RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02481
BRANCH OF SERVICE:  Army 	
DATE PLACED ON TDRL:  20050106	DATE REMOVED FROM TDRL:  20060516

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an Air National Guard or National Guard E5, Unit Supply Specialist, medically separated from the Temporary Disability Retired List (TDRL) for “painful scar, right hand” with a disability rating of 10%.

CI CONTENTION:  “Please consider all conditions.” The applicant’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 IPEB – 20041210/20060420	VARD - 20110302	
TDRL Placement – 20050106	Code	Rating	Condition	Code	Rating
Proximate	
Condition		TDRL
Placement	TDRL Removal			TDRL
Placement	TDRL Removal	
Complex Regional Pain Syndrome, Right Hand	8599-8513	40%	--	Complex Regional Pain Syndrome Causing Pain and
Numbness of the Right Hand	8599-8513	40%	40%	
Painful Scar Right Hand	7804		10%	Scar from Incision and Drainage… 	7804	10%	10%	
Carpal Tunnel Syndrome		Not Unfitting	No VA Placement	
Hypertension		Not Unfitting	No VA Placement	
COMBINED RATING:  40% → 10%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  .

Painful Scar Right Hand Condition.  According to service treatment records (STRs) and the Medical Evaluation Board (MEB) narrative summary (NARSUM) dated 12 October 2004, the CI sustained a spider bite on the palm of the right hand (dominant) and was seen in the emergency room (ER) on 10 June 2004 after an incision and drainage (I&D) was attempted a day earlier.  On examination, there was edema of the palmar and dorsal surfaces of the hand and tenderness to palpation at the base of the thumb.  She was unable to flex or extend her fingers secondary to pain.  Because of a concern of a deep space infection of the right hand, she was admitted for surgery.  A note on 12 July 2004 indicated the CI had multiple I&Ds of the right hand and was treated for MRSA [methicillin resistant staphylococcus aureus]. Postoperative occupational therapy (OT) was carried out.  By August 2004 the CI was doing better, but had soreness over the scars and numbness.  There was some decreased sensation of the index finger, a minimal decrease in flexion at the proximal interphalangeal (PIP) joints, and no sign of infection.  An occupational therapist noted a web space scar extended to the dorsal and palmar surfaces, measured 2 inches, and was hypersensitive.  At an ER visit on 30 August 2004, the CI complained of ongoing swelling and pain of the right hand.  On 7 September 2004, the CI was evaluated in the Physical Medicine and Rehabilitation (PM&R) clinic with the complaint of painful paresthesias in the 1st web space of the right hand, pain in all the fingertips and that she frequently dropped objects.  The ROM measurements of the fingers of the right hand were decreased.  Electro-diagnostic studies revealed evidence of a right motor and sensory demyelinating median neuropathy across the wrist consistent with moderate carpal tunnel syndrome.  The CI also had complaints in a radial nerve distribution, the digital sensory branches of which were untestable.  The examiner opined that given the location of the I&Ds and prominent scar tissue, it was reasonable that the distal radial sensory branches were injured and that this was a more likely explanation for the subjective symptoms.  The CI was given a resting hand splint to wear 23 hours per day along with a nonsteroidal anti-inflammatory drug (NSAID) and gabapentin (for nerve pain).  The scar was injected in October 2004 and occupational therapy continued through November 2004. 

At the time of the NARSUM, the CI’s hand function failed to recover and her pain failed to resolve.  She had significant difficulty with activities of daily living secondary to pain, discomfort, and weakness within her hand.  Her pain was 1/10 (10 being the worst pain) and 4-5/10 with use.  Besides the NSAID and gabapentin, she also took tramadol (an opioid-like medication) for the pain.  The CI had well-healed scars with significant sensitivity distal to the incisions with even the softest of touch (allodynia) distally.  The CI had a minimal Tinel’s (to demonstrate nerve irritation) over her dorsal scar and significant tenderness to palpation over the ulnar scar.  The CI had no swelling and the sweat perfusion pattern appeared normal. The range of motion (ROM) measurement for the right thumb was within normal limits, while the ROMs of her right second to fifth fingers were slightly decreased at the metacarpophalangeal (MCP) joints and PIP joints and mild to moderately decreased at the distal interphalangeal (DIP) joints. The CI’s extended two-point discrimination (to test for sensory innervation) in the fingers was normal except the ring finger measured at 6-7 mm (normal 4-6 mm), which was minimally impaired. 

