RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03542
BRANCH OF SERVICE:  Army 	SEPARATION DATE: 20051122 

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Counterintelligence Agent, medically separated for “chronic pain right wrist/hand status post triquetral bone fracture and left knee status post closed fracture proximal left lateral tibial plateau with anterior horn lateral meniscus and posterior horn medial meniscus tear,” with a disability rating of 20%.  

CI CONTENTION:  The CI’s condition continues to worsen and negatively impacts daily activities.  Additionally, the CI was not rated for a mental health condition.  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 - 20050823	VARD - 20060511  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Wrist/Hand and Left Knee Conditions	5099-5003	20%	Residuals S/P Closed Triqeutal Bone Fracture, Right	5215	0%	20060209	
			Residuals, Left Tibial Fracture	5262	10%		
			Scar, Left Upper Tibial	7802	0%		
Anxiety Disorder, NOS	Not Unfitting 	PTSD	9411	10%	20060208	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Right Wrist (dominant).  The PEB combined the closed fracture (fx) proximal left tibial plateau and the closed fx of the triquetral bone of the right hand conditions as a single unfitting condition characterized as chronic pain right wrist/hand and left knee, coded analogously to 5003 and rated 20%, with application of the US Army Physical Disability Agency (USAPDA) pain policy and AR 635-40 B24.f.  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.  The Board’s initial charge in this case was 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 Board first addressed whether the right wrist and left knee conditions each remained reasonably considered separately unfitting when separated from the PEB’s combined adjudication as elaborated above.  The permanent profile was U3L3 and listed “closed fracture left proximal tibial plateau, closed fracture triquetral bone right hand. Left knee anterior horn lateral meniscus and posterior horn medial meniscus tear.”  The commander’s statement noted 
the CI was unable to perform normal soldier duties as well as the duties of her MOS due to her “current physical state”, including moving and carrying assigned equipment or conduct combat operations with body armor, weapon, and ammunition.  The MEB NARSUM noted duty limitations of inability to run or complete an alternate physical fitness test and inability to hold, support and fire an individual weapon and difficulty with push-ups, writing and typing.  The MEB NARSUM examiner indicated that individually the left knee condition failed to meet retention standards and the right hand condition failed to meet retention standards.  The Board concluded there was not a preponderance of evidence of the service records to overcome the Board’s presumption that each of the bundled right wrist/hand and left knee conditions was reasonably considered separately unfitting.  The evidence for rating the chronic pain right wrist/hand and chronic pain left knee conditions are presented separately, with attendant rating recommendations.

According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s dominant right wrist condition began in December 2004 when a vehicle she was riding in was hit by an improvised explosive device (IED) blast.  Initial X-rays were negative, but MRI in March 2005 showed a minimally displaced avulsion fx of a hand bone (triquetral bone – ulnar aspect of hand).  No surgery was indicated.  The CI was given a wrist brace.  Despite treatment the CI continued to report wrist pain with activities.  The hand fx was noted to be healed and the ongoing symptoms were attributed to traumatic arthritis.  The MEB forwarded “closed fracture triquetral bone right hand” for PEB adjudication.  

The goniometric range of motion (ROM) evaluations 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 Wrist ROM
(Degrees)	OT/MEB ~5 Mo. Pre-Sep
	VA C&P ~3 Mo. Post-Sep
	
Dorsiflexion (70 Normal)	65	70	
Palmar Flexion (80)	50	80	
Ulnar Deviation (45)	30	45	
Radial Deviation (20)	10	20	
Comment	Tenderness, pain at ERM flex and ext.	0%	
§4.71a Rating	10%	#%	

Right Forearm ROM
(Degrees)	MEB ~5 Mo. Pre-Sep
	VA C&P ~3 Mo. Post-Sep
	
Pronation (80 Normal)	90	85	
Supination (85)	90	85	
Comment	-	-	
§4.71a Rating	0%	0%	

The MEB examination dated 11 July 2005, 4 months prior to separation noted the CI was wearing a right wrist brace.  The physical examination showed decreased ROM of the wrist 

At the MEB NARSUM examination on 24 June 2005, 5 months before separation, the CI reported no wrist pain at rest, but pain graded 8/10 with writing, typing, lifting, and push-ups.  There was tenderness to palpation (TTP) over the fx site.  There was pain with grinding at the fx site, without swelling or crepitus.  There was TTP of the ulnar aspect of the wrist, no pain with wrist ROM was noted.  There was no muscle atrophy.  Sensation and pulses were normal.  Clinical testing for carpal tunnel syndrome was negative.  Occupational therapy measured ROM for the MEB on the same day.  Wrist ROM was as indicated in the chart above.  Pain was noted at end of both extension and flexion ROM.  

