RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03217
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20080205

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an activated National Guard E-4 (Infantryman) medically separated for “chronic right (dominant) elbow pain,” rated 10%.  

CI CONTENTION:  Please consider all conditions.

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44.  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 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:  

Admin PEB – Dated 20090316	VA* - Based on Service Treatment Records (STR)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Right (dominant) Elbow Pain	5099-5024	10%	Chronic Right Elbow	5024	10%	STR**	
Left Knee Pain	Not Unfitting	Patella Condition Left Knee	5260	NSC	
Other x 0 (Not In Scope)	Other x 6 	
RATING:  10%	RATING:  10%	

ANALYSIS SUMMARY:  

Chronic Right Elbow Pain Condition.  The service treatment record (STR) supplements and supports the Medical Evaluation Board (MEB) narrative summary (NARSUM) dated 29 June 2007.  The earliest note in the STR of 10 March 2006 indicated the CI had sharp triceps pain when flexing his arm for 2 days that was treated with Flexeril (cyclobenzaprine, a muscle relaxant) and naproxen (a nonsteroidal anti-inflammatory drug (NSAID)).  Magnetic resonance imaging (MRI) dated 27 March 2006 indicated the CI heard a pop doing pushups and it showed findings that most likely represented muscular strain or a partial tear of the triceps at or just below the elbow.  Physical therapy was instituted for triceps/anconeus (a muscle from the elbow to the forearm) strain.  An MRI arthrogram dated 27 April 2006 demonstrated no obvious loose fragments, but extravasation (spillage of dye) within the joint space was thought to represent a medial triceps tear; however, the tendon appeared intact.  Multiple occupational therapy sessions including both exercises and ultrasound were carried out.  In September 2006, electro-diagnostic studies were normal with no evidence of right side cervical radiculopathy, brachial plexopathy (abnormality of the nerves of the brachial plexus), median, ulnar or radial nerve entrapment, axonal neuropathy, or evidence of general peripheral neuropathy.  In October 2006, his right elbow range-of-motion (ROM) was 0-140 degrees and he had tenderness to palpation at the distal right triceps tendon.  An MRI arthrogram with contrast performed on 14 November 2006 demonstrated a shallow partial thickness tear near the olecranon process (proximal ulna bone) along the anterior margin of the muscle with a normal and intact triceps tendon.  In January 2007, the ROMs for flexion of the right elbow were 130, 128, and 127 degrees (Normal 145 degrees), extension 2, 2, 0 degrees (Normal 0 degrees), forearm supination 85, 83, 85 degrees (Normal 85 degrees), and forearm pronation 75, 70, and 73 degrees (Normal 80 degrees).  Electrodiagnostic studies were performed in March 2007 and revealed normal nerve conductions in the right upper extremity and a mildly abnormal EMG (electromyogram) suggestive of proximal median nerve entrapment at the pronator teres muscle of the forearm.  Also in March 2007, an MRI of the right upper arm was normal and no triceps abnormality was seen and a limited MRI of the proximal right forearm was also normal.  In June 2007, X-rays of the right elbow were normal.  In June 2007, electrophysiologic studies were normal with no evidence of a right brachial plexopathy, thoracic outlet syndrome, ulnar neuropathy, carpal tunnel syndrome, focal neuropathy, cervical radiculopathy, or generalized polyneuropathy.  ROM measurements in June 2007 were flexion 125 degrees, extension 0 degrees, pronation 80 degrees, and supination 90 degrees.  An MRI arthrogram dated 27 June 2007 showed a possible injury to the lateral ulnar collateral ligament (connects the distal humerus with the proximal ulna).  In spite of physical therapy, pain continued and became progressively worse and involved the forearm with tingling and numbness in his fingers and subjective weakness helped by deep massage as well as ultrasound.  A pain management specialist recommended a stellate ganglion block (an injection of local anesthetic in the sympathetic nerve tissue in the neck) for diagnostic and therapeutic benefit along with biofeedback.  Amitriptyline and gabapentin (for nerve pain) were prescribed.  In November 2007 at an examination by a Physical Medicine and Rehabilitation specialist there was no evidence for a torn triceps tendon.  The CI was able to use his arm in a normal manner when he undressed, dressed and opened the door.  The best clinical diagnosis was an ill-defined right arm myofascial pain.  A pain management specialist in contradistinction raised the possibility of CRPS (complex regional pain syndrome), although the CI had no outward physical signs, but his symptoms were consistent with it.  A neurology consultant noted the CI lacked the type of features associated with CRPS (trophic skin changes, wasting, sweating abnormalities, loss of hair) were lacking and distribution of pain was atypical for triceps involvement.  Sensory involvement was very focal in the thumb and little finger despite normal electrophysiologic studies.  Local point tenderness in the medial and lateral epicondyles (inner and outer portions of the joint) may have been secondary to enthesopathy (inflammation of tendon or ligament insertions in bone).  Elbow extension (triceps) was full on confrontational testing with intact supination and pronation.  Further evaluation as well as ruling out embellishment was considered.  The NARSUM ROMs were for extension 0 degrees three times and flexion 125 degrees three times with “pain limit.”  The right forearm demonstrated full pronation and supination.

