RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2014-00042
BRANCH OF SERVICE:  Army	BOARD DATE:  20141216
SEPARATION DATE:  20070212

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-3 (Petroleum Supply Specialist) medically separated for left elbow pain.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty or satisfy physical fitness standards.  He was issued a permanent U3 profile and referred for a Medical Evaluation Board (MEB).  The left elbow condition, characterized as “left elbow pain with loss of motion” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other conditions were submitted by the MEB.  The Informal PEB adjudicated “left elbow pain with a history of radial head and neck fracture” as unfitting, rated 10%.  The CI appealed to the Formal PEB (FPEB), which affirmed the PEB finding and rating.  The CI was then medically separated.

CI CONTENTION:  “Please consider all conditions.”

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) 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:

Service FPEB – Dated 20070123	VA - (1 Mo. Post-Separation) 	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Lt Elbow Pain	5010	10%	Lt Radial Head Depressed Fx w/ Residual Elbow Contracture & Lateral Epicondylitis	5099-5024	10%	20070319	
Other x 0 (Not In Scope)	Other x 0	
Combined:  10%	Combined:  10%	
Derived from VA Rating Decision (VARD) dated 20070920 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Left Elbow Condition.  The narrative summary notes the CI fractured his left elbow during basic training activities on 12 February 2006.  He was initially treated conservatively but X-rays showed a displaced fracture of the radius at the elbow and the CI had open reduction and internal fixation of the elbow on 6 April 2006.  Orthopedic follow-up on 8 June 2006 noted left elbow ROM of 130 degrees of flexion and extension lacking 25 degrees (normal 0 degrees-145 degrees) and full pronation and supination.  Repeat X-rays on 17 August 2006 noted non-union of the fracture.  Notes in the service treatment record indicated the CI continued with constant left forearm pain that increased with use.  Occupational therapy range-of-motion (ROM) on 11 October 2006 was extension-flexion 25 degrees-137 degrees, 26 degrees-138 degrees and 25 degrees-137 degrees (0 degrees-145 degrees), supination of 80 degrees, 80 degrees and 80 degrees (normal 85 degrees), and pronation of 85 degrees, 87 degrees and 85 degrees (normal 80 degrees) and left grip strength was approximately 50% of that of the right.  The CI was referred to a pain specialist who diagnosed cervical radiculitis and elbow arthralgia (pain of a joint) and recommended a left ulnar nerve block, but there was no documentation that this was performed in the record.

At the MEB examination on 6 September 2006, approximately 5 months prior to separation, the CI reported elbow pain and inability to do push-ups.  The MEB physical exam noted elbow ROM of flexion of 130 degrees and equal to the non-affected side, and lack of extension of 35 degrees, forearm supination and pronation of 90 degrees, with pain at end ROM and normal elbow, wrist, thumb and finger strength and sensation.  Left elbow X-rays showed incomplete healing of the fracture.  At the VA Compensation and Pension (C&P) exam on 19 March 2007, performed a month after separation, the CI reported pain radiating from the elbow to the forearm that he reported caused him to use his right arm for everything.  On examination the CI was noted to be right hand dominant and there was tenderness of the outer aspect of the elbow (lateral epicondyle - outer side of the elbow with the palm of the hand up).  ROM was flexion of 145 degrees and lack of extension of 35 degrees, supination of 55 degrees and pronation of 80 degrees, with painful ROM noted.  Upper extremity strength, sensation, and reflexes were normal.  VA X-rays noted persistent lucency with sclerotic edges at the radial fracture site and fracture fragments in good alignment.  Electrodiagnostic studies of the left upper extremity on 3 April 2007 were normal without evidence of neuropathy.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the left elbow condition 10%, coded 5010 (post-traumatic arthritis) and the VA rated it 10% coded 5099-5024 (analogous to tenosynovitis).  The Board agreed that the evidence supports the 10% rating, coded with a number of available §4.71a codes IAW §4.59 (painful motion) - 5010, 5206 (limited flexion), or 5207 (limited extension), or 5213 (impairment of supination or pronation), but there was no compensable limited flexion, extension, supination, or pronation based on ROM alone.  The Board reviewed to see if a higher evaluation was achieved with any applicable §4.71a code.  There was a flexion contracture of the elbow in the range of 25 degrees-35 degrees at all three ROM evaluations noted above.  However, if rating analogously to 5205 (elbow ankylosis) the threshold for a compensable evaluation is an angle of 90 degrees to 70 degrees.  There was also no evidence of a false or flail joint, malunion, impairment of the ulna or varus, or valgus deformity of the elbow.  The evidence did support persistent symptomatic non-union of the fracture following the open reduction and internal fixation procedure.  Persistent evidence of non-healing on X-rays was noted at the MEB and the C&P, also noted by the FPEB, which meets the 20% rating criteria of 5212 (radius impairment), specified as “nonunion in upper half.”  After due deliberation, considering all of the evidence and mindful of the VA Schedule for Rating Disabilities (VASRD) §4.3 (reasonable doubt), the Board recommends a disability rating of 20% for the left elbow 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.  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 elbow condition, the Board unanimously recommends a disability rating of 20%, coded 5212 IAW VASRD §4.71a.  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 his prior medical separation:

UNFITTING CONDITION	VASRD CODE	RATING	
Left Elbow Pain	5212	20%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140422, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

				
XXXXXXXXXXXXXXX
President
DoD Physical Disability Board of Review

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 XXXXXXXXXXXXXXX, AR20150008494 (PD201400042)

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		     XXXXXXXXXXXXXXX
			     Deputy Assistant Secretary of the Army
			         (Review Boards)

CF: 
(  ) DoD PDBR
(  ) DVA