RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00765
BRANCH OF SERVICE:  Navy 	SEPARATION DATE:  20070606

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E5, Shipboard Aircraft Rescue, Firefighting and Salvage Specialist, medically separated for “decreased range of motion, left elbow” with a disability rating of 20%.   The “left elbow pain,” “left elbow arthrosis,” “status post excision and curettage of left distal humerus chrondroblastoma,” was determined to be Category II, contributing to the unfitting condition.

CI CONTENTION:  The CI made contends he has “no joint in left elbow, loss of motion and pain.” 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 - 20070228	VARD - 20070821	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Decreased Range of Motion, Left Elbow	5299-5213	20%	S/P Post Excision of Chondroblastoma of the Left Elbow	

5015-5208	

20%	20070307	
Left Elbow Pain	Cat II					
Left Elbow Arthrosis	Cat II					
S/P…Left Distal Humerus…	Cat II					
RATING:  20%	RATING:  40%	

ANALYSIS SUMMARY:  

Decreased Range of Motion, Left Elbow.   According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI reported a several year history of non-dominant left elbow pain and stiffness in December 2004.  Imaging identified a bone tumor which was determined to be a chondroblastoma, a benign, but locally aggressive bone lesion.  The tumor was surgically removed 5 June 2005 with placement of a bone graft with pins.  The CI continued to have symptoms of elbow pain that radiated down the arm with occasional numbness and tingling of the fourth and fifth fingers with limited range of motion (ROM).  A computer tomography scan showed early degenerative changes of the elbow joint and possible migration of one of the surgical pins into the joint.  A second surgery was performed with removal of the pins, capsular release and manipulation of the joint for ROM, and transposition of the ulnar nerve for symptomatic ulnar nerve subluxation.  After the second surgery the CI was treated by occupational therapy (OT) and his ROM improved somewhat and the left hand grip strength steadily improved to approximately 97% of right hand grip strength.  A pain management consult in April 2006 noted chronic pain without other symptoms of chronic regional pain syndrome, with normal left upper extremity (LUE) strength and sensation.  Despite treatment, the left elbow condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for a MEB.  The MEB forwarded “aftercare following surgery of the musculoskeletal system, NEC [not elsewhere classifiable],” “stiffness of joint, not elsewhere classified, involving upper arm,” “pain in joint involving upper arm,” and “osteoarthrosis, unspecified whether generalized or localized, upper arm," for PEB adjudication.

The ROM evaluations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.
		
Left Elbow ROM
(Degrees)	PT ~13 Mo. Pre-Sep	MEB ~5 Mo. Pre-Sep	
MEB 2808 ~4 MO 	VA C&P ~3 Mo. Post-Sep	
Flexion (145 Normal)	90	“42 to 100 degrees”	“~100”	120	
Extension (0)	“-35”		“~45”	45	
§4.71a Rating	20%	20%	20%	10-20%	

According to the MEB NARSUM evaluation on 23 January 2007, 5 months prior to separation, the CI reported chronic pain and limited motion of the left elbow.  On physical exam there was no discoloration, swelling or deformity of the elbow.  There was no forearm or hand muscle atrophy and sensation was intact.  Left hand grip strength was decreased compared with the right and elbow ROM was as indicated in the chart above.  The examiner noted that forearm supination (normal 85 degrees) and pronation (normal 80 degrees) were “approximately 90 degrees” each.  
At the MEB examination (recorded on DD Form 2807 and 2808) dated 8 February 2007, 4 months prior to separation, the CI reported limited motion of the left arm.  Physical examination showed limited strength and muscle mass of the left arm with ROM as noted in the chart above.  

At the VA Compensation and Pension (C&P) examination on 7 March 2007, 3 months prior to separation, the CI reported the same chronic symptoms as previously noted.  On physical exam there was tenderness to palpation of the elbow that elicited shooting pain down the inside of the forearm, with a “flexion contracture.”  Elbow ROM was as recorded in the chart above.  There was decreased strength with resisted flexion, graded 3/5 and resisted extension, graded 4/5.  There was increased pain noted with repetition of ROM, but no additional loss of ROM.  Under the neurological exam, the examiner noted normal and equal muscle strength of the bilateral hands, including grip strength, and no decreased sensation in the left ulnar nerve distribution.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB adjudicated “decreased range of motion, left elbow” as a Category I unfitting condition and rated 20%, coded 5299-5213 (analogous to impairment of forearm supination and pronation).  The PEB adjudicated “left elbow pain,” “left elbow arthrosis,” and “status post excision and curettage of left distal humerus chondroblastoma” as related Category II conditions.  The VA rated the left elbow condition 20%, coded 5015-5208 (benign bone growth - forearm flexion limited to 100 degrees and extension limited to 45 degrees).  The VA also provided a 20% rating for “left arm submuscular nerve transposition and neurolysis,” coded 8516 (incomplete paralysis of the ulnar nerve)  

The Board agreed that the evidence in record provided sufficient support for a 20% rating coded as 5208 for limitation of elbow flexion and extension as documented on the MEB DD Form 2808, MEB NARSUM, and C&P exams.  There was no evidence of elbow ankyloses, or sufficient limitation of flexion or extension of the non-dominant arm to support a higher rating under the respective codes (5205 5206, 5207).  There was no varus or valgus deformity of the elbow or evidence of impairment of the radius or ulna, non-union of the radius, or impairment of forearm supination or pronation to warrant consideration of rating with the applicable codes (5209, 5210-13).  The Board noted the three additional diagnoses determined to be Category II conditions (conditions that contribute to the primary unfitting condition but are not separately ratable) were intertwined diagnoses with the Category I condition and the overall ankle impairment from all listed diagnoses were subsumed under the §4.71a rating for the ankle and more than one rating based on the same impairment is prohibited by the VASRD (§4.14 avoidance of pyramiding).  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 left elbow condition.  

The Board noted the three additional diagnoses determined to be Category II conditions (conditions that contribute to the primary unfitting condition but are not separately ratable) were intertwined diagnoses with the Category I condition and the overall ankle impairment from all listed diagnoses were subsumed under the §4.71a rating for the ankle and more than one rating based on the same impairment is prohibited by the VASRD (§4.14 avoidance of pyramiding).  The Board also considered if there was support for additional rating of the LUE for residual ulnar nerve impairment which could be considered separately unfitting.  The CI reported continued pain with paresthesia’s to the fourth and fifth fingers.  However, left grip strength steadily improved following the nerve transposition surgery and was documented to be nearly equal to right grip strength at post-operative OT visits in the STR.  The MEB NARSUM exam noted moderately degreased left grip strength compared with the right, but the examiner indicated that ulnar nerve function was intact, without evidence of muscle atrophy or sensory deficit and the C&P exam noted normal strength and sensation in the left ulnar nerve distribution.  Since there was no evidence of an ulnar nerve motor or sensory deficit which could be considered separately unfitting the Board concluded that no additional disability rating could be recommended on this basis.  

BOARD FINDINGS:  In the matter of the left elbow 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.  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 20140214, 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 18 Apr 16

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