RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03385
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070920

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Unit Supply Specialist Trainee, medically separated for “bilateral dysesthesias in hand,” with a disability rating of 0%.

CI CONTENTION:  The CI requested consideration of all 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 based upon a 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 IPEB – 20070815	VARD- 20090102	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Dysesthesias in Hand	8799-8715	0%	Peripheral Neuropathy Left Upper Extremity	8515	10%	20081028	
			Peripheral Neuropathy Right Upper Extremity	8515	10%	20081028	
Depression	Not Unfitting	No VA Placement	
RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Bilateral Dysesthesias.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the right hand dominant CI’s bilateral hand condition began in March 2006 after a rucksack march.  The CI reported pain and numbness in both hands, right worse than left.  Examinations noted positive clinical testing for nerve related symptoms at the elbow and wrist bilaterally, without decreased sensation.  The CI was given bilateral wrist braces and a splint for the right elbow and was treated with occupational therapy (OT).  Bilateral upper extremity electrodiagnostic studies in December 2006 were normal, without evidence of cervical radiculopathy or peripheral nerve entrapment.  At a primary care follow-up visit on 5 January 2005, full range of motion (ROM) of the wrists was noted, with positive testing for carpal tunnel syndrome (CTS) bilaterally.  The diagnosis was bilateral tenosynovitis.  Despite treatment, the bilateral upper extremity condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for an MEB.  The MEB forwarded “bilateral dysesthesias in the hands status post overuse during training, etiology unclear” for PEB adjudication.  

At the MEB examination (recorded on DD Form 2807 Report of Medical History and DD Form 2808 Report of Medical Examination) dated 31 January 2007, 8 months prior to separation, the CI reported painful wrists and elbows.  She reported hand and finger numbness with use in cold environments and with exercise and hand swelling with use.  The physical examination noted numbness bilaterally with testing for CTS (Phalen’s maneuver).  A physical therapy (PT) evaluation on 30 April 2007 noted positive testing for CTS bilaterally.  There was normal wrist ROM and full strength with all motions, with pain noted at the end ROM of flexion and extension.

At the MEB NARSUM examination on 25 June 2007, 3 months before separation, the CI reported bilateral hand numbness and swelling with difficulty controlling her weapon and other equipment.  The physical examination showed full ROM of the bilateral shoulders, elbows and wrists.  Upper extremity strength and pulses were normal bilaterally.  The permanent profile dated 8 August 2007 listed “bilateral wrist and hand pain.”  The commander’s statement dated 29 January 2007 implicated the CI’s physical limitations as impairing the performance of her duties in a garrison environment.

At the 28 October 2008 VA Compensation and Pension (C&P) examination, 13 months after separation, the CI reported persistent numbness and pain in both hands and the elbow, right greater than left, with continued use of wrist braces and right elbow splint.  She reported the numbness and tingling of the thumb, index and long fingers of both hands, but not the ring or little fingers of either hand.  She denied incapacitating episodes, but noted decreased ability to hold onto things with her hands during flare-ups.  The physical examination noted the CI was right hand dominant.  The cervical spine was non tender to palpation with full ROM.  There was no swelling or discoloration of the extremities.  There was full ROM of the bilateral shoulders, elbows, wrists and fingers.  All joints were noted to be stable, without crepitus or effusions.  Sensation testing to sharp and vibration was noted to be decreased in both upper extremities (the examiner did not note distribution).  Bilateral upper extremity reflexes and strength, including grip strength, were normal.  Clinical testing for CTS was positive bilaterally (Tinel’s and Phalen’s).  The VA examiner concluded with diagnoses of mild bilateral upper extremity peripheral neuropathy with “mild effect on activities of daily living.”

