RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02406
BRANCH OF SERVICE:  Army  	SEPARATION DATE:  20040321

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Human Resource Specialist) medically separated for bilateral carpal tunnel syndrome, right shoulder pain and rotator cuff tendonitis and neck pain.  These conditions could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty (MOS).  She was issued a permanent U3 profile and referred for a Medical Evaluation Board (MEB).  The MEB forwarded “chronic right shoulder pain,” “right rotator cuff tendonitis,” “carpal tunnel syndrome” and “cervical spine degenerative joint disease” to the Physical Evaluation Board (PEB) IAW AR 40-501.  The Informal PEB adjudicated “carpal tunnel syndrome” as unfitting, rated 10% for the right and 0% for the left with application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The PEB also found “chronic right shoulder pain and rotator cuff tendonitis” unfitting, rated 0%.  The “cervical neck pain” was determined to be unfitting, but existed prior to service (EPTS) without permanent service aggravation and therefore not rated.  The CI made no appeals and was medically separated.  

CI CONTENTION:  The CI requests the Board consider all conditions.  Her complete submission is at Exhibit A.

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 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:  

IPEB – Dated 20040122	VA* - (1 Day Post-Separation) 	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Carpal Tunnel Syndrome	8799-8715	10%	Right Hand Carpal Tunnel	8515	0%	20040322	
Left Carpal Tunnel Syndrome	8799-8715	0%	Left Hand Carpal Tunnel	8515	10%	20040322	
Right Shoulder Pain and Rotator Cuff Tendonitis	5201	0%	Right Shoulder Tendonitis	5201-5024	10%	20040322	
Cervical Pain	5003	EPTS not PSA	Cervical Spine, DJD	5242	10%	20040322	
Other x 0 (Not In Scope)	Other x 3 	
COMBINED RATING:  10%	COMBINED RATING:  40%	
*Derived from VA Rating Decision (VARD) dated 20041115 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY:

Right Wrist.  The service treatment record (STR) documents a 1 to 2-year history of bilateral (R>L) hand numbness and tingling.  At the 9 December 2002 physical medicine and rehabilitation (PM&R) encounter the CI complained of right shoulder pain with finger numbness for a year.  Prior treatments included physical therapy (PT), medications and a right shoulder steroid injection.  Electrodiagnostic studies (electromyogram [EMG] measures electrical activity of muscles and nerve conduction velocity [NCV] measure electrical signals velocity) showed abnormalities in the right median nerve.  These findings were consistent with moderate, right carpal tunnel syndrome ([CTS] compression of the median nerve in the wrist carpal tunnel causing numbness and tingling of the palm side of the thumb and fingers).  The examiner suspected a brachial neuritis (inflammation of nerve network in neck and armpit that innervates upper extremity) secondary to shoulder pressure.  He recommended a wrist brace and a profile.  At the 19 May 2003 neurology encounter the CI complained of 2 years of right shoulder pain and hand numbness.  The numbness and tingling involved right digits (1-3), spared the palm, and was not associated with weakness or pain.  It cited the PM&R electrodiagnostic studies which were consistent with right CTS.  The CI had worn a splint daily for 5 months without relief.  The impression listed symptoms, distribution, and positive Phalen’s test (compresses median nerve at wrist and elicits pain, tingling, and numbness in the hand and fingers) suggestive of CTS.  The 10 June 2003 neurology encounter documented the CI had failed conservative treatment for CTS and may need surgery.  The 19 June 2003 electrodiagnostic studies were consistent with right CTS and showed absolutely no electrodiagnostic evidence to support a diagnosis of thoracic outlet syndrome ([TOS] disorders from compression, injury, or irritation of nerves and/or blood vessels [arteries and veins] in space between collarbone and first rib [thoracic outlet]).  At the 30 June 2003 orthopedic hand surgery encounter the CI complained of numbness and tingling of the bilateral hands (R>L).  The workup demonstrated no evidence of TOS.  Electrodiagnostic testing was consistent with right CTS.  The assessment listed R>L CTS and the recommendation was for carpal tunnel release (CTR) surgery.  On 11 July 2003 the CI underwent a right CTR.  At the 24 July 2003 orthopedic hand surgery encounter, the CI reported decreased sensation of the right posterior/medial arm and persistent numbness in the three median digits.  The constant preoperative burning pain was now decreased to the afternoon only.  The assessment reported “doing well” status post right CTR with a plan to wear a splint for comfort for 2-3 weeks.  The narrative summary (NARSUM), 3 months before separation, recounted the history and interventions to date.  The right-hand dominant CI complained of, right greater then left, tingling in the hands.  She denied radicular symptoms (irritation or injury of a nerve root), weakness, tremors, deformities, diffuse joint pains, swelling, or discoloration.  The physical exam revealed a well-healed, non-tender, surgical scar over the right anterior wrist.  The motor exam revealed no deficits and the neurological exam revealed decreased sensation to light touch and pinprick in the right hand (thumb, index, middle and ring fingers).  The diagnosis listed bilateral CTS requiring surgical release on the right side.  In the VA Compensation and Pension (C&P) exam, a day after separation, the CI reported a history of numbness and tingling in her right arm and hand consistent with CTS.  She denied any specific history of injury.  The CI had a right CTR and indicated that her right hand was significantly better after surgery.  She had lost most of her original symptoms, but wore a hand brace at night.  The left hand symptoms had become worse and the CI had surgery (CTR) on 14 February 2004.  Postoperatively, she complained of left hand pain and numbness that was worse after surgery.  The right hand exam showed a well-healed surgical scar across the palm.  The right wrist tendon exam was normal and there were no neurological deficits.  The left hand exam showed a more recent surgical scar with tenderness to palpation (hypothenar prominence).  There were no neurological deficits.  The diagnosis listed bilateral CTS.  

