RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03496
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050326

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4 Infantry, medically separated for “carpal tunnel syndrome, left arm (minor), …” “left shoulder pain,” and “degenerative disc disease, cervical spine,”rated 20%, 0% and 0%, respectively, with a combined disability rating of 20%.  

CI CONTENTION:  The CI requests the Board consider 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 PEB - 20050124	VARD - 20071204	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Carpal Tunnel Syndrome, Left … Cubital Tunnel Syndrome … 	8716-8714	20%	Left Elbow Strain	5209-5211	10%	20071016	
Left Shoulder Pain	5099-5003	0%	Left Shoulder Strain	5201	20%		
Degenerative Disc Disease, Cervical	5237	0%	Cervical Spine Strain	5237	30%		
Adjustment Disorder w/Mixed Anxiety and Depressed Mood	Not Unfitting	No VA Placement	
Alcohol Dependence		No VA Placement	
Nicotine Dependence		No VA Placement	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  90%	

ANALYSIS SUMMARY:  

Carpal Tunnel Syndrome, Left Arm (Minor) … Cubital Tunnel Syndrome:  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM) the CI developed progressive pain, weakness and numbness in his left arm, wrist and hand over the year following his 2001 injury (above).  He also had a left forearm laceration in July of 2002 with some hand weakness, and fingers with lost sensation and/or paresthesias.  The CI was diagnosed with left cubital tunnel syndrome and left carpal tunnel syndrome (nerve irritation/impingement at the elbow and wrist) and underwent a carpal tunnel release and ulnar nerve transposition on 30 August 2004 (7 months prior to separation).  Surgery relieved some of the pain and numbness in the CI’s left forearm, hand, and wrist.  

The MEB examination (recorded on DD Forms 2807 and 2808) and NARSUM examinations on 7 and 17 November 2004, 4 months prior to separation, noted complaints of left elbow, wrist and shoulder pain with difficulty doing any overhead work, constant 3/10 throbbing pain, which was increased to 9/10 by wearing a rucksack, lifting more than 10 pounds, or any type of pushing or pulling activity using the left arm.  He experienced numbness to his left hand with any overhead work.  The CI was unable to carry and fire his individual assigned weapon, carry a fighting load, construct a fighting position, or participate in unit physical training.  Physical examination showed weakness (strength 4/5 of normal 5/5) in the left biceps, triceps and forearm.  Range of motion (ROM) of the left elbow was 10-130 degrees (normal 0-145), the forearm lacked 5 degrees of supination, and the left wrist ROM was lacking 10 degrees of dorsiflexion and palmar flexion.  

At the 16 October 2007 VA Compensation and Pension (C&P) evaluation, performed 31 months after separation, the CI reported bilateral elbow pain and prior surgery to reposition the nerve on the left elbow.  Elbow pain had daily flares to 6/10 and pain radiated to the tips of the fingers of both sides.  The 26 October 2007 peripheral nerve C&P examination noted the CI developed right arm numbness tingling and burning in service.  The CI reported pain, numbness and tingling in fingers 3, 4, and 5 of the right hand radiating into the arm, with weakness in the hand with decreased grip strength, sensation, and fine motor movements.  Physical examinations showed painful left elbow ROM of 0-120 degrees (normal 0-145), the left forearm ROM was painful and lacked 5 degrees of supination; no left wrist ROM was documented.  The peripheral nerve examination was of the right upper extremity only and showed normal muscle strength in the biceps, triceps, wrist extensors, flexors, and small muscles of the hand, except; for weakness of flexor for some finger muscles.  There was decreased sensation to all modalities in digits 3, 4, and 5, the medial aspect of the right palm, and the medial aspect of the right arm.  Reflexes were normal except for decrease in the right biceps.  The impression was right ulnar neuropathy.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the carpal tunnel syndrome, left arm (minor) … cubital tunnel syndrome condition 20%, coded 8716-8714 (ulnar nerve neuralgia- musculospiral nerve (radial nerve) neuralgia), citing pain which limited left hand function and with incompletely resolved cubital tunnel syndrome not separately rated because of pyramiding.  The VA rated a left elbow strain condition 10% coded 5209-5211 (elbow other impairment – ulnar impairment), based on the VA C&P examination 31 months after separation, citing pain-limited motion and tenderness of the elbow.  The VA also rated a right ulnar neuropathy condition at 30% coded 8516 (ulnar nerve incomplete paralysis) citing weakness and decreased sensation.  

The Board adjudged that the NARSUM examination had the highest probative value for rating due to the remoteness of the VA exam.  There was consideration that the VA peripheral nerve examination and rating had misstated “right” for “left” (similar to the MEB diagnosis’ misstatement of right carpal tunnel syndrome) as the service history was clearly of the left side; however, that was considered undue speculation  
The Board considered the nerve level involved in the left upper extremity as well as the degree of severity (mild, moderate, or severe) IAW VASRD guidelines.  The Board considered that the nerve level and moderate severity awarded by the PEB aligned with the CI’s disability picture at the time of separation.  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 left carpal tunnel syndrome condition.  

Left Shoulder (Minor).  The MEB examination and NARSUM examinations noted complaints of left shoulder pain, difficulty doing overhead work, and radiating pain and paresthesias into the left arm.  Diagnostic imaging indicated a labral tear and the CI declined an offered surgical option.  Physical examinations showed tenderness of the left shoulder with a positive apprehension test, positive lift-off test and decreased muscle strength (4/5) in the left shoulder, biceps, triceps and forearm.  ROM was limited by pain to forward flexion of 120 degrees (normal 180) and abduction to 140 degrees (normal 180).  

