RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02291
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20071101

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Watercraft Operator, medically separated for “complex regional pain syndrome (CRPS) involving the ulnar distribution of the right arm,” “chronic low back pain (LBP),” and “chronic left knee pain,” rated 10%, 10%, and 0% respectively, with a combined disability rating of 20%.

CI CONTENTION:  The CI contends the Medical Evaluation Board (MEB) requires reevaluation.  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 based upon a 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 - 20070705	VARD - 20080627	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Complex Regional Pain Syndrome Right Ulnar Distribution	8799-8716	10%	Complex Regional Pain Syndrome, Right Upper Extremity	8799-8716	0%	20071030	
Chronic Low Back Pain	5299-5237	10%	Lumbar Strain	5237	10%	20071030	
Chronic Left Knee Pain	5099-5003	0%	Left Knee Condition	5003-5261	10%	20071030	
Mild Subjective Tinnitus	Not Unfitting	Tinnitus	6260	NSC	20071108	
Degenerative Disk Disease of the Cervical Spine	Not Unfitting	Cervical Spine Strain	5237	10%	20071030	
Depressive Disorder	Not Unfitting	Depressive Disorder NOS	9435	30%	20071023	
Right Lateral Epicondylitis, Bicipital Tendonitis, Coracoid Bursitis, and Costochondritits	Not Unfitting	Left Elbow Condition	5207	NSC	20071030	
		Costochondritis	5399-5321	NSC	20071030	
		Right Shoulder Strain	5203	10%	20071030	
Acne	Not Unfitting	Acne	7828	10%	20071030	
Right-sided Benign Paroxysmal Vertigo 	Not Unfitting	Benign Positional Paroxysmal Vertigo	6299-6204	NSC	20071030	
Nonallopathic Lesions Sacral Lumbar Lower Extremities	Not Unfitting	No VA Placement	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

Complex Regional Pain Syndrome Involving the Ulnar Distribution of the Right Arm.  According to service treatment records (STR) and the MEB narrative summary (NARSUM), the CI’s right (dominant) upper extremity (RUE) condition began in May 2005 while deployed.  The CI reported RUE pain with numbness and tingling in the little finger and weak grip strength.  The CI was comprehensively evaluated.  Right upper extremity X-rays were negative and a bone scan showed no evidence of CRPS, but there was a possible old stress fracture or bone bruise noted of the right wrist.  Cervical MRI studies in April 2006 showed “early” degenerative disc disease (DDD).  Electrodiagnostic studies did not show evidence of any cervical radiculopathy, neuropathy, brachial plexus injury, or muscle injury.  The MEB forwarded “right upper extremity pain secondary to ulnar nerve irritation and thoracic outlet syndrome” for PEB adjudication.  

At a MEB consult on 19 April 2006, the CI reported constant RUE pain from the shoulder to the hand.  The physical examination showed tenderness to palpation (TTP) of the right shoulder, arm, forearm and hand.  There was no muscle wasting or weakness.  The CI reported decreased sensation over the ulnar aspects of the forearm and hand and medial aspect of the arm.  There was full painful ROM of all joints noted.  There was TTP over the ulnar nerve at the elbow, but Tinel’s signs (radiation of pain in the distribution of a nerve with percussion) of the ulnar and median nerves were all negative at the applicable elbow and wrist locations.  

The CI was evaluated by a vascular surgeon in May 2007 and diagnosed with probable thoracic outlet syndrome (TOS) and underwent TOS surgery in August 2006, without relief of her symptoms.  During the course of her treatment, the CI was diagnosed with various conditions of the RUE including bicipital tendinitis, coracoid bursitis, and cubital tunnel syndrome without relief from therapies targeted to these diagnoses.  Screening for rheumatologic disorders was negative and she was subsequently given the diagnosis of CRPS.  

At the MEB NARSUM on 21 November 2006, 13 months before separation, the CI reported right dominant arm pain and right second rib related pain (costochondritis) that started after the TOS surgery.  The physical examination performed on 27 October 2006 showed full ROM of the cervical spine, elbow, wrist, fingers and thumb.  There was TTP of the neck muscles and right elbow.  There was no muscle atrophy, but strength was graded 4/5 throughout the RUE due to pain.  Sensation was intact.  There was TTP of the elbow, but there was no evidence of nerve compression at the wrist or elbow.  There was painful, limited ROM of the right shoulder, with flexion of 115 degrees and abduction of 135 degrees (normal for each is 180 degrees).  Repeat electrodiagnostic studies in October 2006 and January 2007 were normal.  

