RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX			CASE:  PD-2014-01748
BRANCH OF SERVICE:  Army	 SEPARATION DATE:  20070723

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reserve, E8, Logistical Specialist, medically separated for “chronic back pain” and “chronic right wrist pain,” rated 0% and 0%, respectively, with a combined disability rating of 0%.

CI CONTENTION:  His unfitting back and wrist, along with his right shoulder which was not identified by either the MEB or PEB.  The applicant’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 - 20070717	VARD - 20090109	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Back Pain	5299-5242	0%	Degenerative Disc Disease Lumbar…	5242	10%	20070926	
Chronic Right Wrist Pain	5099-5003	0%	De Quervain's Tenosynovitis, Right Wrist, Status Post
Repair Of Triangular Fibrocartilage Complex Ligaments	5215	10%	20070926	
COMBINED RATING:  0%	COMBINED RATING FOR ALL VA CONDITIONS:  70%	

ANALYSIS SUMMARY:

Chronic Back Pain.  According the service treatment records and an addendum to the Medical Evaluation Board (MEB) narrative summary (NARSUM) dated 13 June 2007, 1 month prior to separation, the CI was diagnosed with back sprain of 3 months duration in May 2006, with no particular trauma noted.  The CI noted the back pain became worse with radiation to his right hip and leg and tingling in his toes.  X-rays in January 2007 demonstrated degenerative disc disease, while hip series X-rays were normal in February 2007.  At a family practice clinic examination in February 2007 there was lumbosacral spine tenderness to palpation and pain on motion.  An MRI in February 2007 showed mild spondylosis (degenerative arthritic changes) of the lower lumbar spine, most prominent at L3-4 with associated mild left neuroforaminal narrowing; however, the CI was not a surgical candidate.  In April 2007, he had normal range of motions (ROM) of the lumbosacral spine and an unremarkable neurologic evaluation.  Mobic (meloxicam, a nonsteroidal anti-inflammatory drug (NSAID) was prescribed along with continued physical therapy.  The NARSUM examination noted no muscle spasm or tenderness and a neurologic evaluation was unremarkable.  ROM measurements performed by a physical therapist are in the chart below.

At the MEB examination (DD Form 2807-1 Report of Medical History), dated 27 February 2007, the CI reported recurrent lower back pain and numbness and tingling in his right leg and foot.  The commander’s statement dated 21 March 2007 indicated the CI was performing light duty, but referred to a P3 profile for the CI’s right wrist (see below).  The medical examiner noted on the DD Form 2808, Report of Medical Examination, dated 14 May 2005, no spine tenderness, a negative log roll (to determine hip pathology), and negative straight leg raises (to determine nerve root irritation).  A permanent L3/U3 profile was issued in June 2007 for lumbar degenerative disc disease and right wrist stiffness after ligament repair (see below) and indicated the CI could do the sit-ups for the PFT (physical fitness test) and participate in all three alternate PFT events; however, limitations included all functional military activities except wearing a protective mask and all chemical defense equipment.

At the VA Compensation and Pension (C&P) examination dated 26 September 2007, performed 2 months after separation, the CI reported that he had back pain on and off since June 1993 after a motor vehicle accident.  Prolonged driving, lifting, and prolonged standing aggravated his back and he wore a brace when he drove.  He denied any bowel or bladder dysfunction and took Tylenol (acetaminophen, a pain reliever) and Advil (ibuprofen, an NSAID) on a regular basis and Vicodin (Hydrocodone, a narcotic and APAP (Acetaminophen, a pain reliever) during flares of pain.  On examination the CI had normal motor function and unremarkable neurologic findings, negative straight leg raising, a normal gait and no tenderness or spasms.  Additionally, the CI reported pain radiating down into his thigh on the left, which the CI related to his hip.  However, the VA examiner rendered a radicular leg pain diagnosis.  At a VA C&P neurologic examination of the peripheral nerves on 27 September 2007, an examiner noted the CI had intermittent lower back pain that radiated to the posterior aspect of the right and the left legs up to approximately the heels with no weakness or incapacitating episodes.  Neurologic evaluation was normal with no evidence of sensory, motor or reflex changes.  The examiner opined the CI’s symptoms were probably secondary to intermittent compression of the nerve roots.

