RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02733
BRANCH OF SERVICE:  AIR FORCE	BOARD DATE:  20141023
SEPARATION DATE:  20080902

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty A1C/E-3 (3M051/Services Journeyman) medically separated for left wrist instability.  The wrist condition could not be adequately rehabilitated to meet the physical requirements of her Air Force Specialty or satisfy physical fitness standards. She was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The wrist condition, characterized as “instability left wrist,” was forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123.  The MEB also identified and forwarded one other condition.  The Informal PEB adjudicated “left wrist pain and instability” as unfitting, rated 10%, with application of the VA Schedule for Rating Disabilities (VASRD).  The one remaining condition was adjudicated Category II, a condition that can be unfitting but is not currently compensable or ratable.  The CI made no appeals and was medically separated.

CI CONTENTION: The CI writes: “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 wrist condition is addressed below, along with the contended right knee.  No additional conditions are 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 Military Records.

RATING COMPARISON:

Service PEB – Dated 20080715	VA - (3 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Wrist Pain and Instability	5099-5003	10%	Left Wrist Strain	5215-5020	10%	20081204	
R Knee Pain due to Contusion	5099-5003	CAT II	Residuals of R Knee Contusion	5099-5024	NSC	20081204	
Other x 0 (Not in Scope)	Other x 0		
Combined:  10%	Combined:  10%	
Derived from VA Rating Decision (VARD) dated 20090326 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Left Wrist Pain and Instability.  On 19 July 2007 the CI presented with a 1-day history of left wrist pain after physical training.  She reported that she heard a snap with pain.  The examination demonstrated pain throughout the left wrist range-of-motion (ROM) with tenderness on palpation at the radial (thumb side) of the wrist.  She was diagnosed with a left wrist strain.  X-ray and magnetic resonance imaging (MRI) of the left wrist were negative.  The CI continued to report left wrist pain despite physical therapy and pain medications.  An orthopedic evaluation dated 1 November 2007 demonstrated mid-carpal instability.  She was placed in a short arm cast.  The CI was subsequently diagnosed with a tenosynovitis and mid-carpal instability with intermittent wrist dislocation.  An orthopedic evaluation determined that there was no specific treatment for her instability other than carpal fusion; which would result in a 50% reduction in ROM of her left wrist.  The narrative summary (NARSUM) dated 21 May 2008 noted significant left wrist pain during the course of her weapons qualification.  The physical examination was significant for pain with left wrist extension, with popping and dislocation with extension and pressure.  There was full ROM with tenderness on the dorsal side of the left wrist.  The examiner diagnosed mid-carpal instability with dislocation of the left wrist.

At the VA Compensation and Pension examination dated 2 December 2008, 3 months after separation, the CI reported weakness, swelling, giving way, lack of endurance and dislocation.  The left wrist pain occurred 9 times per week and each episode lasts for 2 hours.  The pain was rated at 8/10.  The CI wore a wrist brace as needed.  The physical examination demonstrated left wrist tenderness and weakness.  There was full ROM, but additional pain and weakness with repetitive use.

The Board directs attention to its rating recommendation based on the above evidence.  The PEB adjudicated the left wrist instability and pain condition as unfitting.  The PEB and VA rated the left wrist condition at 10%.  The PEB, coded analogous to degenerative arthritis, 5099-5003 and VA coded the wrist condition as impairment of supination and pronation with tenosynovitis, 5213-5024.  The Board considered whether there was evidence for a higher than 10% rating for the left wrist condition.  There was no evidence of ankylosis or muscle weakness for a 20% disability 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 left wrist instability and pain condition.  

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s Category II determination that right knee pain due to contusion could be unfitting, but not compensable or ratable.  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.  Treatment records documented that the CI sustained a right knee injury in March 2008.  Radiographic evaluation demonstrated a slight lateral patellar displacement and tilt.  The CI was treated with pain medications, knee brace, and physical therapy.  In April 2008, the CI re-injured the right knee and an MRI revealed an anterior cruciate ligament strain and contusion of the patella.  There was also evidence of a small effusion.  The NARSUM examination dated 21 May 2008, 3 months prior to separation, documented persistent right knee pain with physical fitness limitations.  The physical examination demonstrated painful flexion motion and tenderness to palpation.  At a family practice evaluation dated 6 June 2008 the CI reported discomfort with going up and down stairs.  The examiner noted that the CI had completed physical therapy with improved strength, level of activity and function.

At the VA Compensation and Pension examination dated 4 December 2008, 3 months after separation, the CI reported weakness, swelling and giving way of the right knee.  She reported daily knee pain of 8/10; lasting 30 minutes.  The pain was worse with activity, steep inclines, stairs and standing on one foot.  It was relieved by rest and wearing a knee brace.  The physical examination was normal.  The right knee was not service-connected by VA.

The right knee pain due to contusion condition was profiled and implicated in the commander’s statement.  It was judged Category II and not compensable because it was not permanently aggravated by service.  The Board considered that a contusion is a bruise and is expected to resolve without permanent impact on duty performance.  The Board considered the improvement in improved strength, level of activity and function at the time of the NARSUM examination, an orthopedic evaluation that noted satisfactory progress 3 months prior to separation and a normal VA examination as evidence that the right knee was not permanently service aggravated.  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 Category II determination for the right knee pain due to contusion condition and so no additional disability rating is 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 left wrist pain and instability (right hand dominant) condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended right knee pain due to contusion condition, the Board unanimously recommends no change to the PEB’s Category II determination.  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 20140609, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

				
XXXXXXXXXXXXXXXXXXXX
President
DoD Physical Disability Board of Review

SAF/MRB
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD 20762

Dear XXXXXXXXXXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Title 10 U.S.C. § 1554a), PDBR Case Number PD-2014-02733.

After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was appropriate.  Accordingly, the Board recommended no re-characterization or modification of your separation.

	I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding and their conclusion that re-characterization of your separation is not warranted.  Accordingly, I accept their recommendation that your application be denied.

							Sincerely,

XXXXXXXXXXXXXXXXXXXX
Director
Air Force Review Boards Agency

Attachment:
Record of Proceedings