RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX 	CASE:  PD-2014-00059
BRANCH OF SERVICE:  Army  	SEPARATION DATE:  20040106

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-7 (Career Counselor) medically separated for right wrist pain.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS).  He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The “avascular necrosis of the scaphoid of the right wrist” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other condition was submitted by the MEB.  The Informal PEB (IPEB) adjudicated the right wrist pain as unfitting, rated 10%, citing application of the US Army Physical Disability Agency (USAPDA) pain policy.   The CI made no appeals and was medically separated.  

CI CONTENTION:  He believes his rating was not fair.  He asks for review of his rating.  His complete submission is at Exhibit A.

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:  

IPEB – Dated 20031121	VA* - (~1 Mo. Pre-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Pain Right Wrist	5099-5003	10%	Scaphoid Nonunion, Right Wrist with Arthritis and Avascular Necrosis	5010	10%	20031209	
Other x 0 (Not In Scope)	Other x 10 	
RATING:  10%	RATING:  60%	
*Derived from VA Rating Decision (VARD) dated 20040207 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY:  

Right Wrist Pain Condition.  The narrative summary (NARSUM) noted the CI injured his dominant right wrist during a sports activity in July 1994.  Initial X-rays were negative for fracture but later imaging, including X-rays and computed tomography (CT) scan, showed a scaphoid (carpal bone that meets the wrist near the thumb) fracture (fx).  The fx appeared to be healed, but it was eventually determined that there was nonunion of the fx and the CI underwent surgery for open reduction and internal fixation (ORIF) on 21 November 1996 due to continued pain.  Repeat CT scan in March 1997 showed persistent nonunion of the fx and an area of possible avascular necrosis (AVN), and the CI had a second surgery for ORIF with bone graft.  According to the NARSUM a third surgery was performed on the wrist in 1999.  Wrist X-rays on 25 September 2003, 3 months before separation, noted an old scaphoid fx with nonunion and degenerative joint disease (DJD) of the wrist (radial–carpal joint).  Orthopedic evaluation on 24 September 2003 noted the CI had constant wrist pain, controlled with use of non-steroidal anti-inflammatory medication.  There was tenderness of the area of the scaphoid bone (“anatomical snuff box”) and wrist ROM was extension of 25 degrees (normal 70) and flexion of 55 degrees (normal 80).  The orthopedic specialist suspected AVN of the scaphoid bone, and a wrist CT confirmed the AVN and noted DJD of the carpal bones, and an MEB was recommended.  

At the MEB exam, three months before separation, the CI reported chronic right wrist pain.  The MEB physical exam noted tenderness around the wrist, without swelling.  The wrist ROM was the same as noted at the 24 September 2003 orthopedic evaluation.  

The original VA Rating Decision cited the findings of the C&P exam.  According to the VARD, at the C&P exam the CI reported constant pain and swelling of the right wrist that did not cause incapacitation.  The exam noted a normal appearance of the wrist.  Wrist goniometric ROM was not reported, but ROM was noted to be limited by pain, without weakness or incoordination.  

A wrist CT 12 months after separation performed for continued wrist pain noted DJD of the wrist and carpal joints and AVN of the scaphoid, without evidence of instability of the carpal bones.  The VARD noted the CI had surgery for fusion of the wrist, presumed to be in favorable position, 15 months after separation.

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB rated the wrist condition 10%, coded as 5099-5003 (analogous to degenerative arthritis), and cited the USAPDA pain policy.  The VA rated the wrist condition 10%, coded 5010 (post-traumatic arthritis).  The Board noted that post-separation evidence indicates the CI underwent fusion of the right wrist 15 months after separation, which is outside the 12-month period for special consideration of post-separation VA evidence IAW DoDI 6040.44, and the evidence can be considered only to the degree that it provides information that reflects the CI’s condition proximate to the date of separation.  The Board consensus was that, this information did not provide additional probative information relative to the CI’s level of disability at the time of separation.  The Board agreed that the evidence in record proximate to separation supports a 10% rating according to VASRD 5003 rating criteria for limited motion of a single major joint with imaging evidence of DJD or for evidence of DJD in two or more major joints or groups of minor joints (DJD wrist and carpal joints), but did not meet the next higher evaluation of 20% for evidence of DJD in two or more major joints or groups of minor joints with occasional incapacitating episodes.  The Board reviewed to see if a higher rating was supported with any other applicable code, but there was no evidence of wrist ankylosis or limitation of ROM sufficient to meet 10% rating based on ROM alone.  The Board determined that the evidence supports a 10% rating for the disability due to the wrist condition and no higher.  The Board also noted that the PEB’s reliance on the USAPDA pain policy was not detrimental to achieving the highest rating and in this case the 5003 code is also VASRD compliant, therefore no change is recommended to the PEB’s coding choice.  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 right wrist 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.  As discussed above, PEB reliance on the USAPDA pain policy for rating the right wrist condition was operant in this case and the condition was adjudicated independently of that policy by this Board.  In the matter of the right wrist condition and IAW VASRD §4.71a, 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 20131226, 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 XXXXXXXXXXXXXXXXXXXXXX, AR20160000321 (PD201400059)

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:

Enclosure

CF: 
(  ) DoD PDBR
(  ) DVA