The 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.

Thoracolumbar ROM
(Degrees)	TMC ~6 Mo. Pre-Sep	PT ~5 Mo. Pre-Sep	PT ~1 Mo. Pre-Sep	VA C&P ~2 Mo. Post-Sep	
Flexion (90 Normal)	Lumbosacral Spine
Normal ROM	Full ROM	(50)48,50,48	0-80	
Extension (30)			(10)10,10,12	0-30	
R Lat Flexion (30)			(30)35,38,36	(30)0-35	
L Lat Flexion (30)			(30)33,32,33	(30)0-35	
R Rotation (30)			(30)55,53,55	(30)0-35	
L Rotation (30)			(30)55,55,58	(30)0-35	
Combined (240)			180	230	
Comment	Normal exam	Tenderness, painful motion	Inclinometer used for flexion and extension; goniometer used for side bending and rotation; limitation of motion due to pain	No pain, fatigue or incoordination with repetitive motion; normal gait; normal spinal contour; no tenderness or spasms noted	
§4.71a Rating	0%-10%	10%	20% (PEB 0%)	VA 10%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 0% rating under an analogous 5299-5242 code (degenerative arthritis of the spine), citing chronic back pain, due to lumbar degenerative disc disease, without neurologic abnormality.  The VA assigned a 10% rating using the 5242 code (degenerative arthritis of the spine) based on the VA C&P examination 2 months after separation, citing forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees.

The Board members first discussed the probative value of the physical therapy examination, which used an inclinometer and was 1 month prior to separation, versus the VA C&P examination, which was just 2 months post-separation.  Board members noted that in April 2007 the CI had a full ROM and noted that there was no indication in the record why or how the PT examination pre-separation was disparate with that examination and the subsequent VA examination approximately 3 months later.  A discussion was then carried out about VASRD §4.46 (accurate measurement), which states in part: “The use of a goniometer in the measurement of limitation of motion is indispensable in examinations conducted within the Department of Veterans Affairs.” The Board members discussed and agreed that a 10% or 20% rating, but no higher, was justified for limitation of flexion (greater than 30 degrees but not greater than 60 degrees); however, because the disparity of the PT measurement with other measurements and the use of an inclinometer rather than a goniometer for flexion and extension, a 10% rating could be supported more appropriately than a 20% rating.

Nevertheless, the Board still sought a route to a higher rating but was unable to do so in the absence of a forward flexion of 30 degrees or less, ankylosis, or any reported episodes of incapacitation.  There was no associated radiculopathy for separate peripheral nerve rating.  Although the CI experienced radiating pain, there was no objective evidence of a radiculopathy or functional impairment with a direct impact on fitness.  While the CI may have experienced radiating pain from the back condition, it is subsumed under the general spine rating criteria, which specifically states “with or without symptoms such as pain (whether or not it radiates).”  There is no evidence in this case that there was radiculopathy with associated functional impairments of either a motor or sensory nature that was separately or significantly functionally impairing.  The Board therefore concludes that additional disability rating was not justified on that basis.  After due deliberation, and in consideration of all the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the chronic back pain condition, coded 5242.

Chronic Right Wrist Pain.   The service treatment records and the MEB NARSUM dated 13 April 2006 indicated the CI sustained a FOOSH (fell onto outstretch hand) in the summer of 2005 when diving for cover during a field exercise.  He sought treatment in March 2006 for pain in the right wrist secondary to a lump, which was worse with ROM of the thumb especially during typing.  The diagnosis of a ganglion of the right wrist was made and treatment consisted of naproxen (an NSAID).  An MRI in June 2006 demonstrated a small amount of fluid in the scapholunate articulation, which represented a small cyst or partial tear of the ligament.  A limited arthrogram of the right wrist was normal.  Because of continued wrist pain the CI underwent diagnostic wrist arthroscopy in November 2006 which revealed a triangular fibrocartilage complex (TFCC) tear, which was debrided and a radial wrist mass was excised.   Occupational therapy was carried out postoperatively for at least 4 months to treat the right wrist stiffness with a goal of wrist flexion to 35-45 degrees or until progress plateaued.  The narrative summary (NARSUM) physical examination of the right wrist/hand revealed a well healed, non-tender [operative site].  ROM measurements performed by an occupational therapist on 26 February 2007 were wrist flexion 25 degrees (90 normal), extension 45 degrees (75 normal), radial 15 degrees (20 normal), ulnar 30 degrees (40-45 normal), pronation 75 degrees (80 normal), and supination 75 degrees (80-85 normal).  Finger joint ROMs were normal.  Grip strength was 35 pounds on the right and 85 pounds on the left and pinch strength was 26 pounds right and 30 pounds left.  Limitation of motion was mechanical, but also painful.  The NARSUM examiner opined the CI was not capable of strenuous or prolonged/repetitive use of his wrist.

