RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	      CASE:  PD-2014-02203
BRANCH OF SERVICE: NAVY                                                                    SEPARATION DATE:  20041004

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Hull Technician, medically separated for “right wrist traumatic injury” and “right hip and knee pain,” rated 10% and 10%, respectively, with a combined disability rating of 20%.

CI CONTENTION:  The CI requests the Board consider all conditions.  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 - 20040824	VARD - 20050701	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Wrist Traumatic Injury	5099-5003	10%	Post-Traumatic and Postoperative Changes, Right Wrist  	5215	10%	20040716	
Right Scapholunate Ligament Tear S/P Debridement and Shrinkage	Cat II					
Central Triangular Fibrocartilage Complex Tear, S/P Debridement	Cat II					
Ulnar Positive Impaction Syndrome S/P Ulnar Shortening	Cat II	Right Ulna Shortening with Fixation Plates and Screws	5299-5211	10%	20040716	
		Ulnar Nerve Impairment, Right Upper Extremity	8516	10%	20040716	
First Dorsal Compartment Tenosynovitis S/P Injection	Cat II	Tenosynovitis, Right Thumb	5228	0%	20040716	
Pain Disorder	Cat II	No VA Placement	
Right Hip and Knee Pain	5255	10%	Right Hip Strain, S/P Arthroscopic Labral Debridement	5252	10%	20040716	
			Chondromalacia Patella, Right Knee	5014-5260	10%	20040716	
History Of Meniscal Tear on the Right Knee	Cat III	Meniscal Tear, Right Knee And Arthroscopic, S/P, Right Hip	5255-5260	VOC	20040716	
Non-Erosive Reflux Disease  	Cat III	Gastroesophageal Reflux Disease	7346	0%	20040709	
Low Back, Neck and Upper Extremity Pain	Cat III	Cervical Strain	5237	0%	20040716	
Fluctuating Bowel Habit Abnormalities	Cat III	Irritable Bowel Syndrome	7319	0%	20040709	
COMBINED:  20%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

Right Traumatic Wrist Injury.  The service treatment record (STR) and Medical Evaluation Board (MEB) narrative summary (NARSUM) documented an injury to the right (dominant) wrist after a fall from a ship ladder in June 2002.  Electro-diagnostic studies of the ulnar, median, and radial nerves in December 2002, 2 years prior to separation, were normal with no evidence of median or ulnar neuropathy.  A January 2002 profile listed the “grasp, right hand” as a specific duty limitation.  Surgery (arthroscopy, synovectomy, neurectomy, and pinning) was performed in February 2003, 20 months prior to separation, with hardware removal in April 2003.  Due to persistent pain, another surgery (arthroscopy, and debridement) was performed in January 2004, 10 months prior to separation, with removal of 2.5 cm of bone (ulnar shortening osteotomy).  Radiographs in July 2004 documented osteopenia, “mild” separation of the wrist (navicular and lunate) bones, and shortening of the ulnar bone.  Despite treatment, the wrist 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 “right traumatic wrist injury,” as well as five related Category II conditions, for PEB adjudication.  

At the MEB NARSUM examination performed on 10 April 2004, 6 months prior to separation, the CI reported limitation of activities secondary to pain and inability to perform strenuous manual labor (push-ups, pull-ups, repetitive axial loading of the wrist).  The examiner documented tenderness over the ulnar side (triangular fibrocartilage complex, TFCC).  There was also painful motion (positive Finkelstein test) and tenderness of the radial side of the wrist (over the extensor tendon of the thumb) with “good” joint motion at the thumb with no evidence of wrist instability.  Dorsiflexion was 25 degrees (normal 70), palmar flexion to 30 degrees (normal 80), radial deviation to 5 degrees (normal 20), and ulnar deviation to 15 degrees (normal 45).  Pronation was to 50 degrees (normal 80) and supination was to 80 degrees (normal 85).  Respective grip and pinch strength was 10 and 3 pounds on the right compared to 48 and 8 pounds on the left.  The commander’s non-medical assessment dated in May 2004 implicated multiple conditions including the wrist; and, described an inability to lift heavy objects, or climb vertical ladders supporting his body weight, and the need to wear a wrist brace, all limiting him from working on board ship.  