At the MEB examination dated 25 June 2007, the CI reported on DD Form 2807-1 he had “pain in arm/elbow from torn triceps,” “sometimes swollen,” and a “hard time using the right arm.”  He also hand/tingling from just above his elbow down to his hand.  The MEB physical examiner noted on DD Form 2808 a decreased “ROM of the right elbow/wrist and hands. The CI was “[u]nable to fully extend digits R (right) hand” and was “TTP (tender to pressure) over distal triceps.”  Sensation was intact and strength was 3/5.  A permanent U3 profile was issued in July 2007 for right elbow pain with limitations of all military functional activities except wearing a mask and chemical defense equipment.  Sit-ups, push-ups, and lifting greater than 10 pounds were also limited. 

At the VA Compensation and Pension (C&P) examination performed 16 December 2009, 10 months after separation, the CI reported right elbow pain since about 2006 and some discomfort of the right forearm, which felt like muscle cramps, and the right hand had muscle cramps, numbness, weakness, cold sensitivity, and a tendency to drop things.  The right elbow ROMs were 0 to 145 degrees bilaterally, pronation 90 degrees bilaterally, and supination 90 degrees bilaterally.  The right elbow had a very mild generalized swelling and was tender at the olecranon and the ulnar nerve had moderate tenderness at the right elbow.  A remote note with limited or no probative value dated 10 May 2010, 27 months post-separation, indicated the CI was 2 months post right elbow anterior transposition and neurolysis (destruction of neural tissue either temporarily or permanently), while another remote note dated 13 July 2010, 29 months post-separation indicated the CI had numbness in the medial right hand with weakness and was 5 months status post right ulnar nerve transposition.  

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating using code 5099-5024 (tenosynovitis) for chronic right (dominant) elbow pain.  The VA also assigned a 10% rating using code 5024 for chronic right elbow pain with tear of the triceps insertion.  The Board sought a route for a higher rating; however, in the absence of ankylosis, limitation of flexion and/or extension, other impairment of the elbow, radius, or ulna, or limitation of supination or pronation, no additional rating could be applied.  The Board also considered application of analogous code 5306 (Group VI-triceps), which IAW VARSRD §4.56 (Evaluation of muscle disabilities) would be consistent with a moderate injury to the triceps, which in the absence of a hospitalization, affords a 10% rating.  A rating using a nerve code was also considered, but proximate to separation, clinical examinations and electrodiagnostic studies did not support its use, although a possible median nerve impingement was raised as a cause of the pain, but not reproduced on MRI, while post-separation, an ulnar nerve transposition was performed that provides only a limited probative value, which at the most would fall in the moderate range with a rating of 10%.  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 adjudication for the chronic right elbow pain condition.  

Contended PEB Condition-Left Knee Pain.  Left knee pain was profiled in 2006 and early 2007, but was not implicated in the commander’s statement and was not judged to fail retention standards.   The knee pain was aggravated when the CI kicked a duffle bag in June 2005, although another version indicated that he fell and hit his knee while working out.   An MRI revealed no evidence of a meniscal tear.  An examiner noted that “Residual symptoms in his knee were somewhat vague and not consistent with a blunt trauma.”  The ROM of his left knee in October 2, 2006 was 0-110 degrees with anterolateral discomfort and a McMurray (to determine meniscal status) test was negative as was a patellar grind test.  X-rays of the knees revealed the appearance of a patellofemoral joint on the left.  He had no instability, but did have a slight lateral patellar tilt on the right.  The left knee contusion and symptoms resolved by 22 November 2006.  At the MEB examination on 25 June 2007, the CI had a full active ROM of the left knee, which was not tender to palpation and was negative for instability or meniscal involvement.  However, a note dated 16 December 2008, approximately 10 months post-separation, indicated the CI had medial line tenderness, although the pain was present at the anterior knee, mostly at the patella (knee cap) and the patella tendon and the ROM was from 0-135 degrees with moderate pain over the ROM.  The VA examiner noted the left knee pain and instability was diagnosed as chronic synovitis and patellar tendinitis and indicated an MRI would be necessary to determine meniscal status.  The MRI of the left knee performed on 19 October 2009 was normal.  The aforementioned was reviewed and considered by the Board.  There was no performance based evidence from the record that left knee pain condition significantly interfered with satisfactory duty performance.  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 left knee pain condition and so no additional disability rating is recommended.

BOARD FINDINGS:  In the matter of the left knee pain condition, the Board unanimously recommends a disability rating of 10%, coded 5099-5024 IAW VASRD §4.71a.  In the matter of the contended left knee pain condition, 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.  

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 20140620, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR Commander, US Army Physical Disability Agency (AHRC-00), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXXXXXXXX AR20160004406 (PD201403217)

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: