RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	    CASE:  PD-2014-01322
BRANCH OF SERVICE:  Army	   SEPARATION DATE:  20090319

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a drilling National Guard, E-3, Motor Transport Operator, medically separated for “left elbow pain resulting from ulnar collateral ligament tear,” rated at 10%.

CI CONTENTION:  The CI contends for the current disability from her elbow condition, and also details thoracic and lumbar disc conditions.  Her complete submission, with attachments, 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 – 20090226	VARD – 20090429	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Elbow Pain ...	5099-5003	10%	Limited Motion,  Ligament Tear, L Elbow	5213	20%	20090326	
COMBINED RATING:  10%	COMBINED RATING FOR ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Left Elbow.  The service treatment record (STR) corroborated the history in the narrative summary (NARSUM) of an injury to the left (non-dominant) elbow early in basic training (October 2008, 5 months pre-separation).  Magnetic resonance imaging (MRI) suggested a ligament tear (ulnar collateral), along with bone contusions (medial epicondyle, radial head) and a chip fracture (tip of the posterior olecranon).  The injury was treated with immobilization (progressing through a hinged brace) and surgery was not required.  The STR documented continuing improvement without the need for a brace, but the residual pain and limitations prohibited completion of training and continued military service.  Various STR entries indicated grossly observed range-of-motion (ROM) limitations which improved over time.  An early entry (a month after the injury) provided measurements for flexion and extension (still significantly decreased) but recorded “supination/pronation within normal limits.”  There were no other STR entries specifically assessing ROM for supination or pronation.  There were ample STR documentation of joint stability (stressed under fluoroscopy), the lack of impingement, and normal alignment.  There were no STR entries contrary to any of these ratable features, or documentation of incapacitation.

The NARSUM was conducted on 15 January 2009 (2 months pre-separation) and documented “constant” pain rated 4/10 with exacerbations to 7/10 by “excessive arm movement.”  The NARSUM physical examination recorded joint tenderness, the absence of instability or impingement, and 5/5 strength.  The NARSUM measured ROM was flexion to 130 degrees (normal 145, 100 for minimum 10%), extension 0 degrees (normal), and stated, “Supination and pronation was within normal limits.”

A VA Compensation and Pension (C&P) examination was conducted 26 March 2009 (7 days post-separation) and documented that the elbow was “sore” with occasional hand numbness and subjective weakness, and did not elaborate pain severity or functional limitations.  The VA physical examination recorded tenderness, the absence of swelling or instability, and 5/5 strength.  The VA measured ROM was flexion 140 degrees, extension 0 degrees, pronation to 55 degrees (normal 80, 60 for minimum 20%), and supination to 55 degrees (normal 85, 30 for minimum 10%).

The Board directed attention to its rating recommendation based on the above evidence.  The PEB’s 10% rating analogous to 5003 (degenerative arthritis) was consistent with VASRD §4.71a criteria for the Service ROM evidence (conceding painful motion) and other ratable findings.  The VA’s 20% rating under 5213 (limitation of supination and/or pronation) was premised on the C&P measurement of pronation to 55 degrees.  There was no evidence supporting a rating higher than 10% under any other ROM code for the elbow or under any other applicable joint code available in §4.71a.  The Board deliberated whether the C&P measurement of pronation was sufficiently probative to support the same recommendation rendered by the VA.  It was considered that the NARSUM ROM evidence for pronation and supination did not appear to have represented goniometric measurement, as was true of the single STR entry corroborating it.  The VA measurement was thus the only ROM evidence unequivocally compliant with VASRD §4.46 (accurate measurement), and, it was most temporally probative to separation.  Member consensus was that this factor, coupled with reasonable doubt, favored concession to the higher rating.  After due deliberation, considering all of the evidence and conceding VASRD §4.3 (reasonable doubt), the Board’s consensus recommendation is a 20% rating for the left elbow condition under code 5213.

BOARD FINDINGS:  In the matter of the left elbow condition, the Board by majority vote recommends a disability rating of 20%, coded 5213, 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, effective as of the date of her prior medical separation:
CONDITION	VASRD CODE	PERMANENT RATING	
Ligamental Injury, Left Elbow 	5213	20%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140308, 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

JUL 14 2016

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation
for XXXXXXXXXXXXXXXXXX, AR20160005890 (PD201401322)

1. 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, accept the Board's recommendation to modify the individual's disability rating to 20% without re-characterization of the individual's separation. This decision is final.

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.

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
( ) DVA