RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	 CASE:  PD-2014-01435	
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20051223		 

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty PFC/E-3 (19K, Armored Crewman/Gunner) medically separated for right hand pain.  The hand condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS).  He was issued a permanent U3 profile and referred for a Medical Evaluation Board (MEB).  The right hand and wrist pain with symptoms of carpal tunnel syndrome condition was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other conditions were submitted by the MEB.  The Informal PEB adjudicated pain in right hand as unfitting rated 10% citing criteria of the US Army Physical Disability Agency (USAPDA) pain policy.  The CI made no appeals and was medically separated.

CI CONTENTION:  “My service left me without the full ability to use my right hand. It still to date cause me great discomfort and the pain still goes all the way into my neck region.  Before I joined the military service I was able to use my right hand profusely for odd jobs that I know how to do.  This has hindered my ability to live the normal life that I would have if I did not enter the service.”  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 20051116	VA – No Show for C&P EXAM	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Pain in Right Hand	5099-5003	10%	Carpal Tunnel Syndrome, Right Upper Extremity	8515	0%	STR	
Other x 0 (Not In Scope)	Other x 2	
Combined:  10%	Combined:  0%	
Derived from VA Rating Decision (VARD) dated 20060412(most proximate to date of separation [DOS]).  

ANALYSIS SUMMARY:  

Right (dominant) Hand Condition.  On 16 July 2004 while deployed, the CI tripped on a curb and fell getting his two fingers (index and long) ‘caught on a metal loop in a concrete barrier’ resulting in a hyper-flexion injury to his right hand.  Initial X-rays were negative for fracture.  A bone scan in late 2004 revealed degenerative changes about the right wrist.  He was not deemed a surgical candidate and his treatment remained conservative with physical therapy (PT), Occupational therapy (OT), pain medication, and restrictions without achieving pain relief.  An Orthopedic evaluation conducted approximately 5 weeks after the injury noted the following comments under the ‘assessment/plan’: 

"No objective findings on exam or radiographs.  Symptoms are largely subjective and seem magnified out of proportion to my finding/pathology.  No functional/structural pathology.  No restrictions based on my exam.”

A Primary Care clinical encounter of 28 October 2004 also commented the following: 

“Extensive evaluation conducted over the last 4 months fails to reveal an organic basis for subjective complaints.  Commander requests 4th opinion.”
       
In November 2004, the CI was diagnosed with carpal tunnel syndrome (CTS) of the right wrist.  Despite local wrist injections, his painful symptoms remained.  In August 2005, he was permanently profiled with a listed diagnosis of chronic pain of right hand and fingers and was referred to an MEB.  At the MEB narrative summary (NARSUM) examination (04 October 2005; 3 months pre-separation), the CI’s chief complaint was right hand and wrist pain with intermittent numbness and tingling of the right index and long finger (digits = D2 & D3).  His physical examination (PE) revealed decreased and painful motion of the right wrist and right D2 and D3.  Suggestive tests for CTS (Tinnel’s and Phalen’s) were positive.  Strength was listed as ‘basically intact’.  His diagnosis remained right hand and wrist pain with symptoms of CTS.  Two weeks later on 18 October 2005, OT obtained measurements of grip strength.  The CI’s right hand grip strength measured an average of 17 compared to 97 of the left (non-injured) hand…greater than 80% comparison deficit.  As previously noted, there was no VA examination available.  The goniometric ROM evaluations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.

Right Wrist ROM
(Degrees)	MEB ~ 3 Mo. Pre-Sep
(20051004) 	OT ~ 2 Mo. Pre-Sep
(20051018) 	
Dorsiflexion (70 Normal)	“decreased”	55 60 60	
Palmar Flexion (80)		40 45 45	
Ulnar Deviation (45)	-	20 25 25	
Radial Deviation (20)	-	20 15 15	
Comment	painful motion; 
(+) Tinnel & Phalen	(+) weakness 	
§4.71a Rating	10%	10%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic right hand pain at 10% using the analogous arthritis VASRD code 5099-5003; indicating involvement of at least two major joints.  The VA utilized the median nerve code (an indication of CTS) and rated 0% due to failure to report.  Clearly there was decreased right wrist ROM on all examinations, but none were compensable under VASRD criteria for wrist limitation of motion.  There was significant evidence of right hand weakness associated with persistent pain without muscular atrophy.  The Board deliberated if the record provided reasonable doubt as to concede either painful motion IAW VASRD §4.59, limited motion §4.71, functional loss §4.40, Joints §4.45, or muscle disability §4.56 and discussed the CI’s subjective limitation of activities as well as the persistent pain and weakness.  Board members first acknowledged that painful motion as shown in the MEB examination would yield a maximum of 10% as well as the degenerative arthritic changes of multiple joints in the hand under the arthritis code (absent incapacitating episodes).  Board members then focused on the evidence of very significant weakness as described in decreased grip strength noting a greater than 80% decrease in comparison to the uninjured left hand.  The Board considered a higher rating within a VASRD muscle code…specifically code 5309 (Group IX) based upon such weakness.  However, after extensive deliberation, all members agreed that in the absence of muscular atrophy, the large decrease in comparison grip strength (functional loss) was judged as principally related to pain on use versus actual muscle loss or damage.  Therefore, not supporting a higher muscle code rating, all members agreed that there were no other coding options available that would render a higher rating than the 10% adjudicated by the PEB.  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. 

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.  As discussed above, PEB reliance on the USAPDA pain policy DoDI 1332.39 for rating the right wrist was operant in this case and the condition was adjudicated independently of that policy /instruction by the Board.  In the matter of the right wrist 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.  

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 20140228, 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, AR20160003116 (PD201401435)

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