RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01558
BRANCH OF SERVICE:  NAVY                                                              SEPARATION DATE:  20080214

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Torpedo-man, medically separated for “reflex sympathetic dystrophy of the upper limb caught accidentally in or between objects,” with a disability rating of 10%.  

CI CONTENTION:  Her condition was not fully evaluated and it continues to worsen, negatively impact her daily activities, and has long term effects.  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 - 20071030	VARD - 20080219 	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Index Finger Reflex Sympathetic Dystrophy Secondary to Crush Injury	8799-8715	10%	Complex Regional Pain Syndrome, Status Post Fracture
2nd Digit, Left Hand (Minor)	5229	10%	20071112	
Left Index Finger Range of Motion Limitations	Cat II					
Healed Left Tuft Fracture	Cat II					
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

Left Index Finger Reflex Sympathetic Dystrophy Secondary to Crush Injury.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s non dominant left index finger condition (on her military enlistment physical the CI reported she was right hand dominant) began in December 2006, when she sustained a crush injury.  She was diagnosed with a tuft fracture (fx) [fracture of the distal phalanx] and treated with a splint.  At follow-up orthopedic evaluations the CI reported pain, numbness, and tingling of the finger.  Exams noted diffuse tenderness and swelling of the index finger with intact flexion and extensor tendon function, and X-rays showed a healed fx of the distal tuft.  The CI was referred to pain management and was diagnosed with reflex sympathetic dystrophy (RSD - also referred to a chronic regional pain syndrome - CRPS) of the left index finger.  The CI received three sympathetic nerve blocks with improvement in the appearance and function of the finger, but reported persistent pain.  Despite treatment, the index finger condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for MEB.  The MEB forwarded “late effect of fracture of the upper extremities”, “stiffness of joint, not elsewhere classified, involving hand”, “reflex sympathetic dystrophy of the upper limb,” and “caught accidentally in or between objects” for PEB adjudication.

At the MEB NARSUM examination on 28 August 2007, the CI reported left index finger pain.  Medications to manage the condition included Lyrica (medication for nerve related pain) and use of a narcotic pain medication less than once per week.  The MEB physical examination showed the index finger was hypersensitive to touch, especially at the tip of the finger and there was “some” tenderness to touch of the hand.  The index finger tendons were intact, with painful motion and strength graded 3/5.  The tip of the index finger could reach to within 2 cm of the palm.  There was normal circulation and sensation to light touch was intact.  Finger X-rays performed that day showed osteopenia (decreased bone density) of the entire finger that the MEB examiner indicated was consistent with RSD and disuse.  

At the VA Compensation and Pension (C&P) examination on 12 November 2007, 3 months before separation, the CI reported constant left hand pain with no change with Lyrica.  The CI reported that at the time of pain she was able to function.  The CI reported she was unable to tie shoelaces, fasten buttons, or tear up a piece of paper with the left hand.  The physical examination indicated the CI was left hand dominant because she wrote with her left hand.  On physical examination there was no swelling, discoloration, or skin changes of the extremities.  There was a gap of 4 cm between the tip of the index finger and the transverse proximal crease of the palm.  A gap of 2 cm with the thumb attempting to oppose the index finger was noted, but the examination also noted that opposition of both thumbs was normal.  Left hand strength was “moderately reduced” compared to the right hand.  Additionally, the VA examination noted decreased painful motion of the left wrist, long finger, ring finger and little finger (finger to palm gaps of 3 cm, 2 cm, and 2 cm, respectively).  There was no additional limitation of joint function on the left due to pain, weakness, lack of endurance or incoordination after repetitive use.  Motor and sensory functions of the left upper extremity (LUE) were unable to be assessed due to pain.  Reflexes were normal.

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB adjudicated the left index finger condition as an unfitting Category I condition, rated 10% and coded 8799-8715 (analogous to neuralgia of the median nerve), an analogous code for RSD/CRPS.  The PEB also adjudicated two conditions of “left index finger range of motion limitations” and “healed left tuft fracture” as Category II conditions, which are conditions related to the Category I unfitting condition.  In this case both Category II conditions reflect the same disability as the Category I condition and cannot be provided additional ratings IAW VASRD §4.14 (Avoidance of pyramiding) and their contributions to disability are subsumed in the rating recommendation below.  The VA rated the left index finger 10%, coded as 5229 for limitation of motion of the index finger.  The CI appealed the VA Rating decision and requested reconsideration.  The VA Rating decision 11 September 2008 changed the coding to a nerve code, 8512 (lower radicular group), and rated 30% for moderate incomplete paralysis of the lower radicular group (non-dominant hand).

