RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03194
BRANCH OF SERVICE:  ARMY	SEPARATION DATE:  20080206

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Signal Intelligence Analyst, medically separated for “bilateral knee pain” and “pain right dominant, wrist, thumb and right elbow,” rated 10% and 0%, respectively, with a combined disability rating of 10%.

CI CONTENTION:  The CI contends she was not rated for her not unfitting conditions.  The CI’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 PEB - 20080206	VARD - 20080229	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Knee Pain	5099-5003	10%	Bilateral Knee DJD	5003	10%	20071211	
Pain Right Dominant Wrist, Thumb and Elbow	5099-5003	0%	S/P Right Wrist Release	5215	0%		
			S/P Right Wrist Tendon Release, Residual Scar	7804	10%		
			Right Hand Chronic Extensor Pollicis Tendonitis [Thumb]	5228	0%		
			S/P Right Elbow Lateral Epicondylitis	5209	0%		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

Bilateral Knee Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI developed right, then left knee pain in 1995 due to strenuous military  physical activities.  She was diagnosed with retropatellar (pain behind the knee cap) and patellofemoral pain syndrome.  X-rays revealed bilateral mild degenerative joint changes.  There was no surgical intervention.  A protracted trial of conservative treatment did not result in improvement sufficient to allow unrestricted duty, and the MEB forwarded “chronic bilateral knee pain, right greater than the left due to degenerative joint disease” to the PEB for adjudication.

There were very few STR entries proximal to separation to determine which knee (if either) was worse, although the NARSUM documented that the right knee was worse.  There were no STR range of motion (ROM) examinations in evidence other than MEB NARSUM examination.  There were no entries documenting an antalgic gait.  During the MEB NARSUM examination in June 2007, 8 months before separation, the CI reported no significant improvement to her knee pain since onset.  The examination of both knees revealed tenderness to palpation, right greater than the left, and positive crepitus (a grinding sensation).  Stability and meniscus testing was negative and there was no effusion.  ROM measurements were not cited.  At a physical therapy examination in July 2007, 7 months before separation, right knee ROM flexion was 125, 126, 125 degrees (normal 140) with extension at -5, -6, -7 degrees (normal 0); and left knee ROM flexion was 135, 135, 135 with extension at 0, 0, 0; and pain with motion of both knees was noted.  

At the VA Compensation and Pension (C&P) examination in December 2007, performed 2 months before separation, the CI reported stiffness after inactivity, swelling after physical activity and giving way when running or walking for prolonged periods.  Both right and left knee examinations revealed a gait within normal limits.  There was no edema, effusion, weakness, tenderness subluxation, guarding of movement, locking pain, genu recurvatum or crepitus.  Bilateral stability testing was negative, while bilateral meniscus testing was within normal limits.  The bilateral ROM measurements were flexion of 0-140 degrees citing no painful motion, altered gait or instability.  

The Board directed attention to its rating recommendations based on the above evidence.  The PEB assigned the bilateral knee condition a 10% rating analogously coded 5099-5003 (degenerative arthritis) with application of the VASRD, but was compliant with VASRD §4.71a criteria of 5003 for two or more major joints.  The VA also assigned a 10% rating coded 5003 based on the VA C&P examination 2 months before separation, citing painful motion of a major joint or group of minor joints.  In this case, there were no unilateral distinctions with regard to physical findings and no functional evidence implicating one joint more than the other.  The VA examination, which was more proximate and before separation, documented normal bilateral knees that the VA determined to have sufficient evidence of painful motion to render a 10% rating.  Hence, members agreed that it was overly speculative to conclude that the disability confined to either knee alone would have rendered the CI incapable of continuing military service; and, that it was reasonable to surmise that it was the combined effect of the bilateral condition which rendered the CI unfit.  Thus, it was agreed that a §4.71a compliant bilateral 10% rating under 5003 was appropriate.  Additionally, there was no limitation of flexion or extension that supported a rating under the VASRD diagnostic codes for limitation of motion (5260 or 5261).  The examinations proximate to separation did not demonstrate the presence of ligamentous instability or laxity (5257); and there was no history of dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258) or history of surgery to remove a meniscus (5259) to support a rating under the respective codes.  There was no fracture, non-union, or malunion of the femur or tibia to support consideration under the respective codes for knee impairment related to long bone conditions (5255, 5262).  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 of the bilateral knee condition.

Right Wrist, Thumb, Elbow.  The evidence for the right wrist, thumb, and elbow conditions is presented separately, with attendant recommendations regarding separate unfitness, and separate rating, if indicated.  

