RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02771
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20061117

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an activated Reservist E-5 (Transportation Management Coordinator) medically separated for left extensor carpi ulnaris with tenosynovitis.  The left arm condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty.  He was issued a permanent U3 profile and referred for a Medical Evaluation Board (MEB).  The “left extensor tenosynovitis, status post left extensor carpi ulnaris tenosynovectomy” and “left ulnar dorsal cutaneous nerve palsy,” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other condition was submitted by the MEB.  The Informal PEB adjudicated “injury to left hand dominant extensor carpi ulnaris with tenosynovitis” as unfitting, rated 10%, with application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  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 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 20061012	VA* - (~2 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Injury to Left Hand Dominant Extensor Carpi Ulnaris with Tenosynovitis	5024-8799-8716	10%	Left Ulnar Nerve Neuropathy, Status Post Reconstruction	8516	30%	20070125	
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 0	
RATING:  10%	RATING:  30%	
*Derived from VA Rating Decision (VARD) dated 20070327 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY:

Left Extensor Carpi Ulnaris with Tenosynovitis.  The left handed CI first injured his left hand in 2003 while pulling a heavy object.  Ongoing pain and weakness led to a diagnosis of left extensor carpi ulnaris tendinopathy which was surgically treated in December 2004 with tendon sheath reconstruction.  Although there was symptomatic improvement post-operatively, pain and weakness returned.  At the MEB exam on 5 January 2006 (10 months prior to separation), the CI marked “No” for “Numbness or tingling” and for “Impaired use of …hands.”  The MEB physical exam noted decreased left wrist range-of-motion (ROM), painful wrist flexion and extension, and decreased left grip strength.

At a VA Compensation and Pension (C&P) exam on 13 April 2006 (7 months prior to separation) the CI reported that since the tendon surgery he experienced decreased strength and numbness of the ring and little fingers.  Physical examination showed some atrophy and weakness of the intrinsic left hand muscles.  The examiner opined that a left ulnar neuropathy was present.  

A neurology evaluation was performed on 10 May 2006 (6 months prior to separation) for a complaint of tingling in the dorsal hand.  Examination showed full strength of intrinsic left hand muscles and no muscle atrophy.  Some sensory loss was present over the dorsal ulnar aspect of the hand.  Electrodiagnostic studies showed severe dorsal ulnar cutaneous neuropathy on the left, but no other abnormalities.  There was no evidence of nerve deficits responsible for muscle strength.  The narrative summary (NARSUM) on 2 June 2006 noted a complaint of constant pain that waxed and waned in severity, and was temporarily relieved by Ibuprofen or a wrist splint.  Examination showed a well healed surgical scar on the left hand.  Sensation was reduced in the distribution of the left dorsal ulnar cutaneous nerve (i.e. the dorsal aspect of the ring and small fingers and that portion of the hand).  Signs of ulnar nerve and median nerve irritability at the wrist were absent.  Painful wrist motion in all directions was present.  Left wrist dorsiflexion was 65 degrees (normal 70 degrees) and palmar flexion was 50 degrees after repetition (normal 80 degrees).  The examiner rendered diagnoses of left extensor carpi ulnaris tenosynovitis and left ulnar dorsal cutaneous nerve palsy.  Due to persistent pain in the distribution of the ulnar dorsal cutaneous nerve, on 23 June 2006 the CI underwent microscopic surgical neurolysis of that nerve.

At the VA Compensation and Pension (C&P) exam on 25 January 2007 (2 months after separation), the CI reported continued pain and numbness in the distribution of the same nerve.  Pain was constant, exacerbated by quick motions or making a fist, and partially alleviated by narcotic medication.  He reported difficulty carrying things, shaving with his left hand or typing with the 4th and 5th fingers.  Examination showed normal muscle strength in all muscles of the left hand and sensory loss of the dorsal, ulnar aspect of the hand.  The examiner opined that left wrist and hand symptoms were likely related to the tendon and not nerve injury.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under a combination 5024 (tenosynovitis) code and analogous 8517 peripheral nerve code (neuralgia of ulnar nerve).  The VA’s original 30% rating in 2005 was assigned for moderate incomplete paralysis under the 8516 code (paralysis of ulnar nerve).  Based on the C&P exam on 25 January 2007 (2 months after separation), the rating was decreased to 10%; however, the 30% rating was later re-instated, effective to near the date of separation.  In deliberating a rating recommendation, the Board considered the clinical ambiguity regarding the etiology of the CI’s disability.  The PEB’s consideration of different coding options was therefore reasonable.  However, since the affected tendon and nerve are anatomically co-located and symptoms in this case could be due to either structure, the Board agreed with the PEB and the VA that assigning a separate rating for each is prohibited IAW VASRD §4.14 (avoidance of pyramiding).  The 5024 code defaults to limitation of motion of the affected joint.  In this case, limitation of wrist motion (code 5215) was insufficient to warrant the highest 10% rating under that code; however, there was satisfactory evidence of painful motion to warrant a 10% rating IAW VASRD §4.59.  The ulnar nerve coding pathway stipulates that moderate incomplete paralysis justifies a 30% rating for the dominant upper extremity, while “mild” paralysis warrants 10%.  In debating this coding option, it was noted that muscle weakness was reported by some examiners but not others; however, electrodiagnostic studies did not support the presence of neurologically mediated weakness.  Board members agreed the available evidence was most accurately depicted by the “mild” descriptor, and therefore a 10% rating was supported.  

The Board finally considered a rating under the muscle code 5307 (Group VII); however, “moderately severe” did not adequately describe the muscle disability in this case; therefore, the 30% rating was not warranted via this pathway.  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 injury to left hand 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.  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 hand dominant extensor carpi ulnaris with tenosynovitis condition and IAW VASRD §4.124a, 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, 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

SAMR-RB						

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXX, AR20160003760 (PD201402771)

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,   I accept the Board’s recommendation and hereby deny the individual’s application.  
This decision is final.  The individual concerned, counsel (if any), and any Members of Congress who have shown interest in this application have been notified of this decision by mail.

 BY ORDER OF THE SECRETARY OF THE ARMY:

Enclosure

CF: 
(  ) DoD PDBR
(  ) DVA