RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXX	CASE:  PD-2013-01972
BRANCH OF SERVICE:  Army 	BOARD DATE:  20140912
SEPARATION DATE:  20050509

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty PFC/E-3 (92G/Food Service Specialist) medically separated for a left arm median nerve injury and a left arm chronic pain condition.  The two conditions could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty (MOS) or satisfy physical fitness standards.  She was issued a permanent U3 profile and referred for a Medical Evaluation Board (MEB).  The nerve and arm conditions, characterized as “persistent medial nerve damage/neuropathy” and “fractured left humerus, mid-shaft, s/p open reduction internal fixation (ORIF) and intramedullary rodding,” were the only two conditions forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The Informal PEB adjudicated “median nerve injury, left (dominant) upper extremity consisting primarily of sensory deficit,” and “chronic pain, left arm, s/p humerus fracture” as unfitting, rated 10% and 10% respectively, citing the US Army Physical Disability Agency (USAPDA) pain for the arm, and the VA Schedule of Rating Disabilities (VASRD) for the nerve.  The CI made no appeals and was medically separated.

CI CONTENTION: The CI writes: “(L) Arm: Nerve Damage, Paralysis, Range of Motion, Loss of Mass.  Open Fracture (Humerous) titanium rod inserted (permanent).”

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 ratings for the unfitting nerve and arm conditions are addressed below; no additional conditions are within the DoDI 6040.44 defined purview of the Board.  Any conditions or contention not requested in this application, or otherwise outside the Board’s defined scope of review, remain eligible for future consideration by the Board for Correction of Military Records.

RATING COMPARISON:

Service IPEB – Dated 20050405	VA - (1 & 2 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Median Nerve Injury, Left (Dominant) Upper Extremity	8515 	10%	S/P Fracture of Left Humerus w/Median Nerve Damage	8512 	40%	20050622	
Chronic Pain, L Arm, S/P Humerus Fracture	5099-5003	10%	S/P ORIF and Intramedullary Rodding, Fractured L Humerus, Midshaft, Scar	5299-5203 	10%	20050719	
Other x 0 (Not in Scope)	Other x 0	20050719	
Combined:  20%	Combined:  50%	
Derived from VA Rating Decision (VARD) dated 20050802 (most proximate to date of separation)

ANALYSIS SUMMARY:  The Board acknowledges the CI’s information regarding the significant impairment with which her service-connected condition continues to burden her; but, must emphasize that the Disability Evaluation System has neither the role nor the authority to compensate members for anticipated future severity or potential complications of conditions resulting in medical separation.  That role and authority is granted by Congress to the Department of Veterans Affairs (DVA), operating under a different set of laws.  The Board considers DVA evidence proximate to separation in arriving at its recommendations; and, DoDI 6040.44 defines a 12-month interval for special consideration to post-separation evidence.  Post-separation evidence is probative to the Board’s recommendations only to the extent that it reasonably reflects the disability at the time of separation.

Left Median Nerve Injury.  The CI is left-handed dominant.  Secondary to a go-cart accident in August 2003, the CI suffered a comminuted (multiple fragment) fracture of her left humerus (upper arm) with subsequent nerve damage that required surgical reduction with rod placement.  She did well post-operatively with healing and physical therapy for improved range-of-motion (ROM), but pain and peripheral sensory deficit remained.  Nerve conduction studies performed on 3 May 2004 revealed mild bilateral median and ulnar neuropathies at the wrists.  An occupational therapy note dated 1 July 2004 (10 months prior to separation), noted worsening symptoms of a sensory deficit (numbness) and weakness in two fingers of her left hand.  She endorsed having difficulty with buttoning clothing, spraying perfume, picking up small objects using pincher grasp.  Her occupational therapy examination revealed left-sided asymmetric grip and pinch strength.  Her grip measurements results were for right hand 66 pounds, left hand 53 pounds while pinch measurements were right hand 21 pounds and left hand 13 pounds.  She was diagnosed with left carpal (median nerve) and cubital (ulnar nerve) tunnel syndrome.  

The narrative summary (NARSUM) (2 months prior to separation), listed “left hand, pain and numbness” as the chief complaint.  She endorsed a feeling of “reduced sensation to touch” as well as a “tingling sensation over the first three fingers of the left hand.”  She reported no current medication use.  During physical examination, the examiner noted painful but non-compensable left shoulder ROM.  Decreased sensation, described as “subtle” was present among three fingers of the left hand, “strength was 5/5 for upper extremity muscles including the intrinsic muscles of the hand.”  The examiner specifically stated, “She is unable to perform her duty in her MOS either in Garrison or in the field.”  