An Informal PEB in January 2007 adjudicated “chronic right upper extremity pain” as unfitting, rated 20%, coded 5099-5003 citing the USAPDA pain policy.  The CI appealed the findings of the PEB and requested an independent review by the Deputy Commander of Clinical Services (DCCS).  In April 2007, a physical medicine evaluation noted that the CI’s arm turned purple during the visit and the examiner’s assessment was that the symptoms were “highly consistent” with CRPS of the ulnar nerve.  The DCCS recommended that the RUE diagnosis be changed to CRPS.  A corrected MEB was issued on 21 June 2007 with “Complex Regional pain syndrome (sic) of the right upper extremity secondary to ulnar nerve irritation and thoracic outlet syndrome” for PEB adjudication.  

In the interim, a right elbow MRI on 4 May 2007 noted subtle enlargement of the ulnar nerve possibly consistent with neuropathy.  A NARSUM addendum, dated 21 June 2007, noted only the change in the RUE diagnosis with no other new information regarding the RUE condition.  Electrodiagnostic studies in July 2007 to evaluate for ulnar neuropathy were normal.  

At the VA Compensation and Pension (C&P) examination 30 October 2007, performed 2 days before separation, the CI reported constant radiating RUE pain aggravated by activity since surgery for TOS.  Physical examination showed the CI was right hand dominant.  The cervical spine examination noted normal flexion and combined ROM of 275 degrees (normal 340 degrees) with painful motion.  There was no tenderness, muscle spasm or radiating pain with movement and no additional limitation of motion with repetition.  The RUE was normal in appearance, without abnormal coloration, or swelling.  There was no muscle wasting or weakness.  There was mild limitation of shoulder ROM (above shoulder level) with pain, and normal elbow, wrist, hand and finger ROM.  There was no swelling, weakness tenderness, subluxation, or guarding of movement of any of these joints and there was no additional limitation of any joint function by repetitive use.  There was normal right hand strength and RUE strength, sensation and reflexes.  Peripheral nerve examination was noted to be normal.  Right shoulder and elbow X-rays were normal.  

The PEB adjudicated multiple diagnoses of the RUE.  The PEB adjudicated “right dominant upper extremity pain secondary to ulnar nerve irritation and thoracic outlet syndrome” as unfitting and multiple conditions were bundled as a single not unfitting condition, including “right lateral epicondylitis, bicipital tendinitis, coracoid bursitis and costochondritis.”  The epicondylitis, bicipital tendinitis, and coracoid bursitis were all clinical working diagnoses in the course of the evaluation and treatment of the CI’s right arm symptoms.  The costochondritis developed after the TOS surgery, which did not resolve the CI’s RUE symptoms.  Following the PEB, the CI requested a second opinion by the DCCS, which recommended that the RUE diagnosis be changed to CRPS.  The Board determined that the multiple diagnoses of the RUE were all related to the unfitting RUE condition, but none could be reasonably considered separately unfitting because the symptoms of the listed diagnoses (other than CRPS) were limited to pain and limited ROM of the RUE.  The same symptoms cannot be provided more than a single rating under two different diagnoses IAW VASRD 4.14 (avoidance of pyramiding).  Therefore, the Board’s rating recommendation for the CRPS subsumes any contributions of the multiple RUE diagnoses to pain and limited ROM of the RUE joints.  

The Board directed attention to its rating recommendation based on the above evidence. The PEB assigned a 10% rating, coded 8799-8716 (analogous to neuralgia, ulnar nerve), which is an analogous code for CRPS, citing painful but full motion, without muscle atrophy.  The VA assigned a 0% rating, also coded 8799-8716, based on the VA C&P examination, 2 days before separation, citing “no functional loss of the right, elbow, wrist, and hand.”  The VA also assigned a 10% rating for the right shoulder coded 5203, based on the same C&P exam, citing limited motion.  The VA noted that care was taken not to pyramid benefits due to the overlap of symptoms between the CRPS and the right shoulder.  

The Board first considered the appropriate nerve code to use in this case and agreed with the PEB and VA coding choice of the ulnar nerve.  The rating criteria of 8716 are subjective, with 10% for “mild” and 30% for “moderate” incomplete paralysis.  According to VASRD §4.124a, when nerve involvement is “wholly sensory”, the rating should be for the mild, or at most moderate degrees and VASRD §4.124 (neuralgia) likewise indicates a rating maximum of “moderate” level.  The Board therefore deliberated whether the nerve impairment at separation was best characterized “mild” or “moderate”.  The evidence supports that following the TOS outlet syndrome, the pain persisted, but the RUE sensation was normal and strength was normal or limited by pain, without muscle atrophy noted.  At the C&P examination (the most proximate examination to the date of separation) findings were limited to RUE pain.  The RUE was normal in appearance, without abnormal skin coloration noted and there were normal strength, sensation, and reflexes.  The Board consensus was that this evidence supports characterizing the residual CRPS of the RUE at separation as “mild” for a 10% rating.  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 RUE CRPS condition.  

