RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2013-01362
BRANCH OF SERVICE:  AIR FORCE	BOARD DATE:  20150428
Separation Date:  20040126

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Munitions Systems Apprentice) medically separated for left wrist pain.  The wrist condition could not be adequately rehabilitated to meet the physical requirements of his Air Force Specialty or satisfy physical fitness standards.  He was issued a temporary U4 profile and referred for a Medical Evaluation Board (MEB).  The “left wrist pain/stiffness” was forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123.  No other condition was submitted by the MEB.  The Informal PEB adjudicated “left wrist pain secondary to cubital tunnel syndrome and dorsal wrist synovitis status post left ulnar nerve decompression and partial synovectomy to left wrist” as unfitting, rated 20% with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The PEB also adjudicated tobacco abuse as Category III (a condition that is not separately unfitting and not compensable or ratable).  The CI made no appeals and was medically separated.

CI CONTENTION:  “I believe that my conditions were worse than what was rated and they continue to get worse.  Also my back and right arm should have been included but were not.”

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:

IPEB – Dated 20031114	VA - (~4Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Wrist Pain….	8716	20%	Left Cubital and Carpal Tunnel Syndrome	8511	20%*	20040507	
			Residuals of Fracture Left Radius	5212	0%	20040507	
Other x0	Other x5 (equals SC, NSC & deferred)	
RATING:  20%	RATING:  50%	
*VARD dated 20050922 increased the Left Wrist condition to 40% effective 20050809

ANALYSIS SUMMARY:  

Left Wrist Pain Condition.  The CI is right-hand dominant.  He tripped on a pallet and fell on his outstretched left wrist on 27 May 2002.  The emergency room doctor noted severe pain in the left wrist, inability to move his fingers with extreme pain and tenderness at distal radius.  An X-ray showed a non-displaced distal radius fracture.  The next day, the examiner noted no movement in 4th, 5th digits; decreased sensation left hand and no two point discrimination.  The examiner diagnosed ulnar nerve dysfunction, ordered a splint, narcotic medication and follow-up with orthopedics.  The orthopedist noted tenderness over the distal radius, an absence of sensation and guarding motion.  A left elbow X-ray showed no bone spurs or other problems.  The CI was seen by a different orthopedist who noted that the CI reported numbness and tingling in the left hand with physical exam findings of a positive Tinel’s sign over the elbow, and a weak grip.  The examiner diagnosed left ulnar neuropathy and ordered a splint and an electromyelogram (EMG).  The civilian neurologist noted that the CI reported pain in the left arm and wrist; and numbness and tingling on the last two digits of the left hand that radiated around the forearm to the elbow.  There were physical exam findings of normal reflexes, positive Tinel’s sign for ulnar nerve; hypersensitivity to pinprick over the ulnar nerve; very weak abduction and adduction of fingers and a hand grip of 19kg on the left as compared with 41kg on the right.  The EMG and nerve conduction study demonstrated a mild entrapment neuropathy of the ulnar nerve at the elbow.  There were physical exam findings of pain with active wrist extension which was limited to 40 degrees, flexion limited to 30 degrees; a positive elbow flexion test; and intrinsic muscle weakness with abduction and adduction of the fingers.  The examiner diagnosed left cubital tunnel syndrome and left wrist dorsal pain syndrome and recommended extensive ulnar nerve surgery.  On 26 February 2003, the CI underwent extensive left wrist arthroscopic surgery.  The civilian neurologist diagnosed left ulnar nerve entrapment, and mild carpal tunnel syndrome.  The examiner recommended a possible trigger point injection on the left elbow and wrist; keep elbow straight.  The physical therapist (PT) noted that the CI reported numbness and weakness in the 4th and 5th digits of the left hand, tingling and sharp pain in his elbow and shoulder and all symptoms were aggravated by any grasping activities and any use of the upper extremity.  The CI wore a left hand cock-up splint.  There were physical exam findings of mild atrophy in the thenar and hypothenar muscles of the hand, decreased active range-of-motion (ROM) at approximately 10 degrees for the left elbow flexion and extension with pain at the end range for wrist flexion, extension and elbow flexion and extension with passive ROM.  The MEB narrative summary (NARSUM) exam, approximately 5 months prior to separation, documented pain, stiffness, numbness and tingling in the left wrist and hand that showed no improvement with surgery.  A NARSUM Addendum, approximately 3 months prior to separation, documented that the CI reported numbness, tingling and weakness in his left hand and wrist.  There was no physical exam done at this evaluation.  The VA Compensation and Pension exam, approximately 3 months after separation, documented constant symptoms of left wrist pain and numbness.  He had a functional impairment as he could not lift objects or bend at the elbow.

There was one ROM evaluation in evidence, with documentation of additional ratable criteria, which the Board weighed in arriving at its rating recommendation; as summarized in the chart below.

Left Wrist ROM (Degrees)	MEB ~5.5 Mo. Pre-Sep	VA C&P ~3.5 Mo. Post-Sep	
Dorsiflexion (70 Normal)	No ROM’s	50	
Palmar Flexion (80)		70	
Ulnar Deviation (45)		Full	
Radial Deviation (20)		Full	
Comment:  Right Hand Dominant	Decreased grip strength & sensation	Pos. painful motion; Normal strength; Abnormal sensation due to pain; Pos. Deluca decrease	
§4.124a Rating	20% (PEB 20%)	20% (VA 20%)	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB coded the left wrist pain condition as 8716 (Ulnar nerve Neuralgia) and rated at 20% for moderate incomplete paralysis.  The VA coded the left cubital and carpal tunnel syndrome condition as 8511 (paralysis for the middle radicular group) and rated it 20% for “mild.”  The Board reviewed the tenants of Neuralgia §4.124 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.  There was ample evidence throughout the service treatment record that the CI had chronic pain, numbness and some weakness of left grip.  The Board considered the coding and rating schema used by the VA; however that would not result in a 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 left wrist pain condition.

Contended PEB Conditions.  The contended condition adjudicated as not unfitting by the PEB was tobacco abuse.  The Board’s first charge with respect to this condition is an assessment of the appropriateness of the PEB’s fitness adjudications.  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.  This condition was not profiled or implicated in the commander’s statement and was not judged to fail retention standards.  This condition was reviewed by the action officer and considered by the Board.  There was no indication from the record that any 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 tobacco abuse contended 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 left wrist pain condition and IAW VASRD §4.124a, the Board unanimously recommends no change in the PEB adjudication.  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 20130912, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

Dear XXXXXXXXXXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2013-01362.

	After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was appropriate.  Accordingly, the Board recommended no re-characterization or modification of your separation.

	I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding and their conclusion that re-characterization of your separation is not warranted.  Accordingly, I accept their recommendation that your application be denied.

Attachment:
Record of Proceedings

cc:
SAF/MRBR