RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXX		                                                                 CASE:  PD-2014-03285
BRANCH OF SERVICE:  AIR FORCE 	SEPARATION DATE:  20060123

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Communication/Navigation Systems Journeyman) medically separated for “mild degenerative arthritis, left thumb, metacarpal phalangeal joint,” rated at 10%.  

CI CONTENTION:  “Please consider all conditions.”  His 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 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 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 20051130	VA* - (~5 Mos. Pre-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Mild Degenerative Arthritis, Left Thumb, Metacarpal Phalangeal Joint	5228-5003	10%	Residuals of Left Thumb Surgery	5228	**10%	20050824	
Tobacco Habituation	Cat III 
Not Unfitting	No VA Placement	
Other MEB/PEB Conditions x 0	Other x 8	
RATING:  10%	RATING:  60%	
*Derived from VA Rating Decision (VARD) dated 20060606 (most proximate to date of separation [DOS]).
**VARD dated 20070202 rated 5228 10% effected day after DOS (original VARD rated 0%).    

ANALYSIS SUMMARY:  

Left Thumb.  The narrative summary (NARSUM) noted that the CI injured his non-dominant left thumb in a motorcycle accident 21 August 2003.  Conservative treatment failed to improve his pain and magnetic resonance imaging showed an ulnar collateral ligament (UCL) tear of the metacarpophalangeal joint (MCPJ), also known as “gamekeeper’s thumb”.  The CI underwent surgery for repair of the UCL 2 February 2004 and subsequently had multiple surgeries on the thumb due to recurrent injury of the ligament and infection at the surgical site, as well as surgery for DeQuervain’s tendonitis (irritation of two thumb tendons as they pass under a ligament at the thumb side of the wrist).  Despite all interventions, the CI continued to have thumb pain and repeat MRI 10 August 2004 noted degenerative joint disease (DJD) and soft tissue thickening of the ulnar aspect of the MCPJ.  

At the MEB exam on 22 November 2005, 2 months before separation, the CI reported left thumb pain.  The MEB physical exam noted left thumb range-of-motion (ROM) of flexion of the first MCPJ of 50 degrees (normal 50*), interphalangeal joint (IPJ) flexion of 65 degrees (normal 80*) with full thumb extension and normal carpometacarpal joint (CMCJ) ROM, without evidence of instability.  (*Normal values for thumb ROM listed taken from the American Academy of Orthopedic Surgeons).  Thumb X-rays in August 2004 showed mild DJD.

At the VA Compensation and Pension (C&P) exam performed 24 August 2005, 5 months before separation, the CI reported thumb pain, aggravated by use and decreased thumb ROM.  The exam noted thumb scars that did not have a significant functional impact.  There was tenderness to palpation at the “base of the thumb.”  Thumb extension was normal and on flexion the thumb could come to within a quarter inch of the base of the fifth finger.  Examination of the wrist was normal and there was normal wrist and forearm ROM, and there was no additional loss of ROM with repetition of ROM of any joints.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the thumb condition 10%, coded 5228-5003 (degenerative arthritis with limited thumb motion).  The VA rated the thumb condition 0%, coded 5024 (tenosynovitis) and also rated the left wrist 0%, coded 5024.  The VA Rating Decision 2 February 2007 increased the rating to 10%, citing that although the thumb condition did not meet the 10% rating criteria of 5228 at the C&P exam, there was increased pain with repetitive thumb motion.  The Board agreed that the evidence supports a 10% rating coded as 5003 or 5024 (according to 5003 rating criteria) based upon limited motion of a group of minor joints with DJD or tenosynovitis.  The Board reviewed the record to see if the next higher rating was supported, but noted that a 20% rating requires evidence of the same pathology at two or more major joints or groups of minor joints, associated with occasional incapacitating episodes.  The CI was treated for ligament injury of the MCPJ and thumb tendonitis, hence there was no evidence of involvement of two or more major joints or groups of minor joints and thus no higher than a 10% rating is supported with these codes.  The Board next considered the rating criteria for 5228, which provides a 0%, 10%, or 20% rating based upon the gap between the thumb pad and the fingers when attempting to oppose the fingers.  The MEB exam described the thumb ROM as normal, except for mildly decreased IPJ flexion and the VA C&P examiner expressed the thumb ROM as flexion reaching to within 1/4-inch of the base of the 5th finger.  Opposition of the thumb to the fingers is usually described as the tip of the thumb to the fingertips, but may be described to the base of the fingers.  The Board concluded from the evidence that thumb ROM was consistent with being able to oppose the tip of the thumb with the fingertips and nearly able to oppose the tip of the thumb to the base of the fingers, which is consistent with the 0% rating specified as a gap of less than 1”.  The Board noted that in any case, there was no evidence in record of “a gap of one to two inches (2.5 to 5.1 cm.) between the thumb pad and the fingers, with the thumb attempting to oppose the fingers” to support the 5228 20% rating.  Therefore, the Board determined that the evidence supports a 10% rating for the thumb condition and no higher.  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 thumb condition.

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the tobacco habituation 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 tobacco habituation was not profiled or implicated in the commander’s statement and was not judged to fail retention standards.   There was no performance based evidence from the record that the smoking condition significantly interfered with satisfactory duty performance.  Furthermore, the Board notes IAW DoDI 1332.38, enclosure 5 (E5.1.3.9.1 uncomplicated alcoholism or other substance use disorder), tobacco use is a condition that does not constitute a physical disability and is not eligible for service disability rating.  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 tobacco use condition and so no additional disability rating are recommended.

BOARD FINDINGS:  In the matter of the left thumb condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended tobacco habituation condition, the Board unanimously agrees that it cannot recommend it for additional disability rating.  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 20140616, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAF/MRB
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD  20762

Dear XXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2014-03285.

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 appropriate.  Accordingly, the Board recommended no re-characterization or modification of your separation.

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding and their conclusion that re-characterization of your separation is not warranted.  Accordingly, I accept their recommendation that your application be denied.

Sincerely,

Attachment:
Record of Proceedings