At the MEB examination (documented on DD Forms 2697, 2807-1, and 2808) in May, June and July 2004 (5, 4, and 3 months prior to separation), the CI reported impaired use of the right hand, limited flexibility of the wrist and right thumb, and intermittent swelling; and difficulty lifting and holding things.  The examiner documented loss of sensation for light touch on the ulnar side of the wrist.  At the VA Compensation and Pension (C&P) examination dated 29 July 2004, 2 months pre-separation, the CI reported 7/10 pain and limited movement.  The wrist examination, ranges of motion (ROM), and grip strength were identical to those documented at the MEB NARSUM.  

The Board directed attention to the rating recommendation based on the above evidence.  The PEB rated the “right wrist, traumatic injury,” along with five related Category II conditions, at 10%, analogously coded 5099-5003 (degenerative arthritis).  

The VA rated the conditions 10% each for “postoperative changes of the right wrist” coded 5215 (wrist, limitation of motion), “right ulnar shortening…” analogously coded 5299-5211 (ulna, impairment of), and “ulnar nerve impairment” coded 8516 (ulnar nerve, incomplete paralysis of, mild).  The VA also granted a 0% rating for “tenosynovitis, right thumb” coded 5228 (thumb, limitation of motion).  All ratings were based on the pre-separation examination.  

The Navy PEB listed the “pain disorder,” “TFCC tear s/p debridement,” “right scapholunate ligament tear s/p debridement,” “ulnar positive impaction syndrome s/p ulnar shortening,” and “first dorsal compartment tenosynovitis s/p injection” conditions as related Category II diagnoses contributing to the disability in this case.  The Board concluded the Category II diagnoses were not separate conditions which could be reasonably justified as separately unfitting; nor would separate ratings be achievable without violation of VASRD §4.14 (avoidance of pyramiding).  

The Board considered the evidence for rating the wrist injury, including all five Category II conditions.  There was evidence painful motion and degenerative disease IAW §4.59 in support of a 10% rating (5299-5003) for the residuals of the wrist trauma and various surgeries in evidence.  Rating under code 5215 was of no advantage to the CI as it provides a maximum 10% rating for limitations of wrist motion.  

The probative values of the MEB NARSUM and VA C&P examinations were deliberated by the Board.  The April 2004 MEB NARSUM examination documented pronation to 50 degrees that met the 20% criteria for the dominant hand for coding under 5213 (supination and pronation, impairment of).  The July 2004 VA C&P examination appeared to be in question as the findings were identical to the NARSUM findings from April 2004, and therefore adjudged by the Board to not accurately represent the true ROM most proximate to separation.  Additionally, there were two visits in July 2004 (the orthopedic and occupational therapy visits) that documented evidence of improving pronation and normal pronation, respectively, along with the VA rating decision that documented an August 2004 VA examination describing normal supination and pronation more proximate to separation.  This documentation was adjudged by the Board to be most probative and more accurately representative of the true disability at the time of separation and would not support a rating higher than 10 % under 5213.  

The Board also considered code 5211 (ulna, impairment of) with respect to the ulnar shortening surgery.  Although there was evidence of the loss of 1 inch of ulnar bone, there was no evidence of “nonunion in lower half,” marked deformity, or false movement to support a higher rating under that code.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the right traumatic wrist injury.  

The Board also considered the evidence for a separate peripheral nerve rating.  There was no evidence in this case that a sensory impairment in the ulnar nerve distribution existed to any degree that could be described as functionally impairing.  Electro-diagnostic studies of the ulnar, median, and radial nerves were normal with no evidence of median or ulnar neuropathy.  There was evidence of grip and pinch weakness, however, no evidence that the motor impairment (weakness) was a result of an ulnar neuropathy, rather than a result of disuse from a painful wrist.  The first through third digits are not innervated by the ulnar nerve, and therefore no weakness could be attributed to an ulnar neuropathy.  There was no clear evidence that linked the weakness to any significant functional consequence that would allow clear separation from the wrist pain.  There is thus no evidence of a functional impairment from a residual neuropathy which interfered with performance of duties, and therefore the Board cannot support a recommendation for an additional disability rating on this basis.  