At the MEB examination he had wrist surgery and did not have full use of his wrist.  The medical examiner noted on DD Form 2808 Report of Medical Examination dated 14 May 2007 decreased flexion and extension of the right wrist.  A permanent U3 profile was issued on 21 June 2007 with limitations addressed above.

At the VA Compensation and Pension (C&P) examination dated 26 September 2007, performed 2 months after separation, the CI reported constant low grade pain in the wrist aggravated by repetitive activity, working a keyboard for any length of time, lifting anything, and occasionally with driving and used a wrist brace.  On examination he had a well-healed, somewhat hypertrophied, V-shaped scar over the anatomic snuff box (inner wrist), which was nontender and not adherent to underlying tissue.  He had a positive Finkelstein’s test (indicative of tenosynovitis) in the wrist and no evidence of a ganglion cyst on palpation of the wrist.  ROM measurements of the right wrist were dorsiflexion 0-70 degrees with pain at the endpoint, palmar flexion 0-65 degrees with pain at the endpoint , radial deviation 0 to 20 degrees, ulna deviation 0 to 30 degrees, pronation 0 to 80 degrees and supination 0 to 80 degrees.  The examiner’s diagnoses were De Quervain’s tenosynovitis (entrapment of tendons at the wrist causing pain during thumb motion) of the right wrist and status post repair TFCC ligaments of the right wrist and dorsal wrist ganglion excision.

The 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)	OT ~4 Mo. Pre-Sep
	VA C&P ~2 Mo. Post-Sep
	
Dorsiflexion (70 Normal)	45	0-70	
Palmar Flexion (80)	25	0-65	
Ulnar Deviation (45)	30	0-30	
Radial Deviation (20)	15	0-20	
Comment	Pronation 75; supination 75 degrees; with painful motion	Painful motion, positive Finkelstein’s test	
§4.71a Rating	10% (PEB 0%)	10% (VA 10%)	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 0% rating using code 5099-5003 (arthritis, degenerative) for chronic right wrist pain rated as minimal constant IAW USAPDA policy.  The VA assigned a 10% rating using code 5215 (wrist limitation of motion) for de Quervain’s tenosynovitis, right wrist, status post repair of triangular fibrocartilage complex ligaments.  The Board noted the CI had significant limitation of motion prior to separation, which improved within 2 months post-separation.  Therefore, use of code 5099-5003 with a 10% rating is appropriate and applicable in the absence of wrist ankylosis (5214) or limitation of motion (5215) with dorsiflexion less than 15 degrees or palmar flexion limited in line with the forearm.  The Board then considered whether code 5213 (impairment of supination and pronation-limitation of pronation where “motion lost beyond the last quarter of arc, the hand does not approach full pronation”) warranted a 20% rating since pronation prior to separation was 75 degrees; however, within 2 months post-separation it was normal at 80 degrees.  The CI’s wrist was not fixed in supination or pronation and was not supinated 30 degrees or less; therefore an additional or alternative rating was not possible.  After due deliberation, and in consideration of all the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the chronic right wrist pain.

BOARD FINDINGS:  In the matter of the chronic back pain condition, the Board unanimously recommends a disability rating of 10%, coded 5242 IAW VASRD §4.71a.  In the matter of the chronic right wrist pain condition, the Board unanimously recommends a disability rating of 10%, coded 5099-5003  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 his prior medical separation:

CONDITION	VASRD CODE	RATING	
Chronic Back Pain	5242	10%	
Chronic Right Wrist Pain	5099-5003	10%	
RATING	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140225, 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 AR20160007317 (PD201401748)

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