RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02011
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20061214

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E1, (Fire Support Specialist) medically separated for “left (non-dominant) wrist limitation of motion” and “left tibial neuropathy” rated 10% and 10% respectively, with a combined disability rating of 20%.

CI CONTENTION:  The applicant makes no specific contention in their application.  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 - 20061102	VARD - 20070613	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left (Non-Dominant) Wrist	5010	10%	Status Post Fracture Wrist, Left with Residuals	5215	10%	20070302	
Posterior Left Tibial Neuropathy	8525	10%	Residual Neuralgia Status Post Shrapnel Injury, Left Lower Extremity	8620	10%	20070302	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  70%	

ANALYSIS SUMMARY:

Left (Non-Dominant) Wrist.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s severe open wrist injury condition began in April 2005 after a blast injury to the left side of his body.  The CI was discharged on 19 May 2005 from the hospital after multiple surgical procedures with the following diagnoses:  open ulnar shaft fracture status post (S/P) open reduction internal fixation, fractures of the lunate, distal radius, and ulnar styloid S/P external fixation, radial artery transection S/P primary repair, dorsal sensory branch of the ulnar nerve injured, and superficial small fragment wounds to the left popliteal fossa (see below), left neck, and left wrist/forearm.  In July 2005 an orthopedic surgeon noted after reviewing X-rays of the wrist and hand a collapse of the lunate with proximal migration, and loss of joint space between the radius and lunate bones.  Occupational therapy was carried out from August through December 2005 at which time supination had improved by 5 degrees; pronation was normal; and left grip strength was 25 pounds on the left compared to 90 pounds on the right.  At 11 months post injury, the CI complained of loss of motion at the wrist as well as chronic dorsal wrist pain, decreased grip strength, no painful mechanical symptoms, and median and ulnar nerve symptoms.  On examination on 12 February 2006 the left wrist range of motion (ROM) was 45 degrees flexion and 20 degrees of extension with moderate tenderness to palpation noted in the radial carpal region especially over the scapholunate region.  Multiple well-healed traumatic and surgical scars were present.  There was a positive Tinel’s sign (to determine nerve irritation) over the median nerve distribution with paresthesias of the distal one-third of the forearm and the thumb, index and middle fingers.  There was also decreased light touch sensation in the ulnar nerve distribution.  Grip strength was decreased on the left compared to the right.  The distal ulna was minimally tender to palpation.  There was no allodynia (pain from a non-painful stimulation such as light touch) and no temperature changes in the left hand; and, there was mild volar displacement of the carpus (wrist bones) in relation to the distal forearm.  X-rays in March 2006 confirmed the clinical findings.  Electrodiagnostic studies on 28 March 2006 revealed a left dorsal ulnar cutaneous neuropathy, and a left radial sensory neuropathy.  The prognosis for the left wrist was guarded and the orthopedic surgeon opined that the CI would require a wrist arthrodesis (surgical fusion) in the future.  Additionally, the CI continued to have constant ulnar nerve changes as well as episodic median nerve symptoms in the respective nerve distributions.  The CI did not desire to proceed with further surgical management.

A permanent U3/L3 profile was issued on 11 January 2006 for left ulnar nerve palsy, left open distal ulnar fracture, and left open lunate fracture as well as a foreign body of the left calf (retained) (see below) with limitations of the physical fitness testing and all functional military activities except wearing a protective mask and all chemical defense equipment.  Additional restrictions included no running, no rucking, no jumping, no marching, no upper body physical training, no pushups, no chin-ups, no sit-ups and no lifting greater than five pounds with the left arm.  However, the CI was able to perform alternate aerobic events for the physical training test.  At the MEB examination (recorded on DD Form 2807 and 2808) dated 13 February 2006, 10 months before separation, the CI reported the wound on the outside of the wrist could not be closed for 3 weeks due to extreme swelling.  The examiner noted decreased ROM supination and decreased grip strength of the left wrist/hand and left forearm scars from surgery and from IED fragments.  The commander’s statement dated 14 February 2006 indicated the CI was physically incapable of reasonably performing his duties as a forward observer due to his physical status and his condition made him non-deployable.  The NARSUM dated 11 March 2006, 9 months before separation, final diagnoses were marked lunate malunion with resultant marked lunate osteonecrosis (bone death) after an open lunate fracture, left wrist arthrofibrosis (scarring in the joint), chronic ulnar neuropathy after compartment syndrome of the left forearm from an IED blast injury, and chronic episodic median neuropathy resulting from a blast injury and compartment syndrome of the left forearm.

