RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00360
BRANCH OF SERVICE:  NAVY	BOARD DATE:  20150610
SEPARATION DATE:  20040405

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Field Hospital Corpsman) medically separated for chronic pain syndrome and right wrist pain.  These conditions could not be adequately rehabilitated to meet the physical requirements of his Rating or satisfy physical fitness standards.  He was placed on limited duty and ultimately referred for a Medical Evaluation Board (MEB).  The “chronic pain syndrome,” “lower eyelid scarring,” and “recalcitrant right wrist pain secondary to arthritic changes” were forwarded to the Physical Evaluation Board (PEB) IAW SECNAVINST 1850.4E.  No other condition was submitted by the MEB.  The Informal PEB adjudicated the chronic pain syndrome and wrist condition as unfitting, rated 10% and 10% respectively, with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The lower eyelid scarring was determined to be Category II (contributing to unfitting).  The CI made no appeals and was medically separated.

CI CONTENTION:  The CI elaborated no specific contention in his application.

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 20040301	VA* - (~55 Mos. Post-Separation) 	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Pain Syndrome	8305	10%	Zygomatic Tripod Fracture with Lower Eyelid Scarring	5299-5296	10%	20081030	
Lower Eyelid Scarring	Category II					
Recalcitrant Right Wrist Pain	5299-5003	10%	Right Wrist Degenerative Joint Disease	5299-5215	0%	20081030	
Other x 0 (Not In Scope)	Other x 0	
RATING:  20%	RATING:  10%	
*Derived from VA Rating Decision (VARD) dated 20090120 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Chronic Pain Syndrome Condition.  The CI sustained a left facial fracture that required surgical fixation in September 2001.  The injury caused damage to the second branch of the trigeminal nerve, and post-operative scarring of the left lower eyelid caused some impairment of lid contraction.  Chronic left facial pain was exacerbated by certain physical activities such as running.

In a rebuttal to a medical dictation on 10 April 2003 (12 months prior to separation) the CI noted that he suffered from loss of sensation in the skin around the left orbit, and that his lower eyelid had “no contractibility.”  Jumping or jarring of his head caused severe pain in the surgical area of the left face, but he did not experience chronic headaches.

According to the narrative summary (NARSUM) examiner on 22 October 2003 (5 months prior to separation) the CI experienced some left facial numbness.  Impaired lower eyelid contraction did not result in cosmetic or functional deficits such as inability to close the eye.  Exertion with head jarring or jumping caused severe facial pain.  At the MEB examination on 19 December 2003, the CI denied taking any current medications.  The physical exam noted “decreased movement and closure of the lower left eyelid…(and) decreased sensation of left maxillary area.”

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating for chronic pain under code 8305 (neuritis of fifth cranial nerve).  The VA’s 10% rating was based on an exam over 4 years after separation, and not relevant to the time of separation.  Rating under cranial nerve codes entails a judgment call regarding the severity of incomplete paralysis, especially the moderate vs. severe distinction.  The PEB’s 10% rating relied on an opinion that the condition was best described by moderate, incomplete paralysis.  Except for some numbness, there was no evidence of organic changes such as muscle atrophy, weakness or loss of reflexes.  The Board considered that IAW §4.123 the maximum rating which may be assigned for neuritis not characterized by organic changes is that for moderate incomplete paralysis.  It was also noted that the CI did not take pain medication for the condition.  It was agreed that the cranial nerve coding pathway was the clinically appropriate choice, and that the chronic pain condition was best characterized by “moderate, incomplete paralysis.”  Therefore the next higher 30% rating was not warranted.  The Board also deliberated if additional disability was warranted for lower eyelid scarring, which was adjudicated by the PEB as a related Category 2 diagnosis.  The CI complained of some impairment of lower eyelid contraction.  The presence of functional impairment with a direct impact on fitness is the key determinant in the Board’s decision to recommend any condition for rating as additionally unfitting.  There is no evidence in this case of functional impairment attributable to scarring of the lower eyelid.  The Board therefore concludes that additional disability was not justified on this basis.  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 chronic pain syndrome condition.

Right Wrist Condition.  On 16 September 2003 (7 months prior to separation) the right handed CI underwent right wrist arthroscopy for chronic right wrist pain.  Areas of chondromalacia (degenerative softening or damage) of the scaphoid and lunate bones as well as the articular surface of the radius were addressed surgically.  Post-operatively, pain and range-of-motion (ROM) improved.

The NARSUM on 4 December 2003 (4 months prior to separation) noted complaints of pain with wrist dorsiflexion and ulnar deviation.  Examination showed well-healed surgical portals, and no wrist swelling or deformity.  Dorsiflexion was 70 degrees (normal 70 degrees) and palmar flexion 50 degrees (normal 80 degrees).  The MEB physical exam on 19 December 2003 noted decreased ROM and strength of the right wrist.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under an analogous 5003 code (degenerative arthritis), while the VA based a 0% rating on an exam over 4 years after separation, which was not probative to the time of separation.  While compensable limitation of wrist motion was not present, the Board concluded that a 10% rating was reasonably conceded IAW VASRD §4.40 (functional loss) or §4.59 (painful motion).  Since wrist ankylosis was not present, a rating higher than 10% was not justified via the 5214 code.  There was likewise no non-union in the lower or upper half of the radius to warrant a rating higher than 10% under the 5212 code (radius, other impairment of).  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 right wrist 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.  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 chronic pain syndrome condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the recalcitrant right wrist pain 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

MEMORANDUM FOR DIRECTOR, SECRETARY OF THE NAVY COUNCIL OF REVIEW
               BOARDS 

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS
 
Ref:   (a) DoDI 6040.44
       (b) CORB ltr dtd 20 Aug 15

      In accordance with reference (a), I have reviewed the cases forwarded by reference (b), and, for the reasons provided in their forwarding memorandums, approve the recommendations of the PDBR that the following individual’s records not be corrected to reflect a change in either characterization of separation or in the disability rating previously assigned by the Department of the Navy’s Physical Evaluation Board:

- XXXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXXX, former USN