Right Hip and Knee Pain.  The PEB combined the right hip and knee pain conditions as a single unfitting condition coded 5255 (femur, impairment of) and rated it 10%.  The approach by the PEB commonly reflected its judgment that the constellation of conditions was unfitting, and there was no need for separate fitness adjudications or implied adjudication that each condition was separately unfitting.  The Board’s initial charge in this case was therefore directed at determining if the PEB’s approach of combining conditions under a single rating was justified in lieu of separate ratings.  When considering a separate rating for each condition, the Board considers each bundled condition to be reasonably justified as separately unfitting unless a preponderance of evidence indicates the condition would not cause the member to be referred into the DES or be found unfit because of physical disability.  When the Board recommends separate fitness recommendations in this circumstance, its recommendations may not produce a lower combined rating than that of the PEB.  The evidence for the right knee and hip pain conditions are presented separately, with attendant recommendations regarding separate unfitness, and separate rating if indicated.  

Right Hip Chondromalacia and Degenerative Arthritis:  The STR and MEB NARSUM documented a 2-year history of right hip pain and locking that worsened with walking.  Arthroscopy was performed in July 2003 for debridement of the cartilaginous structures (anterior superior labrum and glenoid cartilages) due to chondromalacia and early arthritic changes.  At an orthopedic follow up visit in September 2003, 13 months pre-separation, the CI reported 3/10 hip pain.  Physical examination showed a flexion of 100 degrees (normal 125), and abduction of 40 degrees (normal 45), and pain with resisted hip flexion (Stinchfield test).  At an orthopedic visit in January 2004, 9 months prior to separation, the CI reported 4/10 hip pain and was ambulating with a cane.  

Despite treatment, the right hip condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for an MEB.  At the MEB examination, the CI reported hip pain, loss of mobility, and use of a cane.  At the MEB NARSUM Addendum on 11 May 2004, 5 months prior to separation, the CI reported pain limiting activities.  The physical examination showed a flexion of 90 degrees and abduction of 40 degrees, evidence of impingement (pain with testing).  The commander’s non-medical assessment dated 20 May 2004 did not directly implicate the hip. However, it detailed the CI’s inability to run, stand for long periods, or climb ladders and the need to walk with a cane, all preventing him from working on board ship.  At the VA C&P examination dated 9 July 2004, 3 months pre-separation, the CI reported no significant improvement in pain since arthroscopy in 2003.  Physical examination showed flexion to 90 degrees, abduction to 40 degrees, pain with impingement testing, squatting to 50% of normal, and an antalgic gait.  Radiographs were normal.  

The Board directed attention to the rating recommendation based on the above evidence.  The PEB adjudicated both the “right hip and knee pain” as unfitting, rating a combined 10% coded 5255 (femur, impairment of, with slight hip or knee disability).  The VA addressed the right hip condition separately as “right hip strain, s/p arthroscopic labral debridement,” rated 10% and coded 5252 (thigh, limitation of flexion), citing painful and limited motion.  The Board first considered if the right hip condition, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The right hip was not specifically profiled.  It was implicated in the commander’s statement and the NARSUM Addendum, and adjudicated as unfitting by the PEB.  Board members agreed that the evidence reasonably justified that the functional limitations of the condition contributed to the CI’s inability to perform his military duties and accordingly a separate disability rating is recommended.  The Board considered the evidence for rating the right hip chondromalacia and degenerative arthritis.  There was documentation of painful motion, ROM deficits, and surgical evidence of chondromalacia and degenerative arthritis in support of a 10% rating, coded 5003-5252 (degenerative arthritis; thigh, limitation of flexion) or 5014-5252 (osteomalacia; thigh, limitation of flexion).  There was no evidence of ankylosis, extension limited to 5 degrees, or flexion limited to 30 degrees.  There was no evidence of limitations in abduction beyond 10 degrees, adduction (inability to cross legs), or rotation (inability to ‘toe out’ to more than 15 degrees) in support of a higher than 10% rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), §4.59 (painful motion), §4.40 (functional loss) and §4.45 (the joints), the Board recommends a disability rating of 10% for the right hip chondromalacia and degenerative arthritis IAW §4.71a.  