At the VA Compensation and Pension (C&P) examination dated 2 March 2007, 3 months after separation, the CI reported pain in the left wrist 6-7/10 (10 being the worst pain), difficulty opening doors and carrying a milk jug, and difficulty holding his baby.  On examination there was evidence of painful motion and tenderness on the volar and dorsal aspects of the wrist.  The forearm ROM for supination was 0-75-75 degrees (normal 0-90) and pronation 0-90-90 degrees (normal 0-90).  The CI reported no pain of the left forearm at rest, but 7/10 pain with movement.  The ROM measurements for the left wrist were extension 0-30 degrees and 0-35 degrees (normal 0-70), flexion 0-65 degrees and 0-65 degrees (normal 0-80), ulnar deviation 0-31 degrees and 0-25 degrees (normal 0-45), and radial deviation 0-15 degrees and 0-15 degrees (normal 0-20).  Left wrist pain at rest was 6/10 and with movement 7/10.  Grip strength of the left hand was 21, 19, 15 pounds and 10, 10, 10 pounds (normal 104.9).

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating using code 5010 (arthritis, due to trauma, substantiated by X-ray findings) for left (non-dominant) wrist limitation of motion post blast.  The VA assigned a 10% rating using code 5215 (wrist, limitation of motion) for status post fracture wrist, left with residuals.  The Board sought a route to a higher rating.  A higher evaluation of 20% using code 5215 is not warranted unless there is favorable ankylosis in 20 to 30 degrees of dorsiflexion.  Members noted that the CI had diminished ROMs of the wrist and forearm, but he also had significant weakness of grip strength.  Muscle code options (5307-5309) were discussed, since there was significant trauma to the wrist.  However, there was no mention of specific muscle injuries and moderate involvement using code 5307 (Group VII.  Function:  Flexion of wrist and fingers) would offer a 10% rating, while moderately severe would offer a 30% rating.  However, use of nerve codes could address the CI’s overall disability.  A median nerve using code 8515 provides option that captures the CI’s limited flexion of the wrist as well as grip weakness thereby warranting a moderate rating for the non-dominant hand at 20% using code 8515 (partial paralysis) or 8517 (neuralgia).  Weakened flexion the wrist can also be rated using ulnar nerve codes 8516 (partial paralysis) or 8716 (neuralgia), while the musculospiral nerve (radial nerve) codes cover hand grip impairment, but the radial nerve and ulnar nerve deficits cannot be combined with a median nerve code.  However, use of a lower radicular group using code 8512 (mild incomplete paralysis) or 8712 (mild neuralgia) affords a 20% rating, while 8512 (moderate incomplete paralysis) or 8712 (moderate neuralgia), which appropriately captures the level of pain with movement and integrates cutaneous sensation deficits and limited motion, affords a 30% rating.  The issue of whether combining limitation of motion of the wrist with a nerve code appears to be potential pyramiding IAW VASRD §4.14, which was avoided.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 30% for the left (non-dominant) wrist condition, coded 8712.

