RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02757
BRANCH OF SERVICE:  NAVY	BOARD DATE:  20150424
SEPARATION DATE:  20090911

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (Information Systems Technician) medically separated for pain in his right shoulder, wrist and feet.  The conditions could not be adequately rehabilitated to meet the physical requirements of his Rating or satisfy physical fitness standards.  He was placed on limited duty (LIMDU) and referred for a Medical Evaluation Board (MEB).  The “other disorders of bone and cartilage,” “other joint derangement, not elsewhere classified, shoulder region,” “radial styloid tenosynovitis” and “lesion of ulnar nerve” were forwarded to the PEB IAW SECNAVINST 1850.4E.  The MEB narrative summary (NARSUM) listed these conditions as bilateral sesamoiditis of the metatarsophalangeal (MTP) joints, multidirectional instability of the right shoulder, De Quervain's tenosynovitis status post (s/p) release, and cubital tunnel syndrome s/p ulnar nerve transposition.  No other condition was submitted by the MEB.  The Informal PEB (IPEB) determined the CI was fit for duty but the CI appealed this decision to a Formal PEB.  A Reconsideration PEB upheld the IPEB’s adjudication but the CI rebutted this adjudication as well.  A second Reconsideration PEB adjudicated pain in right shoulder, wrist, and feet as unfitting, rated 10%, with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The “…De Quervain’s…”, “…instability of the right shoulder”, and “…sesamoiditis…” conditions were determined to be Category II, contributing to unfitting condition, but not separately unfitting.  The “cubital tunnel syndrome…” was determined to be Category III (not separately unfitting and does not contribute to the unfitting condition).  The CI made no further 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 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:

Recon PEB – Dated 20090603	VA* - (~7 Mos. Pre-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Pain in R Shoulder, Wrist and Feet	5099-5003	10%	No VA Placement	
De Quervain's Tenosynovitis S/P Release	Cat II	Status Post Left Wrist Tendon Release For De Quervain's
Tendonitis with Residuals (Minor)	5215-5024	10%	20090210	
Multidirectional Instability of the Right Shoulder	Cat II	Right Shoulder Impingement Syndrome (Major)	5201-5024	10%	20090210	
Bilateral Sesamoiditis of the MTP Joints Bilaterally S/P Left Tibial Sesamoid Exostectomy	Cat II	Right Foot Sesamoiditis	5299-5284	0%	20090210	
		Status Post Left Foot Arthroplasty with Residuals	5299-5284	0%	20090210	
Cubital Tunnel Syndrome S/P Ulnar Nerve Transposition	Cat III	Right Elbow Cubital Tunnel Syndrome Status Post Ulnar
Nerve Transposition (Major)	8599-8516	0%	20090210	
Other x 0 (Not In Scope)	Other x 15	
RATING:  10%	RATING:  60%	
*Derived from VA Rating Decision (VARD) dated 20091030 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Pain in R Shoulder and Category II Multidirectional Instability Condition.  The first record in evidence for the right shoulder condition was an appointment in primary care on 2 June 2005 when the CI injured himself in training while swimming.  He was treated with medications, physical therapy (PT), and duty restrictions.  The record then falls silent until a 14 August 2007 PT evaluation in which he reported that he had injured himself 2 years earlier in training, but did not seek care at that time to avoid being dropped from training.  He noted a sensation that the shoulder slid out with general activities, especially overhead activities.  Two tests, one for instability and one for impingement, were positive, but others were not.  He was treated with improvement.  On 5 September 2007, he reported in PT that his pain had increased after swimming 500 meters.  In the following few weeks, he stated that he had no shoulder pain in the next two PT appointments.  The next record in evidence was an orthopedic appointment on 18 January 2008.  The right shoulder pain was improving with PT.  The purpose of the appointment was for a LIMDU evaluation; the examiner noted that the CI was also under treatment for the foot and elbow condition.  There were no further entries specific for the right shoulder after this visit until separation.  At the MEB examination on 17 December 2008, the CI reported right shoulder pain and instability.  The examiner only noted multiple scars.  The commander’s letter dated 14 January 2009 noted only that the CI was unable to meet all his duty requirements due to his medical condition without additional detail.  At the VA Compensation and Pension (C&P) examination performed on 10 February 2009, the CI reported that he served in the Iraq and Afghanistan war and saw combat.  He also reported that he dislocated his right shoulder in training in 2005.  He reported that he could not garden, mow the lawn, or take out the trash due to knee and shoulder problems.  On examination, he had signs of rotator cuff injury bilaterally.  However, there was no subluxation (an incomplete dislocation).  The range-of-motion (ROM) was reduced in both shoulders from the VA normal values, but more on the right with flexion of 130 degrees and abduction of 120 degrees.  X-rays were normal.  The NARSUM was dated 11 February 2009, 7 months prior to separation and the day after the VA C&P examination.  No history was recorded for the shoulder, but the examiner noted that the CI was on an extension of his limited duty for the foot condition.  On examination the CI was noted to have full ROM, but it was recorded as 140 degrees abduction (away from the body) and 130 degrees forward flexion (straight in front).  The VA normal values are 180 degrees each.  He was thought to have signs consistent with multi-directional instability.  The goniometric ROM evaluations in evidence 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)	MEB ~7 Mo. Pre-Sep	VA C&P ~7 Mo. Pre-Sep	
Flexion (180 Normal)	130	130	
Abduction (180)	140	120	
Comments	AO	AO	
§4.71a Rating	10%	10%	

