RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02962
BRANCH OF SERVICE:  AIR FORCE	BOARD DATE:  20141021
SEPARATION DATE:  20080806

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SrA/E-4 (2W051/Munitions Systems) medically separated for a wrist pain condition.  The 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 U4 profile and underwent a Medical Evaluation Board (MEB).  The narrative summary (NARSUM) listed her diagnosis as “Bilateral wrist pain.”  The MEB found her condition medically acceptable and recommended return to duty.  However, her case was forwarded to the Physical Evaluation Board (PEB).  The Informal PEB adjudicated “wrist pain” as unfitting, rated 10% with application of the VA 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 those conditions identified but not determined to be unfitting by the PEB when specifically requested by the CI.  The rating for the unfitting wrist pain condition is addressed below.  No other conditions are within the defined purview of the Board.  Any conditions outside the Board’s scope of review may be eligible for consideration by the Board for Correction of Military Records.

RATING COMPARISON:

Service IPEB – dated 20080623	VA – (25 mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Wrist Pain	5003	10%	Peripheral Neuritis and Myopathy, Right Hand/Wrist	8599-8515	30%	20100924	
			Peripheral Neuritis and Myopathy, Left Hand/Wrist	8599-8515	20%	20100924	
Other x 0	Other x 3 (Not in Scope)		
Combined:  10%	Combined:  60%	
Derived from VA Rating Decision (VARD) dated 20101214 (most proximate to date of separation [DOS])

ANALYSIS SUMMARY:

Wrist Pain.  In 2003, the CI developed bilateral wrist pain.  She was seen by many specialists and had numerous tests completed.  An electromyography and nerve conduction velocity studies were performed on 24 September 2007 and both were normal.  In October 2007, she was seen by orthopedics, and there was full range-of-motion (ROM) of both wrists.  Magnetic resonance imaging (MRI) of the left wrist showed a small cystic structure, most likely a ganglion cyst.  MRI of the right wrist was normal.  She had a rheumatology work-up which was negative for any evidence of inflammatory arthritis.  In January 2008, she was seen by neurology.  On physical examination (PE), wrist ROM was full and neurological exam was normal.  The examiner’s assessment was: bilateral wrist pain likely from overuse, no sign of carpal tunnel or other neuropathy.  In spite of all the studies and evaluations that were performed, the etiology of her wrist pain remained unclear.  Due to the chronic, unremitting nature of her symptoms, an MEB was initiated.  The MEB NARSUM was dated 25 April 2008.  On PE of the upper extremities, there was no cyanosis (blueness) or edema (swelling).  Phalen’s test and Tinel’s test were both negative.  Neurological exam was normal.  Wrist ROM was not recorded at that exam.  

The CI separated from service in August 2008.  Two years later, she had a VA Compensation and Pension (C&P) exam.  She complained of intermittent pain, numbness and tingling of both hands and wrists.  Neurological exam of the upper extremities revealed normal pinprick, normal position sense and normal light touch.  Vibration sense was not tested.  Deep tendon reflexes in both upper extremities were present and symmetrical.  Brachioradialis tendon and Biceps tendon reflexes were recorded as 1+ bilaterally.  For a diagnosis, the examiner wrote: mild peripheral neuritis, due to strain of bilateral hands.  Wrist ROM was not recorded.

The Board directs attention to its rating recommendation based on the above evidence.  The PEB chose diagnostic code 5003 (degenerative arthritis) for the wrist pain.  The two wrists were bundled together and treated as a single unfitting condition.  The Board evaluated whether or not it was appropriate for the two wrists to be “bundled” together.  The Board must determine if the PEB’s approach of combining the wrists under a single rating was reasonably justified in lieu of separate ratings.  The Board must apply separate ratings in its recommendations if compensable ratings for each wrist are achieved IAW the VASRD.  If the Board judges that two or more separate ratings are warranted, however, it must satisfy the requirement that each “unbundled” condition was separately unfitting.  After due deliberation, the Board agreed that the evidence does support a conclusion that each of the wrist pain problems, separately, would have rendered the CI unable to perform her required military duties.  Therefore, the Board recommends by majority decision a separate disability rating for each of the wrists.  The Board determined that it is not appropriate for the right wrist to be bundled with the left wrist and treated as a single unfitting condition.

The Board determined that the September 2010 C&P exam was more than 2 years after the DOS and therefore had diminished probative value.  In addition, the Board surmised that the VA rating attached to this exam incorrectly annotated that the exam showed absence of vibration sense when in fact the exam did not test for vibration sense.  The PE that was closest to DOS was the April 2008 MEB exam, just 15 weeks prior to separation.  At that visit, the physical exam and the neurological exam were normal.  The CI’s painful wrist condition was essentially non-compensable based on the VASRD §4.71a diagnostic codes for loss of wrist motion (5214 and 5215).  However, IAW VASRD §4.40 (functional loss), when part of the musculoskeletal system becomes painful on use, it must be regarded as seriously disabled.  A 10% rating is warranted when there is satisfactory evidence of functional loss and disability due to painful motion.  There was no path to a higher rating since there was insufficient evidence of a significantly disabling joint abnormality that would justify a higher rating.  After due deliberation, the Board determined that a disability rating of 10% for each wrist was appropriate.  Considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a rating of 10% for right wrist pain and a rating of 10% for left wrist pain.

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 wrist pain condition and IAW VASRD §4.71a, the Board recommends by majority decision a rating of 10% for right wrist pain and a rating of 10% for left wrist pain.  There were no other conditions within the Board’s scope of review for consideration.

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

UNFITTING CONDITION	VASRD CODE	RATING	
Chronic right wrist pain	5299-5215	10%	
Chronic left wrist pain	5299-5215	10%	
COMBINED (w/ BLF)	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140614, 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-2014-02962.

	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 not appropriate under the guidelines of the Veterans Affairs Schedule for Rating Disabilities.  Accordingly, the Board recommended modification of your assigned disability rating without re-characterization of your separation with severance pay.

	I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding, accept their recommendation and direct that your records be corrected as set forth in the attached copy of a Memorandum for the Chief of Staff, United States Air Force.  The office responsible for making the correction will inform you when your records have been changed.

							Sincerely,

XXXXXXXXXXXXXXXXXXXX
Director
Air Force Review Boards Agency

Attachments:
1.  Directive
2.  Record of Proceedings

cc:
SAF/MRBR
DFAS-IN