Chronic Low Back Pain.  According to STR and the MEB back NARSUM dated 16 February 2007, the CI’s low back condition began while she was deployed in 2005.  She reported back pain that developed while walking between the town and her barracks.  She reported LBP and left lower extremity weakness initially and constant LBP since that time, for which she had not been treated.  Electrodiagnostic studies in November 2005 showed no evidence of lumbar radiculopathy.  At a MEB addendum for the back dated 19 April 2006, the CI reported localized LBP without radiation or neurological symptoms.  The physical examination noted tenderness diffusely throughout the spine with full ROM.  Strength sensation, and reflexes were normal and SLR was negative.  The MEB examination (recorded on DD Form 2807 Report of Medical History and DD Form 2808 Report of Medical Examination) in October/November 2006, noted full active ROM of the TL spine with TTP of the lumbar region. The PEB initially adjudicated “functional low back pain” as not unfitting in January 2007.  The CI appealed the findings of the PEB and requested that her low back be further evaluated for the MEB as noted by the MEB addendum performed on 16 February 2007.  A primary care note dated 6 February 2007 indicated the CI reported LBP with muscle spasms, without radiation to either LE.  She requested an MRI “as suggested by her lawyer.”  The physical examination noted TTP and muscle spasms.  There was limited flexion with painful motion, with all other ROM normal and without pain.  Straight leg raise testing was normal.  The lumbar MRI showed DDD at L5-S1 and multilevel spinal arthritis without central spinal canal stenosis or nerve impingement.  

At the MEB addendum for the back on 16 February 2007, the CI reported she was taking pain medication and muscle relaxant medication for her back.  She denied lower extremity symptoms.  The physical examination noted a stiff gait.  There was normal muscle tone.  The CI could heel and toe walk.  There was “full active ROM of all her joints and lower extremities.”  Forward flexion and lateral bending were described as “somewhat limited” and estimated to be 80% of normal.  There was normal sensation and reflexes, with negative straight leg raise (SLR).  The examiner recommend a MEB.  The amended MEB (21 June 2007) forwarded “functional low back pain” as not meeting retention standards for PEB adjudication.

Physical therapy (PT) was requested to perform thoracolumbar ROM for the MEB on 23 April 2007.  The therapist asked why ROM would be measured when the CI had just recently begun treatment to decrease pain and increase ROM and expressed the opinion that the ROM measurements would not be valid in this circumstance.  The TL ROM was flexion of 54 degrees (normal 90) and combined ROM of 170 degrees (normal 240).  The NARSUM addendum on 21 June 2007 noted the PT ROM.

At the VA C&P examination in October 2007, performed 2 days before separation, the CI reported constant localized LBP aggravated by walking at times.  She reported she could function with the pain and that the back condition did not cause incapacitation.  Physical examination showed a normal gait.  There was no TTP or muscle spasm.  There was no radiating pain with movement and SLR testing was negative.  There were normal spinal contours.  TL flexion was 70 degrees with pain and combined ROM was 210 degrees.  There was no additional loss of joint function with repetition.  There were no signs of intervertebral disc syndrome.  

Similar to the CRPS discussion above, the PEB adjudicated 2 conditions of the low back: “functional low back pain” was adjudicated as unfitting and “nonallopathic lesions sacral, lumbar, lower extremities” was adjudicated as not unfitting.  Both of these conditions are conditions of the low back and their contributions to the CI’s disability due to the low back condition cannot be separated and are subsumed in the Board’s rating recommendation IAW VASRD 4.71a as discussed below.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating, coded 5299-5237 (analogous to lumbosacral strain), citing pain limited motion and tenderness.  The VA also assigned a 10% rating using the straight 5237 code based on the VA C&P examination 2 days before separation, citing limitation of thoracolumbar motion.  The Board agreed that a 10% rating, but no higher, was justified for limitation of flexion (greater than 60 degrees, but not greater than 85 degrees) and/or combined ROM (greater than 120 degrees, but not greater than 235 degrees) reported on the initial MEB NARSUM and VA examinations.  There was no muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour, thus the next higher 20% rating was not justified on this basis.  PT measured TL flexion of 54 degrees in April 2007, but the therapist questioned the usefulness of the ROM measurements when the CI had just started therapy.  The Board consensus was that the preponderance of evidence supports a 10% rating based on limitation of motion.  There was no documentation of intervertebral disc syndrome (IVDS) with incapacitating episodes which would provide for a higher rating under that formula (for IVDS), or evidence of ratable peripheral nerve impairment which would provide for additional rating.  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 chronic low back pain condition

Chronic Left Knee Pain.  According to STR and the MEB addendum dated 19 April 2006, the CI’s knee condition began in approximately April 2005.  The MEB addendum noted the onset was insidious and the CI had minimal treatment until the MEB.  Left knee X-rays and MRI showed no intra-articular pathology.  A small benign tumor of the bone (osteochondroma) was noted on the medial aspect of the knee.  The MEB examination (recorded on DD Form 2807 Report of Medical History and DD Form 2808 Report of Medical Examination) in October/November 2006 noted full active ROM of the knee with TTP of the medial and lateral compartments without instability.  The PEB initially adjudicated “left knee pain secondary to anserine bursitis” as not unfitting.  The CI appealed the findings of the PEB.  The amended MEB (21 June 2007) forwarded “left knee pain” as not meeting retention standards for PEB adjudication.

