RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXX	CASE:  PD-2014-02363
BRANCH OF SERVICE:  MARINE CORPS	BOARD DATE:  20141021
SEPARATION DATE:  20090830

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SSGT/E-6 (1371/Engineer/Construction) medically separated for left hand ray resection and residuals.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty.  He was placed on limited duty for 6 months and referred for a Medical Evaluation Board (MEB).  The left hand condition was forwarded to the Physical Evaluation Board (PEB) IAW SECNAVINST 1850.4E.  Two other conditions (charted below) were submitted by the MEB.  The Informal PEB adjudicated “status post 5th ray resection secondary to retractable contracture” as unfitting, rated 20%, citing criteria of the VA Schedule for Rating Disabilities (VASRD) IAW the Disability Evaluation System (DES) Pilot Program.  The PEB also adjudicated surgical scar of residual of amputation 5th ray, moderately disfiguring, persistent digital neuroma and loss of grip strength secondary to 5th ray resection as Category II (contributing to unfit) conditions.  Additionally, the PEB adjudicated 11 other conditions (charted below) as Category III (not separately unfitting and do not contribute to the unfitting condition).  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 those conditions identified but not determined to be unfitting by the PEB when specifically requested by the CI.  The rating for the unfitting left hand ray resection and residuals condition is addressed below; additionally the 11 conditions (charted below) are also within the DoDI 6040.44 defined purview of the Board.  Any conditions or contention not requested in this application, or otherwise outside the Board’s defined scope of review, remain eligible for future consideration by the Board for Correction of Naval Records.

RATING COMPARISON:

Service IPEB – Dated 20090304	VA - (8 Mos. Pre Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Status Post Fifth Ray Resection …	5156	20%	Status Post Amputation of Left Fifth Ray with Persistent Digital Neuroma (Non-Dominant)	5156	20%	20090126	
Persistent Digital Neuroma …	CAT II					
Loss of Grip Strength…	CAT II	Left Wrist Strain and Tendinitis (Non-Dominant)…	5099-5014	10%		
Surgical Scar Of Residual Of Amputation Fifth Ray…	CAT II	Scar, S/P left Fifth Ray Amputation	7804	10%		
Sprain and Tendonitis of Right Wrist…	CAT III	Sprain and Tendinitis,  Right Wrist	5099-5014			
Obstructive Sleep Apnea	CAT III	Obstructive Sleep Apnea	6847	0%		
Tension Headaches		Headaches	8100	0%		
Rhinitis		Allergic Rhinitis	NSC		
Thoracic Spine Strain	CAT III	Thoracic and Lumbosacral Strain	5237	10%		
Lumbosacral Spine Strain						
Five Seborrheic Dermatitis of the Face…	CAT III	Seborrheic Dermatitis	7899-7806	0%		
Strain and Tendonitis…Left Shoulder		Strain and Tendinitis , Left Shoulder (Non- Dominant)	5099-5019	10%		
Strain and Tendonitis Left Elbow w/o Instability		Strain and Tendinitis, Left Elbow (Non-Dominant)	5099-5019	10%		
Right Ankle Sprain and Tendonitis w/o Instability		Right Ankle Sprain And Tendinitis	5271	0%		
Tinnitus		Tinnitus	6260	10%	20090124	
Other x 0 (In Scope)	Other x 0	
Combined:  20%	Combined:  70%	
Derived from VA Rating Decision (VARD) dated 20090903 (most proximate to date of separation [DOS]).   

ANALYSIS SUMMARY:

Status Post Fifth Ray Resection and Residuals Condition.  Orthopedic surgery entry dated 1 August 2008, noted this right hand dominant CI initially had surgery to remove a small cyst on his 5th digit of the left hand in 2004.  The left hand began to demonstrate flexion contraction with features consistent with early, aggressive Dupuytren contracture (affects a layer of tissue that lies under the skin of your palm).  The first surgical intervention in 2005 excised fibrous tissue (release surgery) with good effect.  Recurrence was quick and more severe.  A second release surgery, this time excision of the contractile cords, was performed in 2006.  The CI underwent a third surgery but continued to experience difficulties.  He then agreed to 5th ray amputation.  Post surgery orthopedic clinic note dated 3 October 2008, noted the CI reported pain at the incision site and mild pain at the wrist.  The CI had received a prescription for medications that addressed neuropathic pain with recorded benefit.  The left hand examination demonstrated full range-of-motion (ROM), minimal tenderness to palpation and no signs of inflammation.  The CI’s 2006 profile prohibited deployment, lifting with left hand, and pushups and pull-ups.  There was no other profile in evidence.  The record indicated the CI did deploy in 2008.

