRD §4.124a.  Members agreed that the evidence in record supports that the disability due to the intermittent LUE symptoms of pain and subjective sensory disturbances, without significant motor or sensory deficit was best described as mild and rated 10%, coded as 8699-8615 (analogous to median nerve neuritis, analogous code for RSD).
The Board also considered the C&P examination findings 9 months prior to separation which noted limited shoulder ROM as an additional coding option.  Corroborating exams consisted of a PT evaluation, 7 months prior to separation, which documented shoulder flexion and abduction ROMs decreased by approximately 15 degrees (approximately 165 degrees, well above shoulder level).  Additionally, a primary care visit for the MEB, 6 months prior to separation, cited arm ROM above shoulder level.  The Board determined this evidence supports a 10% rating IAW §4.59 (painful motion) utilizing code 5201 (arm limitation of motion).  However, the Board concluded that this pain symptom was already a component of the LUE pain criteria noted above and if applied again would be considered pyramiding IAW §4.14 (avoidance of pyramiding).  After due deliberation, considering all of the evidence and mindful of VASRD 4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the LUE RSD condition, coded 8699-8615.

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the depression condition was not unfitting at the time of separation.  The Board’s threshold for countering fitness determinations requires a preponderance of evidence, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.

Depression and PTSD (contended Generalized Anxiety Disorder).  The MEB forwarded “Depression and PTSD, EPTS medically acceptable” to the PEB.  The PEB did not adjudicate an MH condition and the PEB’s silence on the MH condition is taken by the Board as a de facto determination that the MH condition was considered not unfitting, and therefore, not eligible for disability rating.  The MEB NARSUM simply noted “Depression and PTSD, EPTS” and that the CI was on no medications.  Distant records indicated the CI was diagnosed and treated for various MH conditions of “character disorder,” depression, and dysthymic disorder, decades before separation.  Notes in the STR addressed the CI’s past MH history.

An MH note on 19 June 2003, approximately 19 months prior to separation, diagnosed an adjustment disorder, with difficulty due to work stressors and difficulty adjusting to military life.  The CI was started on an anti-depressant and at a visit on 2 July 2003 reported she was doing okay.  The mental status examination (MSE) was normal, without suicidal ideation.  At an MH visit on 8 July 2003 the CI reported a history of severe depression and PTSD due to trauma in childhood, as well as a history of untreated attention deficit/hyperactivity disorder (ADHD).  The examiner noted the CI had obtained a Master’s degree despite these issues.  An undated note within a year of separation indicated that the CI was upset due to a “work incident” the day before.  At remaining MH visits in the record the CI was noted to be focused on MEB issues.  She was tried on various anti-depressant and ADHD medications with some apparent benefit.  At most of these visits she had a normal mood, but reported to have been depressed and anxious mood a few visits.  In all cases she had an otherwise normal MSE.  The MEB NARSUM examination, approximately 9 months prior to separation, noted she was taking no medication.  The psychiatric profiles in evidence were S1 throughout her active duty service.  Her OER indicated the CI’s duty performance was outstanding as a clinical nurse in an intensive care unit.  The commander’s statement stated she was able to complete her duties without limitation but failed the Army physical fitness test.

The depression condition was not permanently profiled or implicated in the commander’s statement and was not judged to fail retention standards.  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 the mental health condition (depression, PTSD, and contended generalized anxiety disorder) and there was no evidence to recommend any MH condition as unfitting at the time of separation, 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.  As discussed above, PEB reliance on the USAPDA pain policy for rating left knee was operant in this case and the condition was adjudicated independently of that policy by this Board.  In the matter of the left knee condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the LUE RSD condition, the Board unanimously recommends that the condition was service aggravated and recommends a disability rating of 10%, coded 8699-8615 IAW VASRD §4.124a.  In the matter of the contended MH 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 recommends that the CI’s prior determination be modified as follows, effective as of the date of her prior medical separation:

CONDITION	VASRD CODE	RATING	
Chronic Left Knee Pain Condition	5099-5003	10%	
Reflex Sympathetic Dystrophy, Left Upper Extremity	8699-8615	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20130911, 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 
forXXXXXXXXXXXXXXX, AR20150011096 (PD201301223)

1.  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 to modify the individual’s disability rating to 20% without recharacterization of the individual’s separation.  This decision is final.  

2.  I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum.   

3.  I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures.

 BY ORDER OF THE SECRETARY OF THE ARMY:

Encl						     

CF: 
(  ) DoD PDBR
(  ) DVA