At the MEB examination, the CI reported (recorded on DD Forms 2807 and 2808) “wrist pain,” “numbness and tingling in finger and thumb area,” “right hand contracted,” “painful joints in the right hand,” and “1st, 2nd, and 3rd fingers will not straighten up” from the surgery and spider bite, and “found out from the doctor I have carpal tunnel syndrome.”  Physical examination showed a positive sensory loss in the median [nerve] distribution, full ROM of finger M[C]P joints and finger IP [interphalangeal] joints, weakness of the right hand, and hyperesthesia of the dorsal hand.  The examiner listed the diagnosis as RPS (regional pain syndrome) of the right hand.  The commander’s statement, dated 19 October 2004, indicated the CI was physically incapable of reasonably performing her duties as an Armor Senior Sergeant and prevented her from performing many of the functional activities of a solder.  A permanent U3 profile was issued on 15 November 2004 for right hand pain with limitations of push-ups, lifting and carrying more than 20 pounds, and all military functional activities. 

No VA Compensation and Pension (C&P) examination or VA Rating Decision (VARD) proximate to separation was available for review.  A remote VA DBQ (Disability Benefits Questionnaire) dated 27 March 2012, 86 months post-separation, offered little to no probative value.  

At a visit dated 19 February 2006, 3 months prior to TDRL separation, the CI’s history was of a spider bite complicated by cellulitis and a deep tissue infection with MRSA that required surgery five times.  As a result, the CI had residual pain with deformity.  Her symptoms at the time of the examination were an inability to “abduct/’control’ DV” (five digits) (the dorsal interossei muscles innervated by the deep branch of the ulnar nerve) and increased “sensitivity” along palmar and dorsal incision lines.  The CI also complained of numbness/tingling in the fingertips of the first and second digits; she had positive pain with wrist flexion and when attempting to open jars.  Pain was 6/10, which was not changed significantly since she was discharged from the hospital.  The CI lost the ability to type since May 2005 and had used a computer with voice recognition software since then.  The CI used a thumb abductor splint and a wrist splint at night and a compression glove during the day along with the medications ibuprofen (an NSAID) and tramadol.  On examination, the CI’s right hand was in an abnormal posture with the thumb abducted/opposed and fingers flexed at the MCPs and extended at the PIPs and DIPs; however, when she gestured during the interview the hand appeared to have a normal ROM at the wrist and digits.  There was tenderness on palpation of the web space between the thumb and index finger over a prominent scar and there was tenderness on palpation of the palmar aspect over the scar.  There was no muscle atrophy, but there was a decreased response to tactile stimulation on the dorsal aspect of the radial 3½ digits.  There was no fine motor dysfunction; the CI was able to grasp pen and print her name legibly.  Flexion and extension strength of the wrists was normal.  No finger weakness was observed.  Tests to determine median nerve status including Phalen's maneuver (to show hand numbness/tingling and Tinel's sign) of the median nerve at the wrist were negative.  The examiner opined the chronic painful scars of the right hand appeared to be focal and not generalized to the entire hand; and, therefore not suggestive of complex regional pain syndrome since the abnormal posture of hand changed with distraction and raised doubt there was a true contracture.  Numbness/tingling in the first and second digits may have been secondary to radial or median nerve injuries, which could not be tested due to post-operative edema.  At a PM&R examination dated 30 March 2006, the CI reported numbness at the dorsal, radial aspect of the right hand and index finger with increased “sensitivity” in those regions and at the right palm.  She described pain at the right wrist, especially with prolonged writing and typing.  Repeat electro-diagnostic studies were performed that revealed evidence of a moderate right motor demyelinating ulnar neuropathy across the elbow (not in scope) without evidence of denervation or renervation (nerve destruction or regeneration) and evidence of a conduction block to the right FDI (first dorsal interosseous muscle).  The examiner concluded that “electrodiagnostic evidence of a moderate right ulnar neuropathy across the elbow may explain some of the patient's hand symptoms.”  Additional findings included right lateral epicondylitis (not in scope), right distal wrist extensor/flexor tendonoses, and right deQuervain's radial tenosynovitis.  The examiner concluded “the electrodiagnostic evidence consistent with very mild right carpal tunnel syndrome found on the previous electrodiagnostic study performed in September 2004 was likely related to the patient's recent hand surgery and soft tissue injury at that time, which have since healed.”

