RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00061
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050322

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a National Guard, E6, Chemical Operations Specialist, medically separated for “bilateral wrist pain” and “bilateral retropatellar knee syndrome,” rated 0% and 0%, respectively, with a combined disability rating of 0%.

CI CONTENTION:  The CI made no specific contention in their application.  The CI’s complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44.  It is limited to those conditions determined by the Physical Evaluation Board (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 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 PEB - 20050225	VARD - 20060303	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Wrist Pain	8799-8715	0%	Carpal Tunnel Syndrome, R Wrist	8515	10%	20060131	
			Carpal Tunnel Syndrome, L Wrist	8515	0%	20060131	
Bilateral Retropatellar Knee Syndrome	5009-5003	0%	Bursitis Right Knee	5019-5257	10%	20060131	
			Bursitis Left Knee	5019-5257	10%	20060131	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY: 

Bilateral Wrists.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the bilateral hand symptoms began approximately 9 years prior to referral for MEB.  An electrodiagnostic (EDX) study showed evidence of a left median nerve neuropathy (injury or irritation of a peripheral nerve) across the wrist.  There was no EDX evidence of left or right ulnar, right median, or peripheral neuropathy.  An orthopedic surgery hand clinic follow-up documented the exam was somewhat equivocal and the EDX was not diagnostic of cubital tunnel syndrome (compression of the ulnar nerve in the elbow cubital tunnel causing numbness and tingling of the ulnar [little finger side]) aspect of the forearm and hand) or carpal tunnel syndrome ([CTS] compression of the median nerve in the wrist carpal tunnel causing numbness and tingling of the palm side of the thumb and fingers [sparing little finger]).  The surgeon did not feel that surgical intervention was warranted and recommended injecting the carpal tunnel.  The CI refused the injection and desired to continue non-operative management with splinting at night.  The NARSUM, 2 months before separation, recounted the history and interventions.  The CI complained of bilateral hand numbness and tingling that wakes him at night.  Symptoms were exacerbated by repetitive motion, driving, and carrying a weapon and relieved by activity modification, splinting, and no carrying or firing of his weapon.  He had not had any awakening since modification of his activity.  The focused upper extremity exam revealed normal-appearing skin and a normal sweating pattern with no dryness or swelling.  The range-of-motion (ROM) of his wrist and finger joints was full.  Capillary refill, grip strength, and sensation were normal.  The Phalen (wrist volar flexion compressing median nerve) and wrist Tinel (percussing volar carpal tunnel over median nerve) tests for were negative and did not elicit pain, tingling, or numbness in the median distribution of hand and fingers.  The Durkan (compression of carpal tunnel compressing median nerve) test was negative for median nerve compression but the CI complained of bilateral paresthesias in the radial nerve distribution (dorsal aspect of his first web space).  The elbow flexion (sustained maximal elbow flexion and compression of the ulnar nerve in the ulnar groove) test was negative and did not elicit pain, tingling, and numbness in the ulnar distribution of hand and fingers.  The elbow Tinel (percussing medial epicondyle ulnar groove over ulnar nerve) test was positive bilaterally with sensory complaints into the small and ring fingers.  Wrist X-rays showed no abnormalities in the bony architecture.  The examiner recounted the findings of the negative EDX.  The diagnosis listed subjective CTS with subjective complaints of bilateral tingling of the entire hand without a dermatomal (areas of skin supplied with nerve fibers from a single nerves) distribution.  The surgeon opined that the subjective diagnosis was without objective data to support the diagnosis.  The examiner documented the symptoms did exist prior to his activation onto active duty.  At 1 and 2 months after separation, the CI was evaluated by another orthopedic surgeon for bilateral hand numbness.  The impression listed left CTS and right wrist median neuritis (nerve inflammation or irritation).  The surgeon recommended a left carpal tunnel decompression procedure and a right carpal tunnel steroid injection.  The CI underwent a left open median nerve decompression and injection of local anesthetic (Lidocaine) and steroid (Kenalog) into the right carpal tunnel.  At the 2-month postoperative encounter, the CI reported that the left side numbness and paresthesias (abnormal sensation, tingling, burning, prickling) had improved significantly but the right side continued to be symptomatic.  The compensation and pension (C&P) exam, 8 months postoperatively, recounted the history and interventions.  The CI continued to use bilateral braces at night.  He endorsed that since the left carpal tunnel decompression, his left hand was essentially asymptomatic.  The CI reported the strength of his two hands seemed “okay” but occasionally dropped things with the right hand (last instance 2 weeks prior).  He denied right hand pain at the time of examination.  Active medications were the two nonsteroidal anti-inflammatory drugs (NSAIDs) of Etodolac and Motrin both taken daily.  The focused upper extremity exam revealed no elbow or wrist tenderness.  The right Phalen and elbow Tinel tests were positive.  The wrist Tinel tests were negative bilaterally.  The wrist active ROM was right flexion of 70 (80 normal), left flexion of 75 (80), bilateral extension of 65 (70 normal), bilateral radial deviation of 40 (20 normal), and bilateral ulnar deviation of 60 (45 normal) degrees.  Finger sensory and motor function was normal.  The impression listed more likely than not bilateral CTS and cubital tunnel syndrome. 