The Board directed attention to its rating recommendation based on the above evidence.  The Informal PEB rated the right wrist condition 10%, coded 8799-8715 (median nerve neuralgia).  The PEB cited no specific history of trauma or injury, bilateral hand tingling (R>L), electrodiagnostic studies, right carpal tunnel surgery, and decreased right finger light touch and pinprick sensation.  The VA rating decision (VARD), citing the C&P exam, rated the right wrist condition 0%, coded 8515 (median nerve paralysis of).  The VARD assigned a non-compensable disability rating and cited a history of right hand numbness and tingling, right carpal tunnel surgery, significant improvement subsequent to surgery, resolution of many preoperative symptoms, normal tendons in the right hand, and no neurological deficits.  The CI experienced a favorable surgical outcome and realized the anticipated/desired effects of the corrective surgery.  Following an appropriate period of convalescence, the CI enjoyed near resolution of her preoperative symptoms.  All members agreed there was no functional loss consistent with mild incomplete paralysis (10%, major).  There was no evidence of disability for consideration under code 5214 (wrist, anklylosis of) or 5215 (wrist, limitation of motion of).  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 0% for the right wrist condition, coded 8799-8715.

Left Wrist.  The STR documents a one to two year history of bilateral (R>L) hand numbness and tingling.  Serial electrodiagnostic testing was consistent with right CTS.  The NARSUM documented right greater then left, tingling in the hands without associated radicular symptoms.  The physical exam revealed a positive Tinel's sign (percussing nerve elicits tingling over distribution of the nerve) over the left anterior wrist.  The motor exam revealed no deficits and the neurological exam revealed decreased sensation to light touch and pinprick in the right hand (thumb, index, middle and ring fingers).  The diagnosis listed bilateral CTS requiring surgical release on the right side.  In the C&P exam, 1 day after separation, the CI reported that her left hand symptoms had worsened.  She had a left CTR 5 weeks prior to separation and complained that her left hand pain and numbness were worse postoperatively.  The left hand exam showed a recent surgical scar with tenderness to palpation (hypothenar prominence).  There were no neurological deficits.  The diagnosis listed bilateral CTS. 

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the left wrist condition 0%, coded 8799-8715.  The PEB cited no specific history of trauma or injury, bilateral hand tingling (R>L), a positive Tinel's sign, and without any neurological findings.  The VARD, citing the C&P exam, rated the left wrist condition 10%, coded 8515.  The VARD cited recent left wrist surgery, worsening left hand pain and numbness, weakness and tenderness.  The Board assigned less probative value to the NARSUM exam as it occurred prior to the left wrist surgery.  The Board assigned more probative value to the C&P exam, as accurately reflecting the CI’s condition at the time of separation.  The Board recognized that being only 5 weeks postoperative, the CI might not yet have realized the anticipated/desired effects of the corrective surgery.  A subsequent VARD, 4 years after separation continued the 10% rating.  This suggests no resolution of the preexisting symptoms.  All members agreed there was functional loss consistent with mild incomplete paralysis.  There was no evidence of disability for consideration of rating under 5214 or 5215.  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 left wrist, coded 8799-8715.