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB assigned a 40% rating using code 8599-8513 (moderate incomplete paralysis-all reticular groups) for right complex regional pain syndrome for TDRL placement.  The VA also assigned a 40% rating using code 8599 for complex regional pain syndrome causing pain and numbness of the right hand.  The VA also assigned a 10% rating for a scar from the incision and drainage procedures between the thumb and first finger, palm, and web area of the right hand.
The Board noted code 8513 has a 70% option for severe incomplete paralysis of all radicular groups; however, the CI’s condition did not rise to that level.  The Board also was aware that the VA assigned a separate rating for the painful scar, which seemed to raise the issue of pyramiding, which is to be avoided IAW VASRD §4.14, since the diagnosis of the regional pain syndrome would encompass pain from any source in the area of the hand.  Therefore, the Board was unable to find a route to a higher rating for TDRL placement.

At TDRL removal, the PEB assigned a 10% rating using code 7804 for a painful scar of the right hand without evidence of chronic regional pain syndrome and without objective evidence of a contracture.  The Board noted the CI was still unable to type at TDRL removal and had tingling and numbness of the first and second fingers of the right hand as well as slight loss of motion of the second (index) and third (middle) fingers.  Code 8715 (neuralgia-mild) offers a 10% rating option since the CI did have a limited functional impairment with sensation subjectively, albeit two-point discrimination testing for the first three fingers was normal.  Alternatively, the code 5299-5229 (Index or long finger, limitation of motion) does also offer a 10% rating option because of the mild limitation of motion of both the index and long fingers.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the right hand painful scar condition but recommends an additional disability rating of 10% for the median nerve neuralgia condition at TDRL removal.

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that right carpal tunnel syndrome and hypertension were not unfitting.  The Board’s threshold for countering fitness determinations requires a preponderance of evidence, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  The right carpal tunnel syndrome and hypertension were not profiled or implicated in the commander’s statement and were not judged to fail retention standards.  

Right Carpal Tunnel Syndrome.  Although electrodiagnostic studies revealed evidence of a right motor and sensory demyelinating median neuropathy across the wrist consistent with moderate carpal tunnel syndrome prior to TDRL placement, the PEB captured the median nerve neuropathy as a component of code 8513 (moderate incomplete paralysis-all reticular groups) for right complex regional pain syndrome.  However, electro-diagnostic studies for the TDRL removal examination found the median nerve neuropathy had resolved, although the CI had residual numbness and tingling of the first and second fingers (see above).

Hypertension.  At the MEB examination the CI indicated that she first had elevated blood pressure in 2000.  Blood pressure was 122/77 and 144/90 in August 2004, while in October 2004 it was 140/82.  A manual blood pressure in November 2004 was 158/82, while in December 2004 it was 155/85.  In January 2005 her blood pressure was 154/87, which on repeat was 128/87.  The record did indicate the CI received the blood pressure medications Vasotec (an ACE inhibitor) in August 2004 and ramipril (an ACE inhibitor) thereafter.  

The aforementioned was reviewed and considered by the Board.   There was performance based evidence from the record that the carpal tunnel syndrome did interfere with satisfactory duty performance, but it was included in the regional pain syndrome diagnosis for which the CI was found unfit and rated at TDRL placement.  At TDRL removal, the carpal tunnel syndrome had apparently resolved, although residual numbness and tingling of the first and second fingers persisted.  The hypertension did not significantly interfere 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 either of the contended conditions and so no additional disability ratings are recommended.

BOARD FINDINGS:  In the matter of the complex regional pain syndrome condition and IAW VASRD §4.124a, the Board unanimously recommends no change in the PEB adjudication at TDRL placement.  In the matter of the right hand painful scar condition and IAW VASRD §4.118, the Board unanimously recommends no change in the PEB adjudication of a 10% rating at TDRL removal and unanimously recommends an additional disability rating of 10%, coded 8715 IAW VASRD §4.124a.  In the matter of the contended carpal tunnel syndrome and hypertension 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.  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	
		TDRL	PERMANENT	
Complex Regional Pain Syndrome, Right Hand	8413	40%	--	
Painful Scar, Right Hand 	7804		10%	
Median Nerve Neuralgia	8715		10%	
COMBINED	40%	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140528, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM   FOR Commander

SUBJECT:   Department  of Defense  Physical  Disability  Board of Review  Recommendation for XXXXXXXXXX,  AR20160007501    (PD201402481)

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  re-characterization   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 SECRETARY  OF THE ARMY:

CF:
( ) DoD PDBR
( ) DVA