RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01187
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20080514

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-2 (Food Service Specialist) medically separated for a right wrist and thumb condition.  The condition could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty (MOS).  She was issued a permanent U3 profile and referred for a Medical Evaluation Board (MEB).  The “chronic right wrist and thumb pain due to flexor tenosynovitis (de Quervain’s),” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded two other conditions (acute left and right foot pain due to metatarsal stress fractures) for PEB adjudication.  The Informal PEB adjudicated “chronic DeQuervains tenosynovitis of the right wrist” as unfitting, rated 10%, 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:  Her conditions continue to worsen and negatively impact her daily activities.  Her 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 20080418	VA* - (~4 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic DeQuervains Tenosynovitis of the Right (Dominant) Wrist	5024	10%	DeQuervain’s Tendonitis, Right Hand	5024-5003	10%	20080926	
Acute Left Foot Pain Due to Metatarsal Stress Fractures	Not Unfitting	Right and Left Metatarsal Stress Fracture	5299-5276	0%		
Acute Right Foot Pain Due to Metatarsal Stress Fractures						
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 4	
RATING:  10%	RATING:  10%	
*Derived from VA Rating Decision (VARD) dated 20081114 (most proximate to date of separation [DOS]).  

ANALYSIS SUMMARY:  

Right Wrist Condition.  The narrative summary (NARSUM) noted the CI developed right wrist pain in September 2007 and was diagnosed with tenosynovitis of thumb tendons at the wrist (DeQuervain’s tenosynovitis).  The CI was casted for a time, but chronic wrist pain aggravated by use continued after the cast was removed.  The wrist pain was improved but not resolved by therapy and a MEB was initiated.  

At the MEB exam on 25 February 2008, 3 months before separation, the CI reported intermittent wrist pain 3 days per week, aggravated by activity.  The MEB physical exam noted the CI stated she was right hand dominant but wrote with her left hand.  There was “minimal tenderness” over the tendons on the thumb side of the wrist (first dorsal compartment).  Wrist range-of-motion was dorsiflexion 60 degrees (normal 70) and palmar flexion 67 degrees (normal 80), with pain.  Thumb ROM was normal and a test to provoke pain indicative of DeQuervain’s tenosynovitis was negative.  There was normal strength of the thumb and wrist.  Right grip and pincer strength was comparable to the left.

At the VA Compensation and Pension (C&P) exam dated 26 September 2008, 4 months after separation, the CI reported intermittent right wrist pain, twice per week for “2-3 hours” aggravated by hand/finger activity, such as typing, and relieved by rest.  The CI reported occasional use of a wrist brace and no lost work time due to the condition in the past 12 months.  The VA exam noted the CI was “left hand dominant by report”.  The exam noted tenderness over the thumb tendons (snuffbox tenderness) with no evidence of nerve compression or wrist or finger joint abnormalities.  Wrist ROM was dorsi flexion 60 degrees and PF 50 degrees, with painful motion.  Finger ROM was normal.  There was no additional loss of wrist or finger ROM with repetition.  Strength, sensation, reflexes, and pulses of the bilateral upper extremities were normal.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the right wrist condition 10%, coded 5024 (tenosynovitis) for slightly limited, but painful ROM.  The VA rated the wrist condition 10% citing the same grounds, but coded 5024-5003 (degenerative arthritis with tenosynovitis).  The Board agreed the evidence in record supports a 10% rating coded as 5024 according to 5003 rating criteria for a single joint with painful, limited ROM.  The next higher rating of 20% can only be achieved with ratable impairment of two or more major joints or groups of minor joints.  The Board reviewed to see if a higher rating was supported with any other applicable code.  The limitation of wrist ROM did not meet the threshold for a 10% rating based on ROM alone (the only rating available for limited wrist ROM) and there was no evidence of limited thumb ROM or ankylosis of the wrist or thumb to support a higher rating.  The Board noted that the Service and the VA designated different dominant hands.  The Board considered the CI’s right hand dominant as self-reported at the MEB exam, but in this case, it was a moot issue as the code for wrist ankylosis was the only one with ratings that differed on this basis.  The Board thus determined the evidence supports a 10% rating for the wrist condition and no higher, including with consideration of functional loss.  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 condition.  

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the left and right foot pain conditions were not unfitting.  The Board’s threshold for countering fitness determinations requires a preponderance of evidence, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  

Bilateral foot pain conditions.  The NARSUM noted that the CI developed pain in both feet in January 2008 after a six mile run.  Bilateral foot X-rays 14 February 2008 noted stress fractures (fx) of the second and fourth metatarsal bones in both feet.  The CI was treated with rest and physical therapy and at the NARSUM she reported 70 percent improvement in the pain, which was still aggravated by activity.  The MEB examiner noted the stress fxs were acute, improving, and medically acceptable.

The left and right foot pain conditions were not permanently profiled or implicated in the commander’s statement and were not judged to fail retention standards.  They were reviewed and considered by the Board.  The Board noted that the bilateral stress fractures acutely impacted the CI’s ability to perform physical activities such as running, marching, or prolonged walking or standing as clearly noted on the permanent profile limitations (and not attributable to the upper extremity tenosynovitis), despite the stress fxs/foot pain not being listed.  However, at the time of the MEB exam, there was no evidence that after an appropriate period of rest to allow the stress fxs to heal, that pain of either or both feet would remain an impairment to 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 left or right foot pain 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 right wrist condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended left and right foot 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 20140303, 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 XXXXXXXXXXXXXXXXXX, AR20160003654 (PD-2014-01187)

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