Right Shoulder.  The STR documents chronic right shoulder pain since December 2001.  At the 9 December 2002 PM&R encounter the CI complained of right shoulder pain with finger numbness for 1 year.  Prior treatments included PT, medications and a right shoulder steroid injection.  Electrodiagnostic studies showed abnormalities in the right median nerve consistent with moderate right CTS.  The examiner suspected a brachial neuritis secondary to shoulder pressure.  At the 19 May 2003 neurology encounter the CI complained of 2 years of right shoulder pain and hand numbness.  She reported gradual onset of throbbing, aching, pain (7-8/10) in her right posterior shoulder.  It was previously intermittent, now constant and made worse by position in sleeping, posture and cold weather.  The impression listed right shoulder/upper back pain that was likely myofascial pain syndrome.  The examiner opined it was probably related to her prior breast reduction and repetitive muscular injury during and thereafter.  The 10 June 2003 neurology encounter physical exam noted significant pain on palpation of the right trapezius/paraspinal muscles.  There was no proximal upper extremity weakness and no apparent atrophy.  The assessment listed myofascial back/neck pain with a plan for possible BOTOX (Clostridium botulinum neurotoxin that blocks neuromuscular transmission) injections as all else seems to have failed.  The 19 June 2003 electrodiagnostic studies were consistent with right CTS and showed no evidence of TOS.  At the 21 October 2003 PM&R encounter the CI complained of chronic right shoulder pain, worse with overhead activity, for 3 years.  It documented that she had a right shoulder steroid injection in June 2002 and experienced pain reduced by 70% for approximately 3 weeks.  The physical exam revealed multiple tender points and normal active range-of-motion (ROM) of all joints.  The assessment listed chronic right shoulder myofascial pain.  The examiner performed a left upper trapezius tender point injection with local anesthetic (Marcaine) and corticosteroid (Kenalog).  The 27 October 2003 right shoulder MRI showed rotator cuff tendinopathy (chronic tendon degeneration without inflammation)/tendonitis (tendon inflammation or irritation) without evidence of tendon tear.  The NARSUM noted the CI complained of chronic right shoulder pain since December 2001.  She reported initial onset in the upper right shoulder with progressive extension to the neck, right upper and middle back, and down the right arm.  The CI denied a history of trauma and the pain was reported throbbing and as high as 7-8/10.  Pain was exacerbated by overhead activity, push-ups, and neck motion and relieved by avoiding activity.  She denied radicular symptoms, weakness, tremors, deformities, diffuse joint pains, swelling, or discoloration.  The right shoulder exam revealed tenderness over the supraspinatus muscle and trigger points were noted over the upper and middle trapezius muscle.  There was no crepitus (grating sound or sensation), popping, atrophy, or tremors.  The Adson test (assesses for TOS) was negative.  The ROM, with guarding, is listed in the chart.  The motor exam revealed no deficits and the neurological exam revealed decreased sensation to light touch and pinprick in the right hand (thumb, index, middle and ring fingers).  The diagnoses listed chronic right shoulder pain of moderate intensity and constant frequency, and right rotator cuff tendonitis.  The examiner opined that the right shoulder pain, with progressive extension, was secondary to a chronic rotator cuff tendonitis with a superimposed myofascial pain syndrome and cervical spine degenerative joint disease.  The C&P exam recounted the history of breast reduction surgery in 2002 for treatment of low back pain.  The CI complained of 3 years of right shoulder pain, tenderness, difficulty raising her right arm, and inability to lift heavy objects with her right arm.  There was no specific history of injury.  The CI reported the shoulder was tender most of the time but denied acute flares, swelling, or weakness.  The right shoulder exam revealed no external abnormalities and the generalized neurological exam was normal.  The ROM is listed in the chart.  The diagnoses listed right shoulder tendonitis and the examiner opined that it was difficult to separate the symptoms resulting from her right shoulder and that from her neck. 
The ROM evaluations which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.

