RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	   CASE:  PD-2014-00588
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  200603020

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (Motor Transport Operator) medically separated for a left arm condition.  The left arm condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS) or satisfy physical fitness standards.  He was issued a permanent U3 profile and referred for a Medical Evaluation Board (MEB).  “Cervicalgia extending to the upper back, with associated left arm/elbow pain and ulnar neuropathy” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded two medically acceptable conditions (gastroesophageal reflux disease and benign nevus on nose) for PEB adjudication.  The Informal PEB adjudicated “left arm pain (major), with radiation to neck” as unfitting, rated 20%, citing application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The remaining conditions were determined to be not unfitting.  The CI made no appeals and was medically separated.  

CI CONTENTION:  The conditions he was separated for negatively impact his abilities for employment and he was not evaluated for all issues/conditions.  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 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 20060213	VA* - (~6 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Arm Pain (Major), with Radiation to Neck…	8712	20%	Chronic Cervical Strain with Left Ulnar Neuropathy	8615	10%	20060919	
Other MEB/PEB Conditions x 2 (Not In Scope)	Other x 8	
RATING:  20%	COMBINED RATING:  30%	
*Derived from VA Rating Decision (VARD) dated 20061214 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY:  

Left Arm and Neck Condition.  The CI was in a motor vehicle accident (MVA) on 26 April 2003.  He was thrown about the vehicle although he was restrained.  He was admitted for 2 days observation for neck strain and then released with light duty for a week.  He was seen several more times over the next few months and then, apparently, had resolution of his symptoms.  A troop medical clinic note on 24 June 2004 noted that he was healthy and cleared him for duty.  He then deployed in November 2004.  In August 2005, he was evacuated from theater for a 2-month history of numbness and tingling in a C8 distribution on the left as well as weakness and pain.  He was seen in neurosurgery on 15 August 2005 and noted to have decreased grip on the left (dominant hand) and decreased sensation in a C8 distribution, consistent with a possible ulnar neuropathy.  However, electrodiagnostic studies (EDX) on 17 August 2005 showed normal ulnar and median nerve function.  He was treated in physical therapy (PT) without resolution.  A cervical MRI on 31 August 2005 was normal.  Due to persistent symptoms, he was returned to his home station for ongoing treatment and evaluation.  In orthopedics on 14 September 2005 he was noted to have decreased two-point discrimination in the small and ring fingers of the left hand (ulnar distribution) and weakness of the hand muscles without atrophy.  Provocative testing of the ulnar nerve in the hand (tapping at Guyons canal) was positive.  Elbow X-rays were normal.  One week later, he was seen in primary care and thought to have a possible ulnar nerve entrapment at the elbow (cubital tunnel syndrome).  X-rays of the cervical spine were normal.  He was again seen in orthopedics on 3 October 2005 and diagnosed with cubital tunnel syndrome; however, it is not clear if the CI was examined at this appointment or on 7 November 2005 when he was diagnosed with intervertebral disc degeneration, again in orthopedics.  On 21 November 2005, the orthopedic addendum was accomplished.  The CI was noted to have reduced range-of-motion (ROM) was as charted below.  Reflexes were normal.  Grip strength was 4/5 on the left.  Sensation showed 5mm of two point discrimination in the median and ulnar nerve distributions (this would be slightly reduced for the fingertips, but normal elsewhere).  He was diagnosed with neck pain (cervicalgia) with an ulnar nerve C8 radiculitis.  At the MEB examination on 30 November 2005, the CI reported numbness in the left hand since the MVA in April 2003.  The examination showed a decreased left triceps reflex (C8) and two-point discrimination of over 8 degrees.  This was not consistent with the examination in orthopedics the day prior and is not an expected change in a chronic condition.  Numbness of the entire left upper extremity was reported with neck extension.  The CI was evaluated in neurology on 12 January 2006, 2 months prior to separation.  He was observed to have questionable weakness of finger abduction on the left, but atrophy was absent.  The EDX study was repeated and showed “very mild slowing.”  The study and the examination were determined to be consistent with mild ulnar neuropathy.  The narrative summary (NARSUM) was dated 30 January 2006.  It noted that the CI had recurrent symptoms while deployed after wearing protective gear on a daily basis.  He reported intermittent numbness in the left ring and little fingers and neck pain which radiated into his left arm.  The examination from 30 November 2005, above, was used for the objective portion of the NARSUM.  The neck was tender, but without spasm.  The ROM was reduced and is charted below.  He was diagnosed with cervicalgia with associated left arm pain and ulnar neuropathy. 

At the VA Compensation and Pension (C&P) examination performed on 19 September 2006, 6 months after separation, the CI reported chronic neck pain with radiation to the left arm and numbness of the left 4th and 5th fingers (ring and little).  He endorsed weakness and dropping things on occasion; lifting was limited to 15-20 pounds.  On examination, the neck ROM was normal and pain free.  Spasm was absent.  Sensation was diminished over the left 4th and 5th fingers and the inside (medial aspect) of the forearm.  Grip was 4/5, but motor function was otherwise normal.  He was determined to have chronic cervical strain and a left ulnar neuropathy.  A provocative test for nerve root irritation (Spurling test) was negative.  A neurology note dated 11 October 2006 documented that the CI wanted to return to military duty.  A full evaluation was then accomplished on 2 January 2007.  The CI reported that his left grip loss was now resolved (normal).  He had some sensory distortion while working as a mechanic, but was completely functional.  His neurological examination was normal and the prior ulnar nerve dysfunction was “completely resolved.”  At a neurology follow up on 7 March 2007, 2 weeks shy of a year after separation, he reported “very slight” discomfort of the distal (end) left arm with exertion or if he slept “on it wrong.”  The neurologist noted a past left ulnar nerve problem and “cannot find any condition that would preclude military service.”  

The Board first considered if the left arm pain (with radiation to the neck) and lower radiculopathy were separately unfitting conditions at separation.  The Board noted that both X-rays and the MRI of the neck were normal.  The ROM was diminished secondary to pain proximate to separation, but normal and pain free at the VA C&P examination.  The Board also noted that the PEB determined that the disqualifying condition was left arm pain with radiation to the neck rather than neck pain.  The preponderance of evidence does not support that the neck was separately unfitting at separation.  

The Board then directed its attention to its rating recommendation based on the above evidence.  The CI had mild changes on the second EDX study and sensory loss and weakness in the ulnar distribution at the neurology evaluation 2 months prior to separation.  This was confirmed on the VA C&P examination, but less than a year after separation, his examination was normal other than subjective sensory changes with increased activity.  The PEB rated the left arm pain at 20%, coded 8712 (mild neuralgia of the lower [cervical] radicular group).  The VA also rated the CI at 10%, but for chronic cervical strain with left ulnar neuropathy, coded 8615 (neuritis of the median nerve).  The Board noted that the code should have been 8616 to reflect the ulnar nerve distribution of symptoms.  The Board also noted that the clinical description is more consistent with an ulnar neuropathy than a C8 radiculitis (as noted by the orthopedic surgeon in the MEB addendum) used by the PEB for rating.  However, the rating for a mild condition under the ulnar code is 10% vice the 20% for a lower radicular neuralgia as adjudicated by the PEB.  No route to a rating higher than 20% was found by the Board.  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 adjudication for the left arm 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 arm pain 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 20140121, 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 XXXXXXXXXXXXXXXXXXXXXXXXX, AR20160003083 (PD201400588)

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