The Board directed attention to its rating recommendation based on the above evidence.  As previously elaborated, the Board must first consider whether each wrist condition is separately unfitting, having been de-coupled from a combined PEB adjudication.  The PEB assigned a 0% rating under an analogous 8715 code (median nerve [carpal tunnel] neuralgia) for the bilateral wrists citing pain, symptoms similar to CTS but without objective data to support the diagnosis, full ROM of wrists and distal joints, no thenar weakness or wasting, and normal EDX studies.  The VA assigned a 0% rating for the left wrist, and a 10% rating for the right wrist, under 8515 (mild incomplete paralysis of the median nerve [carpal tunnel]) based on the VA C&P exam 10 months after separation.  For the left wrist, the VA cited improvement of disabling symptoms following surgery, largely asymptomatic, no wrist tenderness, normal strength, normal motor function, normal sensory function, negative Phalen, negative Tinel, and ROM.  For the right wrist, the VA cited numbness and tingling, occasional trouble gripping objects, pain related to activity, no hand pain, no wrist tenderness, normal strength, normal motor function, normal sensory function, positive Phalen, negative Tinel, and ROM.  While the CI underwent a left carpal tunnel decompression, there was no ulna flail false joint for consideration under 5210 or significant loss of bone substance, marked deformity, nonunion, or malunion for consideration under 5211.  For the bilateral wrists, there was no impairment of supination or pronation for consideration under 5213.  Physical exams, and radiographic imaging, did not demonstrate the characteristic anatomical deformities of wrist ankylosis, unfavorable palmar flexion, ulnar deviation, or radial deviation for consideration under the 5214 code.  The limitation of motion in the proximate (NARSUM and C&P) exams did not attain a minimum rating under 5215.  The board assigned lesser probative value to the more proximate NARSUM exam because it occurred before the left wrist surgery.  Recognizing the temporal relationship, the board assigned higher probative value to the C&P exam because it occurred after surgery and a period of convalescence.  Members debated if 0% was warranted for each wrist or if application of §4.40 (functional loss) or §4.59 (painful motion) justified 10% ratings.  The Board carefully considered the option of rating both wrists together, noting that the VA rated each wrist separately.  The Board concluded that the evidence did provide sufficient grounds for recommending separate wrist disability ratings in this case.  A rating of 10% for the left and 10% for the right, coded 8517, is a good analogy to both the pathology and disability.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the left wrist condition and 10% for the right wrist condition.

Bilateral Knees.  According to the STR and NARSUM, the bilateral knee symptoms began approximately 13 years prior to referral for MEB.  Bilateral knee X-rays showed possible early arthritis of the left patellofemoral joint.  The orthopedic surgery MEB addendum recounted the history and interventions.  The CI complained of daily bilateral 3-6/10 knee pain without a specific inciting injury.  He reported associated popping but denied swelling.  Pain was exacerbated by prolonged standing, prolonged walking, activity, running, jumping, and rucking and incompletely relieved by decreasing activity and medications.  Active medications were an NSAID (Mobic).  The bilateral knee examination revealed anterior knee tenderness with no swelling.  The patellar grind (assesses abnormal patellar movement and painful crepitation) tests were positive.  The valgus/varus stress (assesses medial collateral ligament [MCL] / lateral collateral ligament [LCL]) and anterior/posterior drawer (assesses anterior cruciate ligament [ACL]/ posterior cruciate ligament [PCL]) tests were negative.  The bilateral knee active ROM was full.  Bilateral knee X-rays showed minimal left knee patellofemoral degenerative joint disease (DJD).  The diagnosis listed bilateral retropatellar knee syndrome.  One month after separation, orthopedic surgery injected the bilateral knees with local anesthetic (Lidocaine and Marcaine) and corticosteroid (Depo-Medrol).  Immediately following the procedure, the CI had improvement of his bilateral knee pain.  The assessment listed bilateral patellofemoral pain syndrome with a plan for physical therapy (PT).  At the orthopedic surgery follow-up, the CI had completed formal PT and had progressed to home exercises.  He reported some improvement of pain, though it was difficult to tell since he was taking an opioid (Vicodin), following carpal tunnel surgery.  The assessment listed bilateral PFPS (left>right).  The C&P exam recounted the history and interventions.  The CI complained of equal bilateral knee pain which had progressively worsened over 15 years.  Pain was located behind the knee caps and just inferior to left knee cap.  Pain was exacerbated by deep knee bends, squatting, running, stairs, and activity.  Flare-ups were precipitated by squatting.  His activity was limited by pain but he did not reach a point of fatigue, weakness, or lack of endurance.  He denied knee locking or giving out.  Active medications were the two NSAIDs (Etodolac and Motrin) both taken daily.  The bilateral knee exam revealed no tenderness.  There was right patellar pain with vertical movement and tenderness inferior to the left patella.  The anterior/posterior drawer test was negative and the collateral ligaments were intact.  The knee active ROM was right flexion of 135 (140 normal), left flexion of 125 (140 normal), and bilateral extension of 0 (0 normal) degrees.  Muscle tone, sensation, pulses, and deep tendon reflexes (DTRs) were normal.  Knee X-rays showed unchanged patellar tendon calcification.  The impression listed more likely than not bilateral knee bursitis (inflammation of fluid filled sacs between tissues).

