RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01217

BRANCH OF SERVICE:  Army	SEPARATION DATE:  20080619

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a National Guard O1, Infantry, medically separated for “left non-dominant radial head replacement arthroplasty evaluated as elbow replacement” with a disability rating of 20%.

CI CONTENTION:  The CI attached a one page statement to his application concerning his left upper extremity condition which was reviewed by the Board and considered in its recommendations.  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 - 20080421	VARD - 20070718	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Non-Dominant Radial Head Replacement Arthroplasty	5099-5052	20%	Left Elbow Radial Head Fracture with Osteoarthritis, Status Post Resection and Implantation of Radial Prosthesis	5052	40%	20070517	
			Scar; Postoperative Residuals of Left Elbow Surgeries	7804	10%	20070517	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:

Left Non-Dominant Elbow.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s left elbow condition began in February 2002 after fracturing his left elbow and wrist.  The CI underwent two surgical repairs and was returned to duty.  The CI reinjured his left elbow in 2006 and underwent a radial head implant (prosthesis) and ulnar shortening in May/June 2006.  Following surgery further treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “status post radial head arthroplasty and lateral epicondyle postoperative change,” and “mild ulnohumeral arthritis” for PEB adjudication.

At the MEB examination (recorded on DD Forms 2807 and 2808) dated March 2008, 4 months before separation, the CI reported chronic pain in the left elbow and wrist and inability to carry anything over 5 pounds and pain with supination and pronation.  Examination documented decreased range of motion (ROM) of the arm, elbow, and wrist with decreased handgrip strength.

The NARSUM (March 2008) indicated a chief complaint of left elbow and wrist pain following surgeries.  An electronic note by the specialist (hand surgeon) author of the NARSUM indicated that the CI could not perform all ADLS [activities of daily living].  Physical examinationshowed painful and limited ROMs of the left elbow forearm and wrist (ROMs were flexion over 100 degrees, extension limited to less than 45 degrees, supination over 30 degrees and pronation beyond the last quarter of arc with the hand approaching pronation [the VASRD 10% rating levels]).  The examiner indicated “the patient is unable to defend himself with a weapon and perform Army physical fitness test in the designated format for pushups and sit-ups.”

The internal medicine evaluation (part II physical MEB) and two occupational therapy evaluations (MEB and treatment for grip strengthening) in March 2008 all listed pain as “8/10 Severe” for the left elbow or left elbow and wrist.

At the VA Compensation and Pension (C&P) examination in May 2007, performed 13 months before separation, the CI reported elbow and wrist pain with limitation in activities, and increased pain on use of his left arm and carrying weight.  He complained of lack of endurance and chronic fatigue on a daily basis to 7/10 (moderate-to-severe) with episodes of severe pain 10/10 occurring once a week.  He had wrist pain of 5/10 (moderate).  Physical examination showed that  ROMs were painful, with repetition increasing pain, having objective evidence of fatigability and decreased ROM to supination of 6 degrees with all other ROMs of the elbow, forearm and wrist greater than the VASRD 10% rating limits for the joint coding.  Weakness (4/5) was noted at the elbow.  Sensory and vascular examinations were normal and the scar was well healed.  X-rays showed mild arthritis of the left elbow.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 20% rating under an analogous 5052 code (elbow replacement (prosthesis)), citing full wrist motion and strength and elbow with slight loss of motion and painful motion.  The VA assigned a 40% rating also using the 5052 code based on the VA C&P examination 13 months before separation, citing severe painful motion and weakness in the elbow.

There was insufficient ROM impairment for rating analogously to diagnostic codes 5205 through 5213 (“The Elbow and Forearm”) or for the wrist.  The critical rating element under 5052 was therefore if the CI had sufficient evidence of “chronic residuals consisting of severe painful motion or weakness in the affected extremity” or warranted the minimum evaluation.  The VA examination clearly documented severe painful motion, but was 13 months before separation.  The NARSUM examination noted decreased grip strength, but made no comment on the severity of painful motion beyond ROM limitations.  However, all of the specialty evaluations proximate to separation noted left elbow severe pain with motion.

The Board adjudged that the CI’s left elbow disability picture at separation more nearly approximated the 40% criteria under code 5052 which met the requirement for chronic residuals consisting of severe painful motion in the affected extremity.

After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 40% for the left elbow condition, coded 5052.  

BOARD FINDINGS:  In the matter of the left elbow condition, the Board unanimously recommends a disability rating of 40%, coded 5052 IAW VASRD §4.71a.  There were no other conditions within the Board’s scope of review for consideration.

The Board recommends that the CI’s prior determination be modified as follows; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective as of the date of the prior medical separation:

CONDITION	VASRD CODE	PERMANENT RATING	
Left Non-Dominant Radial Head Replacement Arthroplasty	5099-5052	40%	
COMBINED	40%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140306, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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 XXXXXXXXXXXXXXXXXXXXX AR20160009926 (PD201401217)

1. Under the authority of Title 10, United States Code, section 1554(a), I approve the
enclosed recommendation of the Department of Defense Physical Disability Board of
Review (DoD PDBR) pertaining to the individual named in the subject line above to recharacterize the individual's separation as a permanent disability retirement with the
combined disability rating of 40% effective the date of the individual's original medical
separation for disability with severance pay.

2. I direct that all the Department of the Army records of the individual concerned be
corrected accordingly no later than 120 days from the date of this memorandum:

         a. Providing a correction to the individual's separation document showing that
the individual was separated by reason of permanent disability retirement effective the
date of the original medical separation for disability with severance pay.

        b. Providing orders showing that the individual was retired with permanent
disability effective the date of the original medical separation for disability with
severance pay.

       c. Adjusting pay and allowances accordingly. Pay and allowance adjustment will
account for recoupment of severance pay,] and payment of permanent retired pay at
40% effective the date of the original medical separation for disability with severance
pay.

      d. Affording the individual the opportunity to elect Survivor Benefit Plan (SBP)
and medical TRICARE retiree options.

3. I request that a copy of the corrections and any related correspondence be provided
to the individual concerned, counsel (if any), any Members of Congress who have
shown interest, and to the Army Review Boards Agency with a copy of this
memorandum without enclosures.

BY ORDER OF THE SECRETARY OF THE ARMY:
CF:
( ) DoD PDBR
( ) OVA