The evidence in record supports that the residual disability due to the left index finger injury was due to nerve related pain and therefore, the Board consensus was that rating the left finger condition according to VASRD §4.124a criteria was most consistent with the medical evidence.  The C&P examination pre-separation indicated significant functional limitations due to the left hand CRPS and the Board majority agreed that coded as 8799-8715, the 20% rating for “moderate” incomplete paralysis was warranted.  According to VASRD guidance ratings for neuralgia (or neuritis without reflex changes or muscle atrophy, 8615) the maximum rating which may be assigned is that associated with “moderate” incomplete paralysis.  The C&P examiner indicated the left hand was dominant, however, the CI indicated she was right hand dominant at the time of military enlistment, all service medical records indicated the CI was right hand dominant, and the September 2008 VARD (based on all records) rated the left hand for nerve injury of the non-dominant hand.  Therefore, based on all the evidence, the Board continued the designation of the LUE as the non-dominant extremity as per the Service and the VA.  The VA chose a different nerve code than the PEB for rating the RSD condition, however, the Board judged that the 8715 code was most appropriate code based on the objective medical evidence in record.  Furthermore, if rating the condition under 8512, which encompasses multiple nerves with a larger distribution of innervation of the arm, the Board concluded that the RSD condition of the left index finger would be appropriately rated as “mild” incomplete paralysis, which also provides a 20% rating.  The Board also reviewed alternative rating of the index finger condition according to VASRD §4.71a criteria for limitation of finger motion, however, the index finger and long fingers are maximally rated 10% each (only 0% available for the ring finger and little fingers), coded as 5229 for limitation of motion, also resulting in a combined 20% rating with this approach.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 20% for the left index finger condition, coded 8799-8715.  

BOARD FINDINGS:  In the matter of the left index finger reflex sympathetic dystrophy condition, the Board unanimously recommends a disability rating of 20%, coded 8799-8715 IAW VASRD 4.124a.  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	RATING	
Left Index Finger Reflex Sympathetic Dystrophy Secondary to Crush Injury	8799-8715	20%	
RATING	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140219, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR COMMANDER, NAVY PERSONNEL COMMAND
	         DEPUTY COMMANDANT, MANPOWER & RESERVE AFFAIRS	
	                          
Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS          

Ref:  (a) DoDI 6040.44
	(b) PDBR ltr dtd 15 Apr 16 ICO XXXXXXXXXXXXXXXXXX
	(c) PDBR ltr dtd 23 May 16 ICO XXXXXXXXXXXXXXXXXX  
	(d) PDBR ltr dtd 27 May 16 ICO XXXXXXXXXXXXXXXXXX 
	(e) PDBR ltr dtd 23 May 16 ICO XXXXXXXXXXXXXXXXXX
	(f) PDBR ltr dtd 23 May 16 ICO XXXXXXXXXXXXXXXXXX
	(g) PDBR ltr dtd 09 May 16 ICO XXXXXXXXXXXXXXXXXX 
	(g) PDBR ltr dtd 27 May 16 ICO XXXXXXXXXXXXXXXXXX
	(i) PDBR ltr dtd 22 Jan 16 ICO XXXXXXXXXXXXXXXXXX
	(h) PDBR ltr dtd 29 Apr 16 ICO XXXXXXXXXXXXXXXXXX 
	(i) PDBR ltr dtd 14 Apr 16 ICO XXXXXXXXXXXXXXXXXX

1.  Pursuant to reference (a), the recommendations of the Physical Disability Board of Review set forth in references (b) through (i) are approved.

2.  The official records of the following individuals are to be corrected to reflect the stated disposition:

     a. XXXXXXXXXXXXXXXXXX, former USMC: Retroactive placement on the Temporary Disability Retired List for six months with a 50 percent disability rating effective date of discharge followed by transfer to the Permanent Disability Retired List with a final rating of 30 percent (increased from 10 percent).

     b. XXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge.

     c. XXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge.

     d. XXXXXXXXXXXXXXXXXX, former USMC: Retroactive placement on the Temporary Disability Retired List for six months with a 50 percent disability rating effective date of discharge followed by transfer to the Permanent Disability Retired List with a final rating of 30 percent (increased from 10 percent).

     e. XXXXXXXXXXXXXXXXXX, former USN: Retroactive placement on the Permanent Disability Retired List with a 40 percent disability rating (increased from 10 percent) effect date of discharge. 

     f. XXXXXXXXXXXXXXXXXX, former USMC: Retroactive placement on the Permanent Disability Retired List with a 30 percent disability rating (increased from 20 percent) effect date of discharge.

     g. XXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge.

     h. XXXXXXXXXXXXXXXXXX, former USN: Retroactive placement on the Permanent Disability Retired List with a 30 percent disability rating (increased from 10 percent) effect date of discharge. 
     
     i. XXXXXXXXXXXXXXXXXX, former USMC: Retroactive placement on the Permanent Disability Retired List with a 70 percent disability rating (increased from 10 percent) effect date of discharge.
 
     j. XXXXXXXXXXXXXXXXXX, former USN: Retroactive placement on the Permanent Disability Retired List with a 30 percent disability rating (increased from 20 percent) effect date of discharge.       

3.  Please ensure all necessary actions are taken to implement these decisions, including the recoupment of disability severance pay, if warranted, and notification to the subject members once those actions are complete.

		XXXXXXXXXXXXXXXXXX
		Assistant General Counsel
		(Manpower & Reserve Affairs)