The Board directed attention to its rating recommendation based on the above evidence.  As previously elaborated, the Board must first consider whether each knee condition is separately unfitting, having been de-coupled from a combined PEB adjudication.  The PEB assigned a 0% rating under an analogous 5003 code (degenerative arthritis) for the bilateral knees citing full ROM and no instability.  The VA assigned a 10% rating for the left knee and a 10% rating for the right knee under 5019-5057 (bursitis-knee, other impairment of: slight) based on the VA C&P exam 10 months after separation.  For both knee ratings, the VARD cited pain located behind knee caps, patellar tenderness, pain exacerbated by deep knee bends, running, and stairs, activity limited by pain, no fatigue, no weakness, no lack of endurance, no locking, no giving out, negative drawer test, intact cruciate ligaments, intact collateral ligaments, normal sensation, normal DTRs, ROM, and X-ray findings.  The proximate (MEB addendum and C&P) exams did not demonstrate a limitation of motion to support a minimum rating under the limitation of flexion (5260) or extension (5261) codes.  There was no dislocated meniscus (5258), symptomatic removed meniscus (5259), knee ankylosis (5256), knee recurrent subluxation/lateral instability (5257), tibia and fibula nonunion/malunion (5262), or genu recurvatum (5263) for consideration under the respective codes.  Members debated if 0% was warranted for each knee or if application of §4.40 (functional loss) or §4.59 (painful motion) justified separate 10% ratings.  The Board carefully considered the option of rating both knees together, noting that the VA rated each knee separately.  The Board concluded that the evidence did provide sufficient grounds for recommending separate knee disability ratings in this case.  A rating of 10% for the left and 10% for the right, coded 5099-5003, is a good analogy to both the pathology and disability.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the left knee condition and 10% for the right knee condition, coded 5099-5003.  

BOARD FINDINGS: In the matter of the left wrist condition, the Board, by a majority vote, recommends a disability rating of 10%, coded 8715 IAW VASRD §4.71a.  In the matter of the right wrist condition, the Board, by a majority vote, recommends a disability rating of 10%, coded 8715 IAW VASRD §4.71a.  In the matter of left knee condition, the Board, by a majority vote, recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a.  In the matter of right knee condition, the Board, by a majority vote, recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a.  The single voter for dissent recommended modification without re-characterization of the separation and did not elect to submit a minority opinion.  There were no other conditions within the Board’s scope of review for consideration.  The Board recommends that the CI’s prior determination be modified as follows; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	RATING	
Right Wrist Pain	8715	10%	
Left Wrist Pain	8715	10%	
Right Retropatellar Knee Syndrome 	5099-5003	10%	
Left Retropatellar Knee Syndrome 	5099-5003	10%	
RATING (w/ BLF)	40%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20131216, 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 XXXXXXXXXXXXXXXXXX, AR20160005811 (PD201400061)

1.  Under the authority of Title 10, United States Code, section 1554(a), I approve the enclosed recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) pertaining to the individual named in the subject line above to re-characterize the individual’s separation as a permanent disability retirement with the combined disability rating of 40% effective the date of the individual’s original medical separation for disability with severance pay.  

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:

	a.  Providing a correction to the individual’s separation document showing that the individual was separated by reason of permanent disability retirement effective the date of the original medical separation for disability with severance pay.

	b.  Providing orders showing that the individual was retired with permanent disability effective the date of the original medical separation for disability with severance pay.

	c.  Adjusting pay and allowances accordingly.  Pay and allowance adjustment will account for recoupment of severance pay, and payment of permanent retired pay at 40% effective the date of the original medical separation for disability with severance pay.

	d.  Affording the individual the opportunity to elect Survivor Benefit Plan (SBP) and medical TRICARE retiree options.

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:
						      					
Enclosure
					
CF: 
(  ) DoD PDBR
(  ) DVA