The Board directed attention to its rating recommendation based on the above evidence.  The PEB combined the right and left hand dysesthesia conditions as a single unfitting condition coded 8799-8715 (analogous to neuralgia of the median nerve), an analogous code for carpal tunnel syndrome (CTS), and rated 0%, citing normal electromyography (EMG) studies, full ROM of all joints, and intact strength and sensation.  The approach by the PEB not uncommonly reflected its judgment that the constellation of conditions was unfitting, and there was no need for separate fitness adjudications or implied adjudication that each condition was separately unfitting.  The Board’s initial charge in this case was therefore directed at determining if the PEB’s approach of combining conditions under a single rating was justified in lieu of separate ratings.  When considering a separate rating for each condition, the Board considers each bundled condition to be reasonably justified as separately unfitting unless a preponderance of evidence indicates the condition would not cause the member to be referred into the DES or be found unfit because of physical disability.  When the Board recommends separate fitness recommendations in this circumstance, its recommendations may not produce a lower combined rating than that of the PEB.  The evidence for the right and left hand conditions is essentially the same and is presented together for both hands above, with attendant recommendations regarding separate unfitness, and separate rating if indicated.  The VA rated the right and left upper extremity conditions 10% each, both coded 8515 (incomplete paralysis of the median nerve), citing decreased upper extremity sensation and positive clinical testing for CTS bilaterally.  The Board first considered if both the right and left hand conditions, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  During active duty the CI sought and received treatment for pain and numbness of both upper extremities.  The permanent profile listed “bilateral wrist and hand pain” and the commander’s statement implicated the CI’s physical limitations as impairing her duty performance.  The MEB forwarded the “bilateral dysesthesias in the hands” condition as medically unacceptable.  The Board concluded that there was not a preponderance of evidence in the service records that overcame the Board’s presumption that the bundled right and left hand conditions are each reasonably considered separately unfitting.  The Board noted that the coding and rating features for both hands are essentially identical and therefore considered its rating recommendation for both the unfitting hand conditions at the time of separation.

There was persistent evidence of right and left carpal tunnel syndrome on the basis of clinical examinations, despite a normal EMG in December of 2006.  Therefore, there was sufficient support for a 10% rating for each wrist/hand for CTS, coded 8799-8715 according to VASRD 4.124a (neurological disorders).  At the time of separation, there was numbness and tingling noted in the median nerve distribution of both upper extremities, without objective sensory deficit or weakness of either extremity.  The Board determined that the next higher evaluations of 30% and 20% (dominant right hand and non-dominant left hand, respectively), were not warranted.  There was no limitation of motion of the upper extremity joints which supported a rating higher than 10% for either upper extremity under the VASRD 4.71a (musculoskeletal system) diagnostic codes for limitation of motion.  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 dysesthesia of the right hand condition and 10% for the dysesthesia of the left hand condition.  

Contended Depression Condition.  The Board’s main charge is to assess the fairness of the PEB’s determination that the depression condition was not unfitting.  Notes in the STR indicated the CI was seen on 14 January 2006 for depression and wanting to hurt others.  She reported intermittent depression symptoms for approximately a year and half, without any medication or treatment.  She was referred to the emergency room, and from there referred to behavioral health for follow-up.  A psychiatry memorandum dated 9 May 2007 indicated the CI had been seen at Community Mental Health Services on five occasions and had been admitted as a psychiatric inpatient on 20 March 2007 with symptoms of depression.  The Axis I diagnosis was adjustment disorder with depression and anxiety.  The psychiatrist determined that the condition was not medically disqualifying and did not “necessitate an addendum” for the PEB.  The permanent profile was S1.  The commander’s statement dated 25 July 2007 specifically noted that the CI’s “psychological difficulties” did not impact her duty performance.  The depression condition was not profiled and was not judged to fail retention standards.  There was no performance-based evidence from the record that the depression condition significantly interfered with satisfactory duty performance at separation.  After due deliberation, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the depression condition and so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the “bilateral dysesthesias of the hands” condition, the Board unanimously recommends an unfitting dysesthesia of the right hand condition and an unfitting dysesthesia of the left hand condition, each rated 10%, both coded 8799-8715 IAW VASRD §4.124a.  In the matter of the contended depression 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 the CI’s prior determination be modified as follows, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Dysesthesia of The Right Hand	8799-8715	10%	
Dysesthesia of The Left Hand	8799-8715	10%	
COMBINED W/BLF	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140512, 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, AR20160011471 (PD201403385)

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