Right Wrist.  The CI had swelling of the right wrist in 1997, which was diagnosed as tenosynovitis and treated with a splint, ice, and a nonsteroidal anti-inflammatory drug (NSAID).  An X-ray in September 1998 of the hand and wrist showed no significant abnormality.  The CI was a month status post surgery for an intersection syndrome (tenosynovitis of the radial wrist extensor muscles marked by pain and swelling).  In 2003, a note indicated the CI had forearm/wrist pain for 5 years and symptoms were worse with prolonged use.  Electrodiagnostic studies were within normal limits and there was no evidence of a myopathy (muscle abnormality) in the right upper extremity distal to the elbow.  In 2006 the CI had a permanent U2 profile for carpal tunnel syndrome, which if she typed for more than 30 minutes, she had pain.  Examination revealed full ROM and normal strength.  

At the MEB examination the CI reported on DD Form 2807-1 dated 29 March 2007, pain in the hand, wrist, and elbow since 1999, surgery for the intersection syndrome in 2000, persistent pain, and occupational therapy off and on since the surgery.  The examiner noted on DD Form 2808 dated 12 June 2007 no discoloration or edema of the right wrist with surgical scars noted over the dorsum.  Allen’s test (to determine ulnar artery patency) was normal; slight tenderness of the wrist was present; one test was positive (Phalen’s) and one negative (Tinel’s) for carpal tunnel syndrome; no ulnar nerve entrapment was present; and there was evidence of tenosynovitis.  At the MEB NARSUM examination in June 2007, 8 months before separation, the CI reported wrist and elbow pain with significant difficulty when hooking up cables at work or when typing.  The NARSUM examiner referred to a positive Finkelstein test (pain in the wrist with motion) performed by occupational therapy.  X-ray examinations of the right wrist and right elbow in June 2007 showed no evidence of acute osseous injury.  In August 2007 the CI reported she no longer had digit paresthesia at night as long as she wore the wrist splint.  On examination she was tender at the dorsal wrist extensor compartments with evidence of tenosynovitis (positive Finkelstein’s test) and carpal tunnel syndrome.  Grip strength was 8 pounds on the right and 60 pounds on the left and pinch testing was 2 pounds on the right and 19 pounds on the left.  

A permanent U3L3 profile was issued on 10 October 2007 for bilateral knee pain, right tennis elbow, right wrist pain, and right thumb pain with limitations of the 2-mile run and push-ups and all military functional activity except wearing a protective mask and all chemical defense equipment.  Additionally, the CI was restricted to lifting or carrying a maximum weight of 25 pounds.  An X-ray series of the right wrist in December 2007 was negative.

At the VA Compensation and Pension (C&P) examination in December 2007, performed 2 months before separation, the CI reported surgery for tendon release with residual weakness while attempting to lift or grasp and fatigability when typing, lifting or grasping and pain at the wrist daily.  She was able to function without medication although Ultram (tramadol, an opioid-like medication) and naproxen were prescribed.  Examination of the right wrist revealed no signs of edema, effusion, weakness, tenderness, redness, heat, subluxation or guarding of movement.  The ROM measurements of the right and left wrist joints were dorsiflexion 70 degrees, palmar flexion 80 degrees, radial deviation 20 degrees, and ulnar deviation 45 degrees. There was no limitation of joint function with repetition.

Right Thumb.  The CI had a history of right wrist pain with surgery in 2000 (see above) and right thumb pain, which was aggravated when she grasped objects.  She avoided holding a glass with her right hand to avoid triggering pain; and, she also had difficulty firing a weapon.  Occupational therapy was carried out in late 2006 and 2007 using various modalities including iontophoresis and splinting directed to tenosynovitis of the wrist.  However, a note in July 2007 indicated the CI had a 2 week history of pain in the right thumb, but had similar pain for 8 years.  She used a thumb spica splint (to decrease movement and provide support) and had an injection of the right thumb in January 2007 with 2-3 weeks of functional efficiency.  When she slept the wrong way, she had numbness/tingling and stated the splint interfered with job performance and ability to type term papers for classwork.  Pain was localized to the right thumb volar (palmar) surface/thenar eminence and volar aspect of the wrist, which was described as a “dull, achy pain” with a severity of 3/10 at rest and 5/10 with typing activities.  On examination there was tenderness to pressure at the 1st and 3rd fingers and the thumb pain was a component of the overall diagnosis of de Quervain’s tenosynovitis (entrapment tendonitis of the thickened tendons (abductor pollicis longus and extensor pollicis abductus) of the dorsal compartment at the wrist), wrist tenosynovitis, and mild carpal tunnel syndrome.  In September 2007 there was 1/10 pain with thumb opposition to small finger (SF) tip.  Grip strength was 8 pounds on the right and 52 pounds on the left while pinch strength was 2 pounds on the right and 21 pounds on the left.  