Right Knee Chondromalacia and History of Meniscal Tear on the Right Knee.  The STR and MEB NARSUM documented an injury to the right knee after a fall on board ship in June 1997.  Lateral and medial knee pain persisted.  Radiographic imaging in July 1997 documented tendonitis or partial tear of the anterior cruciate ligament and degenerative changes in the meniscus.  Arthroscopy in September 1997 documented hypertrophic synovial plica with excision.  Physical examination in February 2000 showed pain free and a ROM of 0-140 degrees (normal).  After another knee injury from a slamming hatch in September 2002, physical examination in October 2002 showed “good” ROM without effusion or laxity.  On re-examination by orthopedics in November 2002, there was some “fullness” in the peripatellar fat pad, with no ligamentous laxity and no impingement.  Radiographs were interpreted to show early degenerative osteoarthrosis.  

Radiographic imaging (MRI) in December 2002, 22 months prior to separation, documented bony and soft tissue edema consistent with a contusion (bruising) and no evidence of internal derangement (normal menisci, normal cruciate ligaments and normal medial collateral ligaments).  

At an orthopedic visit in January 2003, 21 months prior to separation, the examiner opined that there was sufficient damage to the articular surface of the lateral knee, that would warrant arthroscopy if pain persisted for another 6 months.  

At an orthopedic visit in April 2003, the physical examination showed a “stable” knee, with a flexion of 0-135 degrees (normal 140), and no medial or lateral joint line tenderness.  Despite treatment, the right knee condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty.  The MEB NARSUM examination was performed on 10 April 2004, 6 months prior to separation.  The CI reported wearing a knee brace that made it feel better, however he still was unable to run and had pain at the end of the day.  Physical examination showed no effusion, no ligamentous instability, an equivocal evidence of meniscal injury (medial and lateral joint line tenderness and negative McMurray testing).  ROM was from hyperextension (negative 3 degrees) to a flexion of 125 degrees.  Pain was not addressed.  On the MEB DD Form 2807-1 Report of Medical History dated 3 May 2004, the CI reported pain, giving way, locking, and occasional swelling, and full time wear of a knee brace.  The commander’s non-medical assessment dated 20 May 2004 implicated the knee, and detailed the CI’s inability to run, stand for long periods, or climb ladders; and the need to walk with a knee brace and cane, all preventing him from working on board ship.  At the VA C&P examination dated/performed on 9 July 2004, the CI reported wearing a knee brace that makes it feel better, however he still was unable to run and had pain at the end of the day.  He denied swelling, instability, and weakness.  The examiner documented a ROM of 0-130 degrees, tenderness with patellar testing (compression and inhibition tests), and no evidence of instability, or meniscal injury.  Radiographs in July 2004 documented mild narrowing of the patellofemoral compartment with possible chondromalacia patella, and no significant degenerative changes.  

The Board directed attention to the rating recommendation based on the above evidence.  The PEB adjudicated both the “right hip and knee pain” as unfitting, rating a combined 10% coded 5255 (femur, impairment of, with slight hip or knee disability).  The PEB also included the “history of meniscal tear on the right knee” as a Category III condition, that was considered to be not separately unfitting and not contributing to the unfitting condition.  The VA rated the “chondromalacia patella, right knee” at 10% analogously coded 5014-5260 (osteomalacia; leg, limitation of flexion), citing limited flexion, pain with patellar examination, and functional loss.  The Board first considered if the right knee condition, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The conditions was profiled as “traumatic arthritis of the right knee” in January 2003.  It was implicated in the commander’s statement and the NARSUM Addendum, and adjudicated as unfitting by the PEB.  Board members agreed that the evidence reasonably justified that the functional limitations of the condition contributed to the CI’s inability to perform his military duties, and, accordingly a separate disability rating is recommended.  There was documentation of tenderness and pain with patellar examination, ROM deficits, and a diagnosis of chondromalacia in support of a 10% rating analogously coded 5299-5260.  There was no evidence of recurrent subluxation or lateral instability for a higher rating under 5257.  There was no documentation of flexion limited to 45 degrees and no documentation of extension limited to 10 degrees in support of a 20% rating.  There was no documentation of persistent or recurrent meniscal injury for a higher rating under 5259 and 5258.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), §4.59 (painful motion), §4.40 (functional loss) and §4.45 (the joints), the Board recommends a disability rating of 10% for the right knee condition IAW §4.71a.  