At the 16 October 2007 VA Compensation and Pension (C&P) evaluation the CI reported left shoulder pain 6-7/10 which radiated down to the fingertips.  Physical examination showed painful ROM with forward flexion to 70 degrees and abduction to 70 degrees that decreased to 60 degrees of abduction after repetition due to pain and lack of endurance  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the left shoulder condition 0%, coded 5099-5003 (Arthritis, degenerative), citing “rated for pain – marked, intermittent.”  The VA rated the left shoulder condition 20% coded 5201 (Arm, limitation of motion), based on the VA C&P examination citing flexion and abduction of 70 degrees (below shoulder level).  

The Board adjudged the NARSUM examination had the highest probative value for rating due to the remoteness of the VA examination.  The VASRD §4.71a threshold for rating for ROM impairment (code 5201, arm limitation of motion) is “at shoulder level” (approximately 90 degrees from the side), and the service examinations in evidence demonstrated motion above this level; however, Board members agreed that a 10% rating was justified with application of VASRD §4.59 (painful motion).  There was no malunion or recurrent dislocation of the humerus and no dislocation or nonunion of the clavicle or scapula to justify a higher rating under the 5202 (humerus, other impairment of) or 5203 (clavicle or scapula, impairment of) codes.  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 left shoulder condition, coded 5099-5003.  

Degenerative Disc Disease, Cervical Spine.  The MEB examination and NARSUM examinations noted complaints of shoulder and upper extremity radiating pain, weakness and paresthesias as noted above.  Diagnostic imaging noted mild joint hypertrophy with osteophyte at C5-C6 with a small left central paracentral protrusion.  Although the consult for diagnostic imaging cited a left side C6 radiculopathy by EMG (electromyogram), an orthopedic consultant indicated the EMG showed left ulnar nerve delayed distal nerve conduction suggestive of a cubital tunnel syndrome (see above).  Physical examination documented cervical ROM of forward flexion of 45 degrees (normal) and combined ROM of 340 degrees (normal).  There was no mention of painful motion or tenderness.  

At the 16 October 2007 VA Compensation and Pension (C&P) evaluation the CI reported neck pain, radiating pain and paresthesias in both shoulders and arms.  Physical examination showed neck tenderness with an incomplete cervical ROM as the CI declined forward flexion and lateral flexions due to pain.  The CI also declined repetitive testing and X-rays.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the cervical DDD condition 0%, coded 5237(cervical strain), citing no significant loss of ROM, radiculopathy, or tenderness.  The VA rated the cervical condition 30% coded 5237, based on the VA C&P examination, citing ROM criteria.  The Board adjudged that the NARSUM examination had the highest probative value for rating due to the remoteness of the VA examination.  There was no limitation of cervical spine motion to support a minimum rating under the General Rating Formula for Diseases and Injuries of the Spine.  The left upper extremity peripheral nerve disability was not adjudged as being attributed to the cervical spine condition.  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 cervical spine condition.  

Contended PEB Conditions:  Adjustment Disorder w/Mixed Anxiety and Depressed Mood, Alcohol Dependence, Nicotine Dependence.  The Board’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  The adjustment disorder w/mixed anxiety and depressed mood, alcohol dependence, and nicotine dependence are conditions not constituting a physical disability, IAW DoDI 1332.38.  Therefore, the Board has no basis for recommending any of the contended conditions as unfitting.  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 of the contended conditions and so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the left carpal tunnel syndrome condition and IAW VASRD §4.124a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the left shoulder condition, the Board unanimously recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a.  In the matter of the cervical spine condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended adjustment disorder with mixed anxiety and depressed mood, alcohol dependence, and nicotine dependence conditions, the Board unanimously recommends no change from the PEB determinations as not unfitting.  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; 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	
Carpal Tunnel Syndrome, Left … Cubital Tunnel Syndrome …	8716-8714	20%	
Left Shoulder	5099-5003	10%	
Degenerative Disc Disease, Cervical	5237	0%	
COMBINED	30%	

The following documentary evidence was considered:
Exhibit A.  DD Form 294, dated 20140716, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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 XXXXXXXXXXXXXXXXXX, AR20160013319 (PD201403496)

1.  Under the authority of Title 10, United States Code, section 1554(a), I approve the enclosed recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) pertaining to the individual named in the subject line above to re-characterize the individual’s separation as a permanent disability retirement with the combined disability rating of 30% effective the date of the individual’s original medical separation for disability with severance pay.  

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:

	a.  Providing a correction to the individual’s separation document showing that the individual was separated by reason of permanent disability retirement effective the date of the original medical separation for disability with severance pay.

	b.  Providing orders showing that the individual was retired with permanent disability effective the date of the original medical separation for disability with severance pay.

	c.  Adjusting pay and allowances accordingly.  Pay and allowance adjustment will account for recoupment of severance pay, and payment of permanent retired pay at 30% effective the date of the original medical separation for disability with severance pay.

	d.  Affording the individual the opportunity to elect Survivor Benefit Plan (SBP) and medical TRICARE retiree options.

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:

			       
						      					
Enclosure
					
CF: 
(  ) DoD PDBR
(  ) DVA