RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2013-01377
BRANCH OF SERVICE:  AIR FORCE	BOARD DATE:  20150416
Separation Date:  20030722

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an activated Reserve E-7 (Heavy Equipment Operator) medically separated for carpal tunnel syndrome (CTS).  The condition could not be adequately rehabilitated to meet the physical requirements of his Air Force Specialty (AFS) or satisfy physical fitness standards.  He was issued a temporary U4 profile and referred for a Medical Evaluation Board (MEB).  The MEB forwarded “right hand pain/numbness/tingling/weakness” to the Physical Evaluation Board (PEB) IAW AFI 44-113 and 48-123.  No other condition was submitted by the MEB.  The Informal PEB adjudicated “carpal tunnel syndrome” as unfitting, rated 20% citing Department of Defense and Veterans Affairs Schedule for Rating Disabilities (VASRD) guidelines.  The IPEB found “obstructive sleep apnea” (OSA) and “degenerative joint disease right knee” as Category II conditions (conditions that can be unfit but are currently not compensable or ratable).  Finally, the IPEB found “obesity” as Category III (conditions that are not separately unfitting and not compensable).  The CI made no appeals and was medically separated.

CI CONTENTION:  The CI made a lengthy statement on his application, which the board reviewed, essentially contending for his unfit right wrist as well as his Category II (as determined by the IPEB) right knee.

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 20040617	VA* - (~5 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Carpal Tunnel Syndrome	8715-8799	20%	S/P Right Carpal Tunnel Release	8699-8615	20%	20041102	
DJD Right Knee	Category II	Degenerative Arthritis, Rt. Knee	5010	10%	20041102	
Other x2 (Not In Scope)	Other x10	
RATING:  20%	RATING:  30%	
*Derived from VA Rating Decision (VARD) dated 20060106 (most proximate to date of separation (DOS))

ANALYSIS SUMMARY:

Carpal Tunnel Syndrome Condition.  The CI was left hand dominant.  The CI injured his right upper extremity in February 2002 when he was climbing into a bulldozer and his foot slipped off of a step and he fell hanging by his right hand and arm.  The CI was seen in Sick Call the following day for onset of pain, numbness, tingling and weakness in the right hand radiating up the right arm.  The orthopedist noted right wrist tenderness with good range-of-motion (ROM).  The examiner reported that a right wrist X-ray showed degenerative joint disease (DJD).  The orthopedist documented physical exam findings of tenderness over the wrist; physical signs consistent with CTS.  The electromyogram (EMG) demonstrated severe right CTS.  The CI underwent a right carpal tunnel release on 13 November 2003.  The occupational therapist noted physical exam findings of impaired right grip strength to about 10% of left hand; significantly impaired functional grip and pinch strength, and pain at 5/10 which interfered in gripping as well as weakness.  The MEB narrative summary exam approximately 5 months prior to separation documented that the CI had right hand pain, numbness tingling and weakness.  A repeat EMG demonstrated moderate bilateral neuropathy across the wrist and there was no definite evidence of neuropathy, plexopathy or radiculopathy.  The neurologist documented that the CI reported right hand numbness and paresthesias mostly the first three fingers, and weakness in his hand and an intermittent tremor.  There were physical exam findings of normal motor function, decreased sensation to pin prick and light touch, and normal reflexes.  The examiner opined that the tremor was either from anxiety or a benign tremor, and the carpal tunnel was moderate without significant denervation and recommended a wrist brace/splint.  The right wrist X-ray was consistent with DJD.  

The VA Compensation and Pension exam, approximately 3 months after separation, documented a numb sensation to the right hand and fingers, weak grip due to involvement of the ulnar and median nerve of the right arm.  There were two evaluations in evidence, with documentation of additional ratable criteria, which the Board weighed in arriving at its rating recommendation; as summarized in the chart below.

Right Wrist ROM (Degrees)	MEB ~5 Mo. Pre-Sep	VA C&P ~3 Mo. Post-Sep	
Dorsiflexion (70 Normal)	20	70	
Palmar Flexion (80)	20	80	
Ulnar Deviation (45)	10	45	
Radial Deviation (20)	10	20	
Comment
Left Hand Dominant	Gross tremor on right upper extremity (RUE); spasticity to resisted flexion with augmentation of tremor; sensation absent RUE to light touch, temperature and 2 point below mid forearm, radial, ulnar and median in a glove distribution ulnar nerve strength 3/5	Grip weak; incisions well healed; decreased sensation to the right hand and fingers	
§4.71a Rating	20% (PEB 20%)	20% (VA 20%)	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB coded the CTS condition as 8799 analogous to 8715 (Median Nerve Neuralgia) and rated at 20% for “moderate.”  The VA coded the status post right carpal tunnel release condition as 8699 analogous to 8615 (Median Nerve Neuritis) and also rated it 20% for “moderate.”  The Board reviewed the tenants of Neuralgia (§4.124a) - characterized usually by a dull and intermittent pain, of typical distribution so as to identify the nerve versus Neuritis (4.123a), characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating.  All exams proximate to separation showed chronic decreased to absent sensation in a glove stocking pattern in the right wrist area and impaired grip.  The neurologist documented right hand numbness and paresthesias mostly the first three fingers, and weakness in the hand.  The EMG most proximate to separation demonstrated moderate bilateral median neuropathy across the wrist.  The Board considered coding 8699-8615 and wrist ROM based coding/rating; however, no other rating schema would rate higher than 20% moderate.  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 carpal tunnel syndrome condition.

Contended PEB Conditions.  The PEB coded the DJD right knee as Category II (conditions that can be unfit but are currently not compensable or ratable).  The Board’s first charge with respect to this condition is an assessment of the appropriateness of the PEB’s fitness adjudication.  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 DJD right knee condition was not profiled; the CI was given a temporary U4 profile only.  The commander’s statement focused solely on the hand condition, there was no mention of a knee condition.  The PEB adjudicated the condition as a Category II, indicating that this condition did not fail retention standards.  There was no indication from the record that this condition significantly interfered with satisfactory duty performance.  Although the MEB examiner documented a ROM of 0-110 degrees for flexion (norm 0-130), patellar grind, crepitus, and diffuse medial joint line tenderness; the examiner opined that the right knee condition was not the most limiting factor for the CI in his AFS.  The CI’s records pertaining to the right knee condition were thoroughly reviewed by the action officer and considered by the Board.  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 DJD right knee contended condition and, therefore, no additional disability rating 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 CTS condition and IAW VASRD §4.124a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended DJD right knee 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 20130911, 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-2013-01377.

	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