RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02178
BRANCH OF SERVICE:  Army	BOARD DATE:  20150113
SEPARATION DATE:  20031009

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-3 (Track Vehicle Repairer) medically separated for a right hand condition.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS) or satisfy physical fitness standards.  He was issued a permanent U3 profile and referred for a Medical Evaluation Board (MEB).  The right hand condition, characterized as “pain (neurogenic) secondary to right hand injury” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other conditions were submitted by the MEB.  The Informal PEB adjudicated “right (dominant) hand dorsum pain post injury” as unfitting, rated 20%, citing criteria of the US Army Physical Disability Agency (USAPDA) pain policy.  The CI made no appeals and was medically separated.

CI CONTENTION:  “Please consider all conditions.”

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 20030630	VA* - (~2 Mos. Pre-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right (Dominant) Hand Dorsum Pain Post Injury	5099-5003	20%	Right Hand Nerve Damage	8599-8514	50%	20030813	
Other x 0 (Not In Scope)	Other x 2	
Combined:  20%	Combined:  60%	
*Derived from VA Rating Decision (VARD) dated 20031020 (most proximate to date of separation (DOS))

ANALYSIS SUMMARY:

Right Hand Condition.  The first record in evidence is an aid station note dated 13 May 2002 in which it is documented that the right dominant CI “smaked” [sic] his right hand on a piece of metal while climbing on a tank.  He was noted to have mild swelling on examination, but the examination was otherwise normal including the range-of-motion (ROM), vascular, and neurological examinations.  His pain continued despite treatment and he was referred to orthopedics 3 weeks later on 3 June 2002.  The referral noted that the X-rays were normal, but that he had reduced active and passive ROM of the 3rd and 4th digits (middle and ring fingers).  He was seen in occupational therapy (OT) 4 days later and reported hitting the dorsum (top) of his hand between two pieces of metal while working on a tank 3 weeks previously.  He reported continued pain and decreased ability to bend the middle fingers.  On examination, he was noted to have minor swelling and tenderness over the middle knuckles, but with intact sensation and blood supply.  His grip strength was reduced to 12 pounds (vice 92 on the left) secondary to pain over the middle knuckle.  X-rays were again noted as normal.  Rehabilitation was recommended and duty restrictions given.  At a re-evaluation on 24 June 2002, the CI stated that his symptoms persisted and “may be a little worse.”  He continued to smoke (which impairs any healing process).  He was noted to be taking his medication (Motrin) to excess, but without side-effects.  On examination, he continued to show reduced ROM and tenderness.  “Very minor” edema was present.  The color was good, but the right hand was cooler than the left.  He was noted to have pain out of proportion to the injury or physical examination.  Repeat X-rays were normal.  Orthopedics recommended placement in a short arm cast (to allow the injury to heal without re-aggravation from activity).  He was rechecked at the 2-week point on 8 July 2002 and reported a lot less pain.  The sensory and vascular examination was normal (hand temperature was now normal) as was the ROM other than the middle finger, which was slightly reduced.  His cast was removed after 4 weeks on 24 July 2002.  The examination that day in OT showed persistent symptoms with sensory abnormalities (pins and needles) with reduced ROM of the middle finger as before.  Regional pain syndrome was entertained as a possible diagnosis.  On 14 August 2002, he injured his right middle finger while playing around with a friend.  He was treated with a splint, but his symptoms persisted.  Five days later, X-rays were normal.  He was thought to have a sprain and ROM exercises were recommended.  Subsequently, he was referred to physical medicine for the right hand contusion and suspected reflex sympathetic dystrophy, (an old name for complex regional pain syndrome [CRPS]).  A trial of acupuncture was begun.  The 1 October 2002 visit documented that he had apparently been in a mild car accident and now had pain in his lateral arm and hand.  The neurological examination was intact.  He was then referred to the pain clinic and evaluated on 23 October 2002.  He was thought to have a mixed pain picture and a nerve block recommended.  Early evidence of a contracture was present.  The physical medicine summary for the MEB was dated 4 March 2003.  The examiner recorded that the symptoms began after the CI caught his hand between a sheet of metal (depleted uranium) and the hull of a tank.  Most of his pain was at the 3rd and 4th fingers and radiated to the fingertips and elbow.  The pain was aggravated by activity including gripping with his hand and saluting.  His activities were limited due to pain in his right hand.  The commander’s statement was dated 27 March 2003.  It noted a different mechanism of injury.  The commander wrote that the CI was climbing on a tank and put his hand between the tank skirt and the tank when someone above him pulled him up and he was unable to remove his hand.  This bent his fingers towards his forearm.  He had not worked in his MOS since his accident.  His duty performance was noted to be poor with repeated failure to report and uniform violations.  He assisted others by getting their tools and also by clerical work although was limited to typing with one hand.