The Board first considered if the right shoulder condition was separately unfitting.  The CI was not seen specifically for his shoulder for over a year prior to separation until in the PEB process.  The NARSUM, at the time of its dictation, indicated that the CI was not fit for duty for the foot condition.  The first two PEBs found the CI fit for duty.  The Board considered the evidence and found that a determination that the right shoulder condition was separately unfitting at separation was not supported by the evidence.  Therefore, no separate rating is recommended.

Pain in (L) Wrist and Category II De Quervain’s Tenosynovitis S/P Release Condition.  The CI was first seen for a left wrist sprain on 6 August 2004 following an injury in pugil stick training.  The next record in evidence for the left wrist was dated 27 June 2007 when the CI was evaluated for atraumatic pain which had not improved with splinting.  He was referred to orthopedics and diagnosed with De Quervain’s tenosynovitis.  He was treated with PT and injections with improvement, but recurrent symptoms.  He then underwent a surgical release on 23 September 2008.  He was seen monthly for post-operative follow-up.  The final appointment in evidence was dated 4 December 2008 and noted continued improvement in his symptoms and increased activity was recommended.  It was noted that he was on a LIMDU for his feet and would likely need a PEB.  At the VA C&P examination, the CI reported left wrist pain since 2006 related to a blow to the left wrist while working security aboard ship.  This history is not consistent with the prior records in evidence.  He reported that it was hard to drive, do push-ups, and work around the house.  On examination, the scar was noted to be well healed and asymptomatic.  Both wrists showed tenderness and a positive test for the tenosynovitis condition.  The ROM was reduced in dorsi-flexion (wrist up) and palmer flexion (wrist down) from the VA normal values at 60 and 70 degrees (VA normal 70 and 80), both respectively.  However, the unaffected right wrist had the identical values implying that these are normal for this individual.  Motor function and X-rays were normal.  The NARSUM (5 months after surgery and 7 months prior to separation) recorded that the CI was still in occupational therapy for treatment of the post-operative scar.  His symptoms were improved though.  On examination, the incision was healed with a prominent scar.  A provocative maneuver for De Quervain’s tenosynovitis was reduced from the pre-operative examination.  A C&P exam on 6 June 2011, remote from separation and the surgery, noted normal strength and ROM bilaterally with no use of a brace. 

The Board first considered if the left wrist De Quervain’s condition was separately unfitting.  The CI was not seen specifically this condition after the 3 month post-operative follow-up other than evaluations for the PEB process.  The NARSUM, at the time of its dictation, indicated that the CI was not fit for duty for the foot condition.  The first two PEBs found the CI fit for duty.  A VA C&P examination 2 years after separation found an essentially normal examination.  The Board considered the evidence and found that a determination that the left wrist condition was separately unfitting at separation was not supported by the evidence.  Therefore, no separate rating is recommended.