The narrative summary dated 12 January 2009, notes the CI’s condition began around 2004-2005.  After the first two surgeries, the CI had recovered enough to allow his deployment to Iraq but the contracture recurred and limited his ability to perform his duties.  The CI reportedly was unable to perform pull-ups and had problems with heavier forceful gripping, grasping and manipulation of objects.  His limitation was due to pain and or loss of strength.  Physical examination of the left hand revealed a well-healed 5th ray resection scar with focal tenderness on attempted grip and grasp “with radiating symptoms consistent with a buried deep neuroma.”  Pain was recorded at 3/10 during rest and up to 7/10 with forceful grip.  There was full ROM and no signs of neurovascular compromise or adhesions.  In addition to the diagnosed 5th ray resection, the diagnosis of persistent digital neuroma was recorded.  At the VA Compensation and Pension exam performed 8 months prior to separation, the CI reported weakness in the left hand.  Physical examination noted grip strength in the left hand significantly reduced compared to the right hand (Left hand 28, 23, 18 foot-pounds; right hand 105, 110, 104 foot-pound), opined to indicate a generalized weakness of the left thumb and three surviving fingers.  Inspection of the left hand revealed a four inch surgical incision that extended from the dorsal aspect of the hand around the palm reaching the metacarpophalangeal (MP) joint of the third finger and then into the palm.  The scar was moderately tender and mildly disfiguring.  Signs of inflammation were absent.  Tendon function of the remaining digits and thumb of the left hand was intact.  Pain on motion was recorded but no evidence of ROM limited by pain.  Radiographs taken during the evaluation showed amputation of the fifth digit to the level of the fifth metacarpal base.  The physician diagnosed “amputation of the fifth ray with persistent digital neuroma, weakness of the left hand with residual decreased sensation in the left ring finger medial digital nerve, and accompanying early contracture of the ring finger.”

The Board directs attention to its rating recommendation based on the above evidence.  The PEB noted the condition of status post 5th ray resection secondary to retractable contracture,  rated under the pilot DES, assigned a disability rating of 20% coded 5156.  In addition to rating the 5th digit amputation, the VA assigned a rating for painful scar, rated 10%, coded 7804.  The 5156 code is specific for 5th digit amputation, allowing for a 10% and 20% rating.  Therefore, a higher rating could not be recommended under code 5156.  The PEB recorded the conditions of “Lost of grip strength secondary to fifth ray resection, surgical scar of residual of amputation left fifth ray, and persistent digital neuroma,” Category II diagnoses, related to the primary condition and not separately unfitting.  The Board first deliberated the associated conditions of loss of grip strength and persistent digital neuroma, followed by a discussion of the surgical scar.  The Board deliberated whether the scar could be compensated under the 7804 code.  All Board members agreed, the surgical scar was intimately associated with the 5th digit amputation, had not interfered with performance.  The Board concluded the conditions of persistent digital neuroma, loss of grip strength and surgical scar were integral components of the amputation pathology and could not be recommended for additional rating IAW VASRD 4.14 (avoidance of pyramiding).  Thereupon, 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 5th ray resection condition.

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the conditions of right wrist sprain and tendinitis, obstructive sleep apnea (OSA), tension headaches, thoracic spine strain, rhinitis, lumbosacral spine strain, seborrheic dermatitis, left shoulder strain and tendinitis, left elbow strain and tendinitis, tinnitus, and right ankle sprain and tendinitis were not unfitting.  The Board’s threshold for countering fitness determinations is higher than the VASRD §4.3 (reasonable doubt) standard used for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  The above stated conditions were neither profiled, nor implicated in the non-medical assessment of the command and were not judged to fail retention standards.  All were reviewed by the action officer 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, 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 of the contended conditions; no additional disability ratings are recommended.

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.  The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised.  In the matter of the status post 5th digit resection secondary to retractable contracture condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended right wrist, right ankle, left shoulder, left elbow, OSA, tinnitus, tinnitus, headaches, thoracic, lumbosacral spine strain and seborrhea conditions, 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.

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 20140527, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

				
XXXXXXXXXXXXXX
President
Physical Disability Board of Review

MEMORANDUM FOR DIRECTOR, SECRETARY OF THE NAVY COUNCIL OF REVIEW
               BOARDS 

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS
 
Ref:   (a) DoDI 6040.44
       (b) CORB ltr dtd 22 Apr 15

      In accordance with reference (a), I have reviewed the cases forwarded by reference (b), and, for the reasons provided in their forwarding memorandums, approve the recommendations of the PDBR that the following individual’s records not be corrected to reflect a change in either characterization of separation or in the disability rating previously assigned by the Department of the Navy’s Physical Evaluation Board:

- XXXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXXX, former USN

						  XXXXXXXXXXXXXXX
	     				  Assistant General Counsel
		  (Manpower & Reserve Affairs)