The NARSUM addendum dated 21 June 2007 indicated the CI was further evaluated by orthopedics for knee pain.  The physical examination noted TTP over the site of the osteochondroma.  Patellar grind was positive.  There was no instability or effusion.  No change in size of the tumor was appreciated on imaging.

Due to tenderness of the benign bone tumor of the knee that did not respond to anti-inflammatory medication, the CI underwent surgical removal in July 2007.  At a follow up visit at the joints clinic on 13 September 2007, 2 months before separation, the CI reported improvement in the knee pain related to the tumor, but retropatellar pain continued.  She denied effusion or instability.  The physical examination noted a normal gait.  There was a well-healed knee incision and normal alignment.  There was no TTP or effusion, and no muscular atrophy.  There was a positive patellar grind and crepitus.  Knee ROM was 0 degrees extension (normal 0 degrees) and 130 degrees flexion (normal 140 degrees).  There was no evidence of patellar apprehension, instability or meniscal pathology.  Left knee X-rays on the same day noted mild joint narrowing and a normal patellofemoral joint and surgical changes following the tumor excision.  

At the VA C&P examination in October 2007, performed 2 days before separation, the CI reported constant left knee pain without weakness, giving way, locking, or instability.  She reported she could function with the pain.  Physical examination showed left knee tenderness without effusion, weakness, subluxation, or guarding of movement.  The ROM was 0 degrees extension and 140 degrees flexion.  There was no additional limitation of joint function after repetition.  There was no evidence of instability or meniscal pathology.  Left knee X-rays were normal.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 0% rating coded 5099-5003 (analogous to degenerative arthritis), citing knee pain with full ROM.  The VA rated the knee condition 10% coded 5503-5261 (degenerative arthritis-limitation of leg extension).  The evidence in record supports that following the excision of the benign tumor of the knee and a period of convalescence, the CI had a normal examination of the left knee at the C&P examination with normal ROM, except for some noted residual tenderness of the knee.  The Board agreed that there was imaging evidence of arthritis of a single major joint, but at the C&P examination, the most proximate examination to the date of separation, there was no objective confirmation of limited motion to support a 10% rating.  There likewise was no limitation of motion which attained a minimum rating under the diagnostic codes for limitation of flexion or extension (5260, 5261).  The examinations proximate to separation did not demonstrate the presence of ligamentous instability or laxity (5257), and there was no history of dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258), or history of surgery to remove a meniscus (5259) to support a rating under the respective codes.  There was no fracture, non-union, or malunion of the femur or tibia to support consideration under the respective codes for knee impairment related to long bone conditions (5255, 5262).  No additional functional limitation was evidenced by the examinations.  Therefore the Board concluded there was not sufficient evidence to support a rating higher than the 0% 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 left knee condition.

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the “mild subjective tinnitus”, “degenerative disk disease of the cervical spine,” “depressive disorder”, “acne”, “right-sided benign paroxysmal positional vertigo” conditions were not unfitting, as well as the “right lateral epicondylitis, bicipital tendinitis, coracoid bursitis and costochondritis” and “nonallopathic lesions sacral, lumbar, lower extremities” conditions discussed above in the analysis summary.  

The “mild subjective tinnitus”, “degenerative disk disease of the cervical spine,” “depressive disorder”, “acne”, “right-sided benign paroxysmal positional vertigo,” “right lateral epicondylitis, bicipital tendinitis, coracoid bursitis and costochondritis” and “nonallopathic lesions sacral, lumbar, lower extremities” conditions were not profiled or implicated in the commander’s statement and were not judged to fail retention standards.  There was no performance-based evidence from the record that any of these conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, and 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 and so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the complex regional pain syndrome of the right arm condition and IAW VASRD §4.124a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the chronic low back pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the chronic left knee pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended “mild subjective tinnitus”, “degenerative disk disease of the cervical spine,” “depressive disorder”, “acne”, “right-sided benign paroxysmal positional vertigo,” “right lateral epicondylitis, bicipital tendinitis, coracoid bursitis and costochondritis” and “nonallopathic lesions sacral, lumbar, lower extremities” conditions, the Board unanimously recommends no change from the PEB determination as not unfitting.  There were no other conditions within the Board’s scope of review for consideration.  

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 20140428, with attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB						

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, AR20160016556 (PD201402291)

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
(  ) DVA