Pain in Both Feet and Category II Bilateral Sesamoiditis of the MTP Joints… Condition.  The CI was first seen for foot pain on 13 July 2004 when someone stepped on his right foot while he was running.  He was again seen on 9 September 2004 for a second (identical) injury.  He apparently did well until 28 September 2006 when he reported that 4 days previously he had jumped from a pier to a barge and injured his heel.  X-rays were normal.  In February 2007, he broke the small toe of the left foot.  Four months later, in June 2007, he reported pain near the left great toe and was treated with orthotics, activity restrictions, and then casting for what was diagnosed as sesamoiditis (inflammation of a sesamoid bone, a bone found in a tendon), left greater than right.  This was confirmed on a bone scan which is not separately in evidence.  At a 21 April 2008 podiatry evaluation, he stated that his injury dated to landing on concrete after jumping “over a flight of stairs” while chasing a suspect.  On 1 May 2008, the sesamoid bone was surgically excised.  In follow-up on 24 June 2008 in podiatry, the examiner recommended continuation of LIMDU and considered surgery of the right foot.  On 8 August 2008, the podiatrist noted that the strength was normal and the scar well healed.  The CI reported a decrease in symptoms bilaterally.  Two weeks later in orthopedics the CI was noted to be on extended LIMDU for his bilateral foot condition and surgery of the right foot was under consideration.  At the MEB examination, the CI reported bilateral foot pain.  At the VA C&P examination, the CI reported bilateral foot pain since chasing a suspect in 2006.  He could not walk, run, or stand without pain.  On the scar examination, the scar on the left foot was well healed and non-tender.  On the foot examination, the scar on the left foot was tender.  His posture and gait were normal as was tandem walk.  Both feet were tender to examination, but motion was not painful.  He used no foot support.  X-rays were normal.  The NARSUM noted that the bilateral sesamoiditis condition was “the limiting source of symptoms in his inability to return to active duty.”  The symptoms in both feet had improved with treatment and the right was not thought to warrant surgery.  On examination, he was noted to have tenderness on the left at the site of the surgery.  The scar was well healed.  Motor function was normal.

The Board first considered if the bilaterally foot condition was separately unfitting, either separately or as a combined condition.  The NARSUM, at the time of its dictation, indicated that the CI was not fit for duty for the foot condition.  The CI had surgery on the left foot and the right foot was not thought to warrant surgery.  A bone scan a year earlier had noted changes consistent with sesamoiditis in both feet, but the left was worse than the right.  His symptoms in both feet were noted to be improving at the NARSUM and his gait was noted as normal on the VA examination.  Review of the LIMDU document showed that only the left foot was documented.  The Board determined that the evidence supports that the left sesamoiditis was separately unfitting, but that the evidence did not support a finding that the right foot was also unfitting.  The Board noted that even if it were, the evidence would support only a 0% rating providing no advantage to the CI.

The Board directed its attention to its rating recommendation for the left foot (sesamoiditis) condition based on the above evidence.  The PEB rated the right shoulder, (left) wrist, and feet at 10% using an analogous code 5099-5003 (degenerative arthritis.  The PEB rated the left foot at 0% using the analogous code 5299-5284 (other foot injuries).  There is no code specific for the sesamoiditis condition in the VASRD.  The Board considered these codes and others available for the foot and found no route to a rating higher than the 10% adjudicated for the combined condition by the PEB.  Accordingly, there is no advantage for the CI to adjudicate the left foot as separately unfitting and ratable.  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 the pain in the right shoulder, (left) wrist, and feet condition.

Contended PEB Conditions. The Board’s main charge is to assess the fairness of the PEB’s determination that the cubital tunnel syndrome s/p ulnar nerve transposition condition was 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 cubital tunnel syndrome s/p ulnar nerve transposition was not listed on the final LIMDU before the PEB process began.  An orthopedic note dated 20 August 2008 noted that it had resolved.  The VA C&P examination noted a normal neurological examination and ROM symmetric with the left side.  It was reviewed and considered by the Board.  There was no performance based evidence from the record that this condition significantly interfered with satisfactory duty performance at separation.  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 the ulnar nerve 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 right shoulder pain, left wrist, and feet condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended cubital tunnel s/p (right) ulnar nerve transposition 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.

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 20140610, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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 29 Sep 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 USN
- XXXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXXX, former USN
- XXXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXXX, former USN