Posterior Left Tibial Neuropathy.  According to service treatment records and the MEB narrative summary (NARSUM), the CI’s sustained a shrapnel injury to the left knee popliteal fossa (behind the knee) in April 2005 after a blast injury to the left side of his body.  He additionally complained of left foot numbness and tingling in the medial and dorsal foot especially in the first, second and third toes region and in the plantar aspect of the foot.  The shrapnel was not removed from the popliteal fossa since it was close to the neurovascular bundle.  In July 2006 the CI was noted to have a scar of the posterior lower leg and had 3/5 gastroc soleus strength on the left.  His gait was normal and he was able to squat and rise without difficulty.   Examination of the left leg revealed tenderness to palpation and well healed traumatic wounds from the IED blast injury.  There was focal tenderness to palpation in the popliteal region, a positive Tinel's sign over the popliteal region that radiated to the foot, decreased light touch sensation in the deep peroneal nerve medial and lateral plantar distributions, and normal light touch sensation in the superficial peroneal and sural nerve distributions. The motor examination was intact with normal dorsiflexion and plantar flexion strength of the ankle, decreased toe flexion strength (4/5) of the left foot and normal toe extension strength.  There was no hypersensitivity or allodynia noted in the left lower extremity and arterial pulses were normal.  ROM measurements at the ankle were 10 degrees dorsiflexion and 35 degrees plantar flexion; and the left knee ROM was 0 to 140 degrees.  There was no laxity or effusion of the knee; quadriceps tone was excellent; and there was a well healed traumatic wound in the posterior aspect of the knee.  Light touch sensation examination of the left lower extremity revealed decreased light touch sensation predominantly along the medial plantar region of the left foot.  Radiographs of the left knee revealed a large shrapnel fragment in the posterior central knee.

An addendum dated 4 September 2006 indicated ankle dorsiflexion and plantar flexion ROMs were normal compared to 10 degrees of dorsiflexion and 35 degrees of plantar flexion in March 2006 and the knee ROM was unchanged.  Again there was no laxity and no effusion and there was excellent quadriceps muscle tone.  Knee alignment was normal when standing and there was no loss of ankle dorsiflexion.  Decreased toe flexion at the hallux (big toe) and the second through fifth toes stemmed from the posterior tibial neuropathy, which was noted in electrodiagnostic studies in March 2006 that also involved the left gastrocnemius (calf muscle) and abductor halluces muscle of the toe.  

A permanent U3/L3 profile was issued on 11 January 2006 with restrictions as noted above.  At the MEB examination (recorded on DD Form 2807 and 2808) dated 13 February 2006, 10 months prior to separation, the CI reported an injury to his left knee by an IED. The examiner noted a left calf scar.  The commander’s statement dated 14 February 2006 indicated the CI was physically incapable of reasonably performing his duties as a forward observer due to his physical status and his condition made him non-deployable.

At the VA Compensation and Pension (C&P) examination dated 2 March 2007, 3 months after separation, the CI reported tingling, numbness, and shooting pain down below the knee to the ankle with constant numbness and tingling to the bottom of his feet.  He could not walk barefoot because it felt funny.  On examination sensation of the lower extremity was normal as was posture and gait.  There was no lower extremity clubbing, cyanosis or edema.  The examiner’s diagnosis was left leg shrapnel injury behind the knee with residual neuralgia of the left lower extremity and left foot.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating using code 8525 (posterior tibial nerve incomplete paralysis mild) for posterior left tibial neuropathy confirmed by electrodiagnostic studies (NCV and EMG).  The VA assigned a 10% rating using code 8620 (sciatic nerve mild neuritis) for residual neuralgia status post shrapnel injury, left lower extremity.  The Board sought a route to a higher rating, but the condition did not rise to a moderate level since the CI’s gait was normal and his strength was 3/5 in the gastro soleus region 5 months prior to separation and 4/5 in the left toe.  After due deliberation, and in consideration of all 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 posterior left tibial neuropathy condition.

BOARD FINDINGS:  In the matter of the left (non-dominant) wrist condition, the Board unanimously recommends a disability rating of 30%, coded 8712 IAW VASRD §4.124a.  In the matter of the posterior left tibial neuropathy 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.  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 prior to medical separation:

CONDITION	VASRD CODE	PERMANENT RATING	
Left (Non-Dominant) Wrist	8712	30%	
Posterior Left Tibial Neuropathy	8525	10%	
	40%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140501, 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 XXXXXXXXXXXXXXXXXX, AR20160007469 (PD201402011)

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 (000 PDBR) pertaining to the individual named in the subject line above to re--
characterize 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:

Enclosure
CF:
( ) DoD PDBR
( ) DVA