Right Shoulder ROM
(Degrees)	NARSUM ~3 Mo. Pre-Sep	PM&R ~3 Mo. Pre-Sep
	MEB/PT ~3 Mo. Pre-Sep
	C&P ~ 1 Day Post-Sep
	
Flexion (180 Normal)	Normal AROM	100	78, 80, 82	140	
Abduction (180)	Normal AROM	120	71, 74, 75	100	
Comments	Guarding @ 90 FL/AB/IR/ER	Painful ROM noted	Goniometer with pain	Painful ROM noted	
§4.71a Rating	0%	10% with §4.59	20%	10% with §4.59	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the right shoulder condition 0%, coded 5201 (arm, limitation of motion of).  The PEB cited chronic pain, no specific history of trauma or injury, MRI findings compatible with tendonitis, imaging findings compatible with the origin of the pain, and ROM limited by pain.  The VARD, citing the C&P exam, rated the right shoulder condition 10%, coded 5201-5024 (arm, limitation of motion of-tenosynovitis).  The VARD cited MRI findings compatible with tendonitis and ROM limited by pain.  Board members agreed that the limitation of shoulder motion in three of four proximate exams (NARSUM, PM&R, C&P) did not attain a minimum rating under 5201.  The limitation of motion in only one exam (MEB/PT) was consistent with compensable limitation of shoulder motion (at shoulder level) supporting a 20% rating.  The Board assigned less probative value to the MEB/PT exam because it represented an isolated limitation of motion amongst three exams performed in a week.  The Board assigned the most probative value to the C&P exam, as accurately reflecting the CI’s condition at the time of separation.  There was no evidence of scapulohumeral ankylosis to support a rating under 5200, and no evidence of malunion of the humerus, clavicle or scapula, or of dislocation, to support a rating under 5202 or 5203.  Board members agreed there was sufficient evidence of painful motion (§4.59) to support a 10% rating.  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 shoulder condition.

Neck Condition.  The STR documents a history of left neck rotation producing right shoulder pain and upper extremity paresthesia (abnormal sensation, tingling, burning, prickling), concerning for TOS.  The 9 December 1999 enlistment report of medical history denied a history of recurrent back pain, neuritis (nerve inflammation or irritation), or bone, joint or other deformity.  The 25 March 2003 cervical spine X-ray showed degenerative disc disease at C4-5 and C5-6 and mild foraminal (nerve root opening) stenosis (narrowing) at C3-4, C4-5, and C5-6.  The 11 May 2003 cervical spine MRI showed reversal of the normal lordosis (anterior spine curvature) with a resultant kyphosis (posterior spine curvature), central disc extrusion with moderate central canal stenosis (C4-C5), central disc protrusion with mild central canal stenosis (C5-C6), and a mild disc bulge (C6-C7).  At the 19 May 2003 neurology encounter the CI complained of 2 years of right shoulder pain and hand numbness.  The physical exam revealed a supple neck and Spurling’s (assesses cervical nerve root compression by a herniated disc) and Lhermitte’s (assesses compression of the cervical spinal cord from disc herniation, tumor, malformations, spondylosis, etc.) tests were negative.  There was normal muscle bulk, tone, and strength (5/5) throughout except for neck flexion (pain limited).  Reflexes were intact and symmetric.  Sensation was intact except for reduced sensation in the right digits (1-3), sparing the palm.  The impression listed right shoulder/upper back pain that was likely myofascial pain syndrome.  The examiner opined it was probably related to prior breast reduction and repetitive muscular injury during and thereafter.  The 10 June 2003 neurology encounter physical exam noted significant pain on palpation of the right trapezius/paraspinal muscles without proximal upper extremity weakness or atrophy.  The assessment listed myofascial back/neck pain.  In the NARSUM the CI complained of initial pain onset in the upper right shoulder with progressive extension to the neck, right upper and middle back, and down the right arm.  The CI denied a history of trauma and the pain was exacerbated by overhead activity, push-ups, and neck motion and relieved by avoiding activity.  The neck exam revealed tenderness in the right lower paraspinal muscles extending into the right trapezius muscle.  The head compression (assesses cervical nerve root compression), Spurling’s, and Lhermitte's tests were negative.  The ROM (except for left rotation of 50 degrees) is listed in the chart.  The motor exam revealed no deficits and the neurological exam revealed decreased sensation to light touch and pinprick in the right hand (thumb, index, middle and ring fingers).  The diagnoses listed cervical spine degenerative joint disease.  The examiner opined that the right shoulder pain, with progressive extension, was secondary to a chronic rotator cuff tendonitis with a superimposed myofascial pain syndrome and cervical spine degenerative joint disease.  The C&P exam recounted the history of right shoulder tendonitis and cervical spine degenerative disc disease.  The external exam of the neck was unremarkable.  The neck was tender and painful but the generalized neurological examination was normal.  The ROM (pain at full flexion and extension) is listed in the chart.  The diagnoses listed cervical spine degenerative joint disease.  The examiner opined that it was difficult to separate the symptoms resulting from her right shoulder and that from her neck.