The commander’s statement summarized the CI’s medical condition noting the loss of feeling in her left hand.  She was described as an “invaluable asset to any team.”  The permanent profile listed “status post left humerus ORIF and median nerve injury” as the diagnosis, noting a 20 pound lifting and or carrying restriction.  

At the VA Compensation and Pension (C&P) peripheral nerve specialty examination (performed 2 months after separation), the CI reported the inability to “hold anything” and left hand pain, weakness and tingling in her “first two fingers.”  Her physical exam revealed a positive tinels sign (indicative of carpal tunnel) and muscular atrophy and weakness of muscles innervated by the median nerve (both in the hand and arm).  Ulnar nerve innervated muscles did not reveal atrophy nor weakness.  Her sensory examination remained abnormal in a portion of the finger distribution of the median nerve; thus indicating partial nerve involvement.  She was unemployed and was taking narcotic pain medication.  At the VA C&P general medical examination (performed 3 months after separation), the CI’s physical exam noted “normal extremities” without atrophy, motor loss, nor loss of sensation.  However, the examiner did note the presence of “…weakness of both grip strength and flexion of left arm at the elbow.”

The Board directs attention to its rating recommendation based on the above evidence.  The challenge before the Board is to appropriately rate the total disability of the left hand and fingers; as the available joint codes in VASRD §4.71a do not provide for a compensable rating based on orthopedic features alone.  Both the PEB and VA rated the mix of hand, finger and nerve disabilities under a single peripheral nerve code; which the Board agreed was proper and the most straightforward approach, since it avoids conflict with VASRD §4.14 (avoidance of pyramiding).  The VA used a more proximal peripheral nerve code, 8512 (lower radicular group), rated as 40% for “moderate” incomplete paralysis.  The PEB assigned a more distal peripheral nerve code, 8515 (median nerve), rated as 10% for “mild” incomplete paralysis.  Board members first considered the obvious disparity between two post-service VA examinations (general vs. specialty) with regards to physical findings, with very significant implications regarding the Board's final rating recommendation.  The Board thus carefully deliberated its probative value assignment to these conflicting evaluations and carefully reviewed the service file for corroborating evidence in the 12-month period prior to separation.  For purposes of the Board’s rating recommendation, members concluded that between the two VA exams, the specialty (peripheral nerve) examination carried the highest probative value.  It was the more proximate to the date of separation and its objective examination was most detailed, accurate in nerve description, and complete.

Both the NARSUM and the probative VA exam evidenced sensory loss encompassing median nerve distribution.  Although the NARSUM indicated 5/5 muscle strength to the entire left arm, this specific finding was not consistent within the service treatment record.  Muscle weakness associated with the median nerve was predominant in the record as noted by decreased grip and pinch ability as compared to the non-dominant extremity.  The Board deliberated between the 8512 (proximal) and 8515 (distal) codes and, between the “mild” and “moderate” ratings.

Both codes include clinical muscular deficits involving the wrist, hand and fingers; however, the presence of muscular atrophy (lower thumb portion of the hand) in the probative VA exam is directly supported under 8515 code for the median nerve.  Members considered the profiled weight restrictions, muscle weakness, non-continuous presence of symptoms and CI’s self-reported “subtle” symptom severity and concluded that a fair characterization of overall impairment was “mild;” yielding a major rating of 10%.  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 median nerve injury condition.

Chronic Pain, Left Arm, s/p Humerus Fracture.  As discussed above, PEB reliance on the USAPDA pain policy (DoDI 1332.39) for rating the left arm pain condition was operant in this case and the condition was adjudicated independently of that policy by the Board.  Board members concluded that there was no rating higher than 10% under any applicable code and no coexistent pathology which would merit additional rating for the left arm pain condition under a separate code.  The PEB’s choice of applying the USAPDA pain policy was not detrimental in arriving at the highest achievable rating IAW VASRD §4.71a.  With all evidence considered, there was no reasonable doubt in the CI’s favor supporting a change from the PEB’s coding or rating decision for the left arm pain condition.

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.  In the matter of the median nerve injury, left upper extremity 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 20140625, 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 XXXXXXXXXXXXXXXXX, AR20150006248 (PD201301972)

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:

Encl						
						         
CF: 
(  ) DoD PDBR