RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXXX		CASE:  PD-2014-00871
BRANCH OF SERVICE:  Army		SEPARATION DATE:  20090531

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Motor Transport Operator) medically separated for left cubital tunnel syndrome.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty.  He was issued a permanent U3 profile and referred for a Medical Evaluation Board (MEB).  The condition, characterized as “chronic left cubital tunnel syndrome with pain and numbness and tingling of left forearm status post left cubital tunnel release,” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded four other conditions (hypertension, insomnia, bilateral claw toes on 2nd and 4th toes, and recurrent ankle sprains).  The Informal PEB adjudicated his cubital tunnel syndrome as unfitting and rated it at 10%.  The remaining conditions were determined to be not unfitting.  The CI made no appeals and was medically separated.

CI CONTENTION:  “I was given a 10% rating for chronic left dominant cubital tunnel syndrome but VA records and army records show paralysis.  Bilateral claw toes was not rated.  High blood pressure was not rated.  Recurrent ankle sprains were not rated.  Cubital tunnel has always been defined as paralysis of my left dominant arm which caused me not to be able to do my job duties as a soldier and also did the claw toes with recurrent ankle sprains prevented me from doing my duties as well because between my arm and my feet I was on constant profile and unable to do any of my job duties.” 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:

Service IPEB – Dated 20090327	VA - (7 Months Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Left Dominant Cubital Tunnel Syndrome	8716	10%	Left Cubital Tunnel Syndrome (Minor)	8515-5206	10%	20091230	
Hypertension	Not Unfitting	Hypertension	7101	0%	20091230	
Bilateral Claw Toes…	Not Unfitting	Claw Toes…	5278	10%	20091230	
Recurrent Ankle Sprains	Not Unfitting	Bilateral Ankle Sprain	5271	-	20091230	
Other x 1 (Not In Scope)	Other x 8	
Combined:  10%	Combined:  20%	
Derived from VA Rating Decision (VARD) dated 20100225 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Left Cubital Tunnel Syndrome.  Multiple entries indicated the CI was right hand dominant.  The narrative summary (NARSUM) and records noted the CI had onset of left elbow and forearm pain and tingling (paresthesia).  Surgery (in situ cubital tunnel release) in June 2008 did not relieve symptoms.  At the time of the NARSUM, 3 months prior to separation, the CI complained of tenderness and pain (3-5/10) in the left elbow and numbness and tingling down the inside of the left arm as far as the two little fingers (4th and 5th).  He indicated his grip strength was normal.  Medication had not been effective and the CI was on no medications or therapy.  The physical exam noted normal reflexes, strength and sensory exam.  Positive Tinel testing (for nerve irritation) as well as biceps flexion recreated the CI’s symptoms of “numbness and tingling down the lateral aspect of the left forearm out as far as the 4th and 5th fingers.”  The elbow was moderately tender to palpation, and grip strength was normal.  Goniometer range-of-motion (ROM) of left elbow was extension to 0 degrees (normal), flexion to 145 degrees (normal) with forearm ROM of pronation 75 degrees (normal 80) and supination 60 degrees (normal 85).  Elbow X-rays and magnetic resonance imaging were negative for any joint pathology.

At the VA Compensation and Pension exam performed 7 months after separation, the CI reported a similar history of left elbow pain and forearm/hand paresthesias without weakness.  The examiner stated:  “He does continue to drive a truck in current occupation although he has impediment with left elbow/hand pain (which interferes) with using the steering wheel intermittently.  …  There are no reports of weakness, decrease in strength or function of his elbow.”  Exam documented normal strength and grip.  Left elbow flexion was 0-145 degrees and extension was full at 0 degrees.  Forearm supination was 0-75 degrees and pronation was 0-70 degrees, both limited with pain.  The elbow was tender and the scar was well healed.  X-ray of the left elbow was normal.  Nerve conduction study/electromyogram of left upper extremity were normal.  The diagnosis was “left cubital tunnel syndrome, status post release, no objective findings of paresthesia and no functional limitations.”

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the left cubital tunnel condition at 10% coded 8716 (neuralgia of the ulnar nerve) as mild.  Although the PEB cited “dominate,” record entries indicated the CI was right-handed (left arm was therefore “minor” or “non-dominate”).  The VA coded the same condition as 8515-5206 (median nerve, using rating criteria of limitation of forearm flexion) and cited painful motion and elbow tenderness in their rating determination.  There was insufficient restriction of elbow or forearm ROMs for any rating higher than 10% with consideration of §4.59 (painful motion).  IAW VASRD §4.124a, neurologic lesions are rated by comparison to paralysis of the same nerve.  There was no weakness or motor loss (paralysis) in the left arm, and there were no organic changes (atrophy, skin changes, etc.) noted in the record.  The Board deliberated if the CI’s condition was at the “mild” (10%) or “moderate” (20%) level, the highest neuralgia rating IAW VASRD §4.124.
Considering the totality of the evidence and mindful of VASRD §4.3 (reasonable doubt), members agreed that a disability rating of 10% for the left cubital tunnel syndrome condition was appropriately recommended in this case.

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that hypertension, bilateral claw toes, and recurrent ankle sprains were not unfitting.  The Board’s threshold for countering fitness determinations is preponderance of evidence, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  The hypertension, bilateral claw toes, and recurrent ankle sprains conditions were not profiled or implicated in the commander’s statement and were not judged to fail retention standards.  The hypertension was well controlled with medication.  The bilateral claw toes and ankle symptoms were noted to be chronic (long term), did not require special foot gear, and there were no functional limitations of the lower extremities by profile.  Gait was consistently normal in the treatment records.  Ankle exams were normal and foot exams documented tenderness without pain on manipulation.  All conditions were reviewed by the Board.  There was no performance based evidence from the record that any of these conditions significantly interfered with satisfactory duty performance.  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 any of the contended conditions and so no additional disability ratings are recommended.

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 cubital tunnel syndrome condition and IAW VASRD §4.124a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended hypertension, bilateral claw toes, and recurrent ankle sprains conditions, the Board unanimously recommends no change from the PEB determinations as not unfitting.  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 20140218, 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 XXXXXXXXXXXXXXXXXXXXXXXXXXX, AR20150018797 (PD201400871)

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