The ROM evaluations which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.

Cervical ROM
(Degrees)	PT ~ 12 Mo. Pre-Sep
	NARSUM ~3 Mo. Pre-Sep
	MEB/PT ~ 3 Mo. Pre-Sep
	C&P ~ 1 Day Post-Sep
	
Flex (45 Normal)	45 (58)	Normal ROM	25 (28, 29,27)	35	
Combined (340)	280	-	125	265	
§4.71a Rating	10%	0%	20%	10%	

The Board directed attention to its recommendations based on the above evidence.  The Board does not challenge service EPTS determinations, but does exercise the prerogative of assessing the presumption of aggravation (PSA) element.  Members agreed that the neck condition was a component of, and was contributory to, the disability.  The PEB coded the neck condition 5003 (degenerative arthritis), but assigned no rating.  The PEB cited neck pain without any specific history of trauma or injury, right paraspinal and trapezius muscle tenderness, normal ROM (except left rotation), and degenerative disc disease by radiographs.  The PEB stated “This condition existed prior to service (EPTS) as the development of degenerative disc disease takes more than three years, the length of time this 35-year-old Soldier has been on active duty.”  The VARD, citing the C&P exam, rated the neck condition 10%, coded 5242 (degenerative arthritis of the spine).  The VARD cited degenerative disc disease and painful ROM.  Cervical spine degenerative disease (spondylosis) is more aptly a radiologic diagnosis than a clinical syndrome.  It is commonly seen on imaging studies in both symptomatic and asymptomatic subjects.    Most individuals experience some degree of disc degeneration simply as a function of aging.  Disc degeneration, disc bulging, decreased disc height, osteophyte and spur formation, ligamentous hypertrophy, vertebral subluxation, and facet joint arthropathy all combine to cause narrowing of the spinal canal and intervertebral foramina.  Factors which contribute to acceleration of disease progression include trauma, physical activities, medical conditions, and genetics (congenitally narrow vertebral canals).  In the absence of accelerating factors, spine degenerative disease reflects chronic and progressive changes versus an acute process.  The CI specifically denied a history of trauma or injury and the physical demands of her MOS were unlikely to accelerate disease progression.  There was no indication from the record that the CI's military duties aggravated this chronic, progressive condition beyond its natural progression.  After due deliberation in consideration of the preponderance of the evidence, members agreed that there was insufficient cause to recommend a change in the PEB’s determination for the neck 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 AR 635-40 for rating the right shoulder was operant in this case and the condition was adjudicated independently of that policy by this Board.  In the matter of the right wrist condition, the Board unanimously recommends a disability rating of 0%, coded 8799-8715 IAW VASRD §4.71a.  In the matter of the left wrist condition, the Board unanimously recommends a disability rating of 10%, coded 8799-8715 IAW VASRD §4.71a.  In the matter of the right shoulder condition, the Board unanimously recommends a disability rating of 10%, coded 5201 IAW VASRD §4.71a.  In the matter of the neck 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.

RECOMMENDATION:  The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of her prior medical separation:

CONDITION	VASRD CODE	RATING	
Right Carpal Tunnel Syndrome	8799-8715	0%	
Left Carpal Tunnel Syndrome	8799-8715	10%	
Right Shoulder Pain and Rotator Cuff Tendonitis	5201	10%	
Cervical Pain	5003	---%	
COMBINED (w/ BLF)	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140520, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB

MEMORANDUM FOR Commander

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation
for XXXXXXXXXXXXXXXXXX, AR20160004496 (PD201402406)

1 . 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 accept the Board's recommendation to modify the individual's disability rating to 20% without recharacterization of the individual's separation. This decision is final.

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.

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 SECRET ARY OF THE ARMY:

CF:
( ) DoD PDBR
( ) DVA