The commander’s statement in May 2007 addressed the CI’s right hand pain, which improved little treatment.  At the MEB and NARSUM examinations in June 2007, 8 months before separation, the right thumb condition was not explicitly addressed, although CI reported difficulty grasping and holding with her right hand.  A permanent U3L3 profile was issued on 10 October 2007 included the right thumb with limitations as noted above.  

At the VA Compensation and Pension (C&P) examination in December 2007, performed 2 months before separation, the CI reported she was able to tie shoelaces, fasten buttons, pick up a piece of paper and tear it without difficulty. Right thumb opposition and ROM were normal as was strength of the right hand and there were no limitations with repetition.

Right Elbow.  X-rays of the right elbow in June 2007 were normal.  Treatment by occupational therapy in July 2007 for right elbow lateral epicondylitis and wrist pain was with iontophoresis using dexamethasone (a steroid) and sodium chloride (salt) for several sessions.  Orthopedic evaluation for the right elbow pain rated at 2/10 in November 2007, which had an onset 8 years earlier, and was described as a chronic, intermittent dull ache that was aggravated by raising her arm.  She had lateral epicondylar (outer elbow) discomfort and underwent occupational therapy, used braces, and made ergonomic adjustments to function.  The orthopedic surgeon indicated the CI met the criteria for operative intervention.  An X-ray series of the right elbow was negative in December 2007.  

At the MEB examination in March 2007 the CI reported on DD Form 2807-1 pain in the right elbow since 1999.  The examiner reported in June 2007 on DD Form 2808 no erythema or discoloration, positive tenderness on the lateral epicondyle, positive pain with resistance of the EPL (extensor pollicis longus) muscle and the EI [extensor indicis] muscle, and no tenderness of the medial condyle (inner elbow).  At the NARSUM examination in June 2007, 8 months before separation, the CI reported pain in the right elbow both prior to and after wrist surgery when she had to modify position of the elbow.  Besides treatment with iontophoresis, which provided temporary relief, she also received injections to her elbow.  Both the wrist and elbow pain caused significant difficulty when hooking up cables at work or when typing.  The permanent U3L3 profile in October 2007 included right tennis elbow (epicondylitis) along with other conditions and limitations as noted above.  The commander’s statement noted right elbow pain beginning in 1999, and again in 2003 and 2006, which along with her other conditions were profiled.

At the VA Compensation and Pension (C&P) examination in December 2007, performed 2 months before separation, the CI reported pain and weakness from prolonged use in the right elbow since 1997, which was relieved by rest and NSAIDS.  On examination there were no signs of edema, effusion, weakness, tenderness, redness, heat, subluxation, or guarding of movement.  The ROMs of the elbow were equal bilaterally and are in the chart below; and, joint function was not additionally limited by pain, fatigue, weakness, lack of endurance or incoordination after repetitive use. 
The ROM examinations 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 Elbow ROM
(Degrees)	MEB ~8 Mo. Pre-Sep
	
OT ~8 Mo. Pre-Sep
	VA C&P ~2 Mo. Pre-Sep
	
Flexion (145 Normal)	-	
139,139,140	145	
Extension (0)		11,13,14	0	
Comment	Tenderness on the lateral epicondyle; pain with resistance of EPL and EI	Pain with passive ROM; pronation 90,95,95 with pain; supination 76;70;66 with pain 	No limitation of motion with repetition; pronation 80 degrees; supination 85 degrees	
§4.71a Rating	-	10% (PEB 0%)	VA 0%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 0% rating using code 5099-5003 for pain right dominant, wrist, thumb and right elbow and ROM was limited by pain.  The VA assigned a 0% rating using code 5215 (wrist, limitation of motion) for status post right wrist tendon release; a 0% rating using code 5228 (thumb, limitation of motion) for right hand chronic extensor pollicis tendonitis; and a 0% rating using code 5209 (elbow, other impairment of flail joint) for status post right elbow lateral epicondylitis; and a 10% rating using code 7804 (scar(s), unstable or painful) for status post right wrist tendon release with residual scar, which was not in the scope of review.  

