RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX		CASE:  PD-2014-00940
BRANCH OF SERVICE:  Army		SEPARATION DATE:  20030216

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Utilities Equipment Repairer, medically separated for “status post dislocation of left (dominant) elbow,” with a disability rating of 20%.

CI CONTENTION:  His conditions continue to worsen and negatively impact his daily activities.  The applicant’s complete submission is at Exhibit A.

SSCOPE 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 - 20021205	VARD - 20040310	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Status Post Dislocation of Left (Dominant) Elbow	5206	20%	Traumatic Arthritis Left Elbow	5206-5010	10%	20031015	
			Scars	7804	10%	20031015	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:

Left Elbow.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI injured his left elbow in a motor vehicle accident (MVA) approximately 2 years prior to referral for an MEB.  Serial left elbow X-rays showed a mildly comminuted (multiple fragments or splinters) fracture involving the olecranon process (proximal ulna bony prominence where triceps tendon inserts).  Orthopedic surgery performed a left elbow olecranon fracture open reduction internal fixation (ORIF).  Occupational therapy (OT) measured range-of-motion (ROM) for the MEB.  
The left upper extremity examination revealed moderate (brachium and antibrachium) atrophy.  Left elbow active ROM was flexion of 95 (140 normal), extension of 55 (0), supination of 80 (80), and pronation of 70 (80) degrees.  The left brachioradialis deep tendon reflex (DTR) was intact and the biceps DTR was not detected.  In the NARSUM by orthopedic surgery, 6 months before separation, the CI complained of left elbow pain and stiffness.  Following the left elbow ORIF, he underwent a long convalescence and extensive OT with dynamic splinting.  The CI developed heterotopic ossification ([HO] abnormal bone growth in non-skeletal tissues) and profound stiffness which resulted in an unacceptable ROM plateau.  He subsequently underwent a left elbow extensile capsulectomy, removal of hardware, and dynamic external fixator application.  The fixator was removed at approximately 5 weeks.  The CI complained of baseline 6/10 pain with the elbow being particularly achy the day following substantial lifting.  Pain was exacerbated to 8/10 with attempted heavy use and relieved with heat and extra strength Tylenol.  He complained of elbow stiffness and contracture and that he had been at a functional recovery plateau for several months.  The CI had been forced to change the majority of his activities (writing, eating, and shaving) to his right (non-dominant) hand.  The left upper extremity examination revealed multiple well-healed surgical incisions (lateral and posterior elbow) and keloid (abnormal/excessive scar tissue) formation on the proximal forearm (anteromedial and antecubital fossa).  There was 2.5cm of arm, and 1cm of forearm, muscle atrophy.  There was decreased sensation near the incisions with normal sensation distally in the hand.  There were palpable, firm, and tender areas of HO over the olecranon and lateral elbow.  Left elbow ROM was 55-95 (0-140) with supination of 80 (80), and pronation of 70 (80) degrees.  The left elbow X-ray showed mild recurrent HO with moderate ulnar humeral and radial humeral arthritic changes.  Pain was rated as moderate and constant.  The diagnoses list left elbow posttraumatic arthritis and flexion/extension contracture.  The surgeon discussed surgical options (ulnar humeral arthroplasty, fascial interposition arthroplasty, or total elbow replacement) but the CI deferred surgical considerations at the time of exam.  The Compensation and Pension (C&P) examination recounted the history and interventions.  The CI complained of constant left elbow pain and decreased ROM.  The left elbow condition interfered with his daily function, but he had not had physician recommend bed rest, or lost time from work due to this condition.  The left upper extremity examination revealed multiple scars and keloids with tissue loss to the upper arm.  Some scars were disfiguring but there was no associated tenderness, ulceration, crusting, or limitations.  Left elbow active ROM was flexion of 145 (140 normal), extension of 0 (0), supination of 85 (80), and pronation of 80 (80) degrees.  The ROM was limited by pain, but not by fatigue, weakness, lack of endurance, or incoordination.  Strength, sensation, and DTRs were normal.  The left elbow X-ray showed distal humerus changes consistent with old trauma.  The diagnosis listed left elbow arthritis. 

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 20% rating under the 5206 code (forearm, limitation of flexion of: major) citing status post dislocation of left (dominant) elbow, flexion limited to 95 degrees, extension limited to 55 degrees, posttraumatic arthritis, and mild recurrent HO.  The VA assigned a 10% rating under the 5260-5010 codes (forearm limitation of flexion-traumatic arthritis) based on the VA C&P examination 8 months after separation, citing left elbow painful motion, X-ray evidence of trauma, and traumatic arthritis.  The ROM values in the PT and NARSUM examinations were consistent with a 20% rating under 5206 (forearm limitation of flexion) and a 10% rating under 5207 (forearm limitation of extension).  The ROM values in the C&P examination did not attain a minimum rating under 5206 or 5207.  The ROM values in the PT, NARSUM, and C&P examinations did not attain a minimum rating under code 5208 (forearm flexion limited to 100 and extension to 45 degrees).  While the CI underwent two left elbow surgeries, there was no deformity, fracture, flail joint, false joint, bone loss, nonunion, or malunion for consideration under 5209, 5210, 5211, or 5212.  There was no elbow ankylosis by physical examination or radiographic imaging for consideration under 5205.  There was no impairment of supination or pronation for consideration under 5213.  The Board agreed a 10% rating was supported based on VASRD §4.40 (functional loss) or §4.59 (painful motion).  
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.

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 20140213 with attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB						

MEMORANDUM FOR Commander 

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXXX, AR20160005835 (PD201400940)

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