Contended PEB Conditions:  Non-erosive reflux; low back, neck and upper extremity pain; fluctuating bowel habit abnormalities, and history of meniscal tear on the right knee.  All evidence regarding the right knee was included in the previous discussion.  None of the other conditions were profiled or implicated in the commander’s statement and none were judged to fail retention standards.  All were reviewed and considered by the Board.  There was no performance based evidence from the record that any of these conditions significantly interfered with satisfactory duty performance.  After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for any of the contended conditions other than the right knee and so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the right traumatic wrist injury and the five related Category II diagnoses, the Board unanimously recommends a disability rating of 10%, coded 5299-5003 IAW VASRD §4.71a.  In the matter of the right hip chondromalacia and degenerative arthritis, the Board unanimously recommends a disability rating of 10%, coded 5014-5252 (osteomalacia; thigh, limitation of flexion) IAW VASRD §4.71a.  In the matter of the right knee chondromalacia, the Board unanimously recommends a disability rating of 10%, coded 5299-5260 IAW VASRD §4.71a.  In the matter of the contended Category III conditions of nonerosive reflux, low back, neck and upper extremity pain conditions, and fluctuating bowel habit abnormalities, the Board unanimously recommends no change from the PEB determinations as not unfitting.  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 recharacterized to reflect permanent disability retirement, effective as of the date of his prior medical separation:  

UNFITTING CONDITION	VASRD CODE	RATING	
Right Traumatic Wrist Injury	5299-5003	10%	
Right Hip Chondromalacia And Degenerative Arthritis	5014-5252	10%	
Right Knee Chondromalacia	5299-5260	10%	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140423, with attachments
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 29 Aug 16 ICO XXXXXXXXXXXXXXXXXXXX    
	(c) PDBR ltr dtd 29 Aug 16 ICO XXXXXXXXXXXXXXXXXXXX
	(d) PDBR ltr dtd 27 Jul 16 ICO XXXXXXXXXXXXXXXXXXXX
	(e) PDBR ltr dtd 27 Jul 16 ICO XXXXXXXXXXXXXXXXXXXX
	(f) PDBR ltr dtd 27 Jul 16 ICO XXXXXXXXXXXXXXXXXXXX
	(g) PDBR ltr dtd 22 Jun 16 ICO XXXXXXXXXXXXXXXXXXXX
	(h) PDBR ltr dtd 27 Jul 16 ICO XXXXXXXXXXXXXXXXXXXX
	(i) PDBR ltr dtd 12 Sep 16 ICO XXXXXXXXXXXXXXXXXXXX
	(j) PDBR ltr dtd 26 Jul 16 ICO XXXXXXXXXXXXXXXXXXXX

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

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

     a. XXXXXXXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 30 percent disability rating (increased from 0 percent) effective date of discharge.

     b. XXXXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 10 percent disability rating (increased from 0 percent) effective date of discharge. 

     c. XXXXXXXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 30 percent disability rating (increased from 20 percent) effective date of discharge. 

     d. XXXXXXXXXXXXXXXXXXXX, former USMC: Placement on the Permanent Disability Retired List with a 30 percent disability rating (increased from 20 percent) effective date of discharge.

     e. XXXXXXXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 30 percent disability rating (increased from 20 percent) effective date of discharge. 

     f. XXXXXXXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 30 percent disability rating (increased from 20 percent) effective date of discharge. 

     g. XXXXXXXXXXXXXXXXXXXX, former USMC: Placement on the Permanent Disability Retired List with a 30 percent disability rating (increased from 10 percent) effective date of discharge.

     h. XXXXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 10 percent disability rating (increased from 0 percent) effective date of discharge. 

     i. XXXXXXXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 40 percent disability rating (increased from 10 percent) effective 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.

		XXXXXXXXXXXXXXXXXXXX
		Assistant General Counsel
		(Manpower & Reserve Affairs)