The Board first considered whether the right wrist condition, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The Board concluded that the unbundled the right wrist condition was reasonably supported by the record as separately unfitting.  The Board then considered its rating recommendation for the separately unfitting right wrist condition at the time of separation.  However, in the absence of wrist ankylosis (code 5214), or wrist limitation of motion (code 5215), the Board was conceivably limited to assign only a 0% rating using code 5215.  Alternatively, using code 5307 (Group VII.  Function:  Flexion of the wrist and fingers) offers a 10% rating for a moderate condition and is supported by diminished grip strength of the right hand compared to the left hand or use of code 5309 (Group IX. Function: The forearm muscles act in strong grasping movements), which has no specific rating formula; however, the forearm and hand note states:  “The hand is so compact a structure that isolated muscle injuries are rare, being nearly always complicated with injuries of bones, joints, tendons, etc.  Rate on limitation of motion, minimum 10 percent.”  Therefore, a 10% rating is applicable for the wrist condition using code 5215-5309.  The wrist can also be rated 10% using code 5099-5003 for a noncompensable ROM with painful motion as evidenced by a positive Finkelstein’s test for de Quervain’s tenosynovitis.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the right wrist condition, coded 5099-5003.

The Board then considered whether the right thumb condition, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The Board concluded that the bundled the right thumb condition was reasonably supported by the record as separately unfitting.  The Board then considered its rating recommendation for the separately unfitting right thumb condition at the time of separation.  In the absence of a gap of 1 to 2 inches between the thumb pad and the fingers, with the thumb pad attempting to oppose the fingers, a rating of 10% using code 5228 could not be achieved nor could a 0% rating be assigned with a gap of less than one inch between the fingertip and the proximal transverse crease of the palm.  However, when the CI did oppose her thumb to the small finger, there was pain, albeit a 1/10, which raised the consideration of a 10% rating using code 5099-5003 and was supported by her subjective report of painful motion when working without the spica splint; however, the majority of Board members felt that pain of 1/10 did not rise to the level of a 10% rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board majority recommends a disability rating of 0% for the right thumb condition, coded 5099-5003 for the right thumb condition.

The Board then considered whether the right elbow condition, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The Board concluded that the bundled the right elbow condition was reasonably supported by the record as separately unfitting.  The Board then considered its rating recommendation for the separately unfitting right elbow condition at the time of separation.  In the absence of ankylosis (code 5205), forearm, forearm limitation of flexion limitation to 110 degrees or less (code 5206), forearm limitation of extension to 45 degrees or more (code 5207), forearm flexion limited to 100 degrees and extension to 45 degrees (code 5208), elbow with other impairment of flail joint (code 5209) either radius or ulna impairment (codes 5210, 5211, and 5212), or supination and pronation impairment (code 5213).  However, at an occupational therapy examination prior to separation, albeit less proximate to separation than the VA examination, the CI did have painful motion on pronation and supination, which raises a possible 10% rating using code 5099-5003, but the VA examination more proximate to separation found not only normal pronation and supination without any limitation of motion with repetition and joint function was not limited by pain.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 0% for the right elbow condition, coded 5099-5003 for the right elbow condition.

BOARD FINDINGS:  In the matter of the bilateral knee pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the right wrist condition, the Board unanimously recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a.  In the matter of the right thumb condition, the Board majority recommends a disability rating of 0%, coded 5099-5003 IAW VASRD §4.71a.  The single voter for dissent submitted the appended minority opinion.  In the matter of the right elbow condition, the Board unanimously recommends a disability rating of or 0%, coded 5099-5003 IAW VASRD §4.71a.  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 the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Bilateral Knee Pain	5099-5003	10%	
Right Wrist Pain	5099-5003	10%	
Right Thumb Pain	5099-5003	0%	
Right Elbow Pain	5099-5003	0%	
RATING	20%	

The following documentary evidence was considered:
Exhibit A.  DD Form 294, dated 20140713, with attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record
SAMR-RB							
Minority Opinion.  The CI experienced painful motion of the thumb when she opposed her thumb to her small finger.  While the majority felt a severity of 1/10 did not rise to a ratable level for painful motion, VASRD code 5003 states: “When however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion. . . Limitation of motion must be objectively confirmed by finding such as swelling, muscle spasm, or satisfactory evidence of painful motion.”  Code 5003 does not put an upper or lower limit on the quantification of pain nor does VASRD §4.59 (painful motion), which bases painful motion on “facial expression, wincing, etc., on pressure or manipulation.”   Furthermore, from a functional standpoint the CI had painful motion when her spica splint, which limited thumb motion, was removed, and she had pain when typing.  Therefore, a 10% rating for the thumb disability is not unreasonable especially since the thumb is the most important finger of the hand and grip strength, which requires full and complete functionality of the thumb, was markedly decreased.

Therefore, the minority voter recommends that the following be adopted:

The Board recommends that the CI’s prior determination be modified as follows; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Bilateral Knee Pain	5099-5003	10%	
Right Wrist Pain	5099-5003	10%	
Right Thumb Pain	5099-5003	10%	
Right Elbow Pain	5099-5003	0%	
RATING	30%	

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(AHRC-DO), 

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXX, AR20160011468 (PD201403194)

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