At the MEB examination on 25 April 2003, the CI reported a hand injury.  The examiner noted decreased strength and sensation of the right forearm and hand.  The narrative summary was dated 21 May 2003.  The CI reported that he was working as a courier and answering the telephone.  He continued to have pain in the right hand aggravated by activity.  The examiner documented that the initial injury was a result of the CI having his hand caught between the skirt and body of the tank as he was climbing on it.  The Board observed that this is not consistent with the history documented in the contemporaneous records.  A hand surgeon (record not in evidence) had raised the possibility of compression of the radial nerve at the elbow (arcade of Frohse).  Multiple nerve blocks had provided temporary benefit.  On examination, he had difficulty fully closing (flexing) the index finger of the right hand with pain.  The greatest limitation was for the last joint (the distal interphalangeal joint, DIP); previously, the middle finger had been the most problematic.  Resisted extension was full, but weaker than the other fingers.  The ROM of the wrist and elbow were noted as normal; the former argues against an injury at the arcade of Frohse.  The CI was on a narcotic and nerve stabilizer with continued pain.  He reported extreme difficulty with grip strength with even writing and saluting.

At the VA Compensation and Pension (C&P) examination performed on 13 August 2003, 2 months prior to separation, the CI reported constant pain in his right hand.  He stated that he had caught his right hand while climbing onto a tank.  He reported that he had lost grip strength, could barely write, and could not grip a pencil.  He took narcotic medication three times a day for pain.  The pain was located over the 3rd and 4th knuckles (metacarpals).  He continued to smoke.  X-rays of the right hand performed on 1 May 2003 were noted to be normal.  Sensation was normal.  Elbow flexion and extension were full, but impaired with 3/5 strength for both as well as finger abduction (spreading them apart).  The CI was evaluated in neurology on 29 January 2004, almost 4 months after separation.  He reported that his right arm had been crushed in May 2002 and that he was still unable to completely flex the fingers of his right hand.  The examiner noted that electrodiagnostic testing of the median and ulnar nerves (which innervate the flexor muscles of the hand – used to make a fist) showed no evidence of compression.  He reported pain from the surface of the right hand to the top of the forearm.  Three nerve blocks had only provided temporary relief.  On examination, he had normal muscle bulk and tone.  Strength was full other than reduced right middle finger flexion at 4/5.  Sensory was noted as normal objectively with a subjective loss of the right hand and forearm to all modalities (vibration, light touch, etc.) in a non dermatomal pattern (not matching a nerve distribution).  It was thought that the CI could have CRPS secondary to the crush injury.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the right hand condition at 20% citing the USAPDA pain policy using an analogous code for degenerative arthritis, 5099-5003.  The Board adjudicated the case in accordance with (IAW) the VASRD.  The VA also used an analogous code, 8599-8514, for incomplete paralysis of the radial nerve and rated it 50% for a severe impairment of the dominant hand.  The Board considered the evidence.  It noted multiple descriptions for the injury.  However, the initial note records that the CI struck his hand on a piece of metal, not that it was caught between two pieces of metal.  The examination, performed shortly after the accident, was consistent with this history as there was swelling and pain at the site of injury, but no bruising, neurological deficit, vascular deficit, or reduced ROM.  The sensory examination varied from normal on multiple examinations, to pins and needles to subjectively decreased (but objectively normal) in a non-dermatomal fashion (not following a nerve distribution).  The motor examination also was inconsistent varying from normal to a reduced grip to decreased movement of the 3rd finger then the index finger and the 3rd finger again.  Wrist and elbow flexion were noted as reduced at 3/5 on the C&P examination, but then normal other than the middle finger (4/5) a few months later when seen by a neurologist after separation.  The neurologist also noted normal muscle tone and bulk indicating no atrophy which would be expected with disuse.  Electrodiagnostic testing also did not show an injury.  The limitations cited by the CI were not consistent with the absence of atrophy documented post-separation by the neurologist.  The totality of evidence supports that there was pain with use of the right hand predominantly from the middle finger.  The evidence for motor loss is inconsistent between examinations and not consistent with the lack of atrophy as documented by the neurologist.  The sensory loss and history also were inconsistent between examinations.  The Board considered the coding options available for the right hand and found no route to a rating higher than the 20% rating 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 hand 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 for rating the right hand condition was operant in this case and the condition was adjudicated independently of that policy by the Board.  In the matter of the right hand condition and IAW VASRD §4.71a and 4.124a, 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 20140505, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR Commander, US Army Physical Disability Agency (AHRC-00), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXXXXXXXX AR20160004378  (PD201402178)

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
( ) OVA