At the VA C&P examination on 9 February 2006, 3 months after separation, the CI reported right dominant wrist pain with prolonged twisting motions, without flare-ups.  Physical examination noted normal strength, sensation, and reflexes throughout.  There was full ROM of the wrist with forearm pronation 85 degrees and supination 85 degrees.  No pain with ROM was noted and there was no additional limitation of ROM with repetition.  A single view X-ray of the right wrist was normal.

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB rated the chronic pain right wrist/hand and left knee condition 20%, using an analogous 5003 code (degenerative arthritis), according to the USAPDA pain policy/AR 635-40 as noted above.  The VA rated the right hand condition 0%, coded 5215 (limitation of wrist motion) based on the C&P examination 3 months after separation, citing no evidence of sufficient limitation of wrist ROM or painful ROM.  There was no limitation of wrist dorsiflexion or palmar flexion that supported a rating under the VASRD diagnostic code for limitation of wrist motion (5215) and there was no evidence of wrist ankylosis for rating under 5214.  However there was evidence of painful motion causing functional loss supporting the 10% rating (based on §4.59, §4.40 and §4.45).  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.  

Left Knee. According to STR and the MEB NARSUM, the CI’s left knee condition began in December 2004 also as a result of the IED blast noted above.  Initial imaging did not show a fx, but MRI on 24 February 2005 noted a tibial plateau fx, and tears of the medial and lateral menisci.  Orthopedic evaluation on 19 May 2005 noted the tibial fracture was healed and pain likely due to arthritis.  No surgery was indicated and a MEB was recommended.  The MEB forwarded “closed fracture proximal left lateral tibial plateau” for PEB adjudication.  At the MEB NARSUM examination on 24 June 2005, 5 months before separation, the CI reported left knee pain rated 5/10, aggravated by activity.  The physical examination noted mild difficulty with heel and toe walking.  There was TTP of the knee without swelling, crepitus, or instability.  Physical therapy measured ROM for the MEB on 7 July 2005 was flexion 145 degrees (normal 140 degrees) and extension 0 degrees (normal 0 degrees) with pain with extension noted.

At the VA C&P examination on 9 February 2006, 3 months after separation, the CI reported left knee pain with all activities, especially full extension or squatting.  She was unable to perform all impact activities due to pain.  She denied flare-ups.  The physical examination noted a normal gait.  There was no TTP, crepitus or instability.  Knee ROM was flexion 140 degrees and 0 degrees extension.  There was no evidence of meniscal pathology.  There was painful motion noted at end range of flexion and extension and with squatting.  No additional limitation of motion was noted with repetition.   Lower extremity strength, sensation, and reflexes were normal.  Single view X-rays of the left knee and left tibia were normal.  

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB rated the chronic pain right wrist/hand and left knee condition 20%, as noted above.  The VA rated the left knee condition 10%, coded 5262 (tibia/fibula impairment)) based on the C&P examination 3 months after separation, citing painful ROM.  There was no limitation of motion which supported a rating under the diagnostic codes for limitation of flexion or extension (5260, 5261). However, there was evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45).  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 evidence of non-union, or malunion of the tibial fracture to support consideration under the respective codes for knee impairment related to long bone conditions (5255, 5262).  There was therefore no VASRD §4.71a route to a rating higher than the 10% adjudicated by the PEB under any applicable code, and no grounds for additional rating based on the presence of instability.  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 knee condition.  

Having unbundled the two conditions of the PEB’s combined adjudication, the Board found that though each condition was reasonably considered separately unfitting, individual rating based only on the VASRD provided no ratings benefit to the CI.  The PEB’s reliance on the pain policy was not detrimental to arriving at the highest rating and therefore, no change to the PEB adjudication is recommended.  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 chronic pain right wrist/hand and left knee condition.  

Contended PEB Condition.  Anxiety disorder, not otherwise specified (NOS).  The anxiety disorder, NOS 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 anxiety disorder, NOS 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 anxiety disorder, NOS and so no additional disability rating is recommended.

BOARD FINDINGS:  BOARD FINDINGS:  In the matter of the chronic pain right wrist/hand and left knee condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended anxiety disorder, not otherwise specified, 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 20131030, 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

21 NOV 2016

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for 
XXXXXXXXXXXXXXXXXX, AR20160017507 (PD201403542)

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.

Enclosure

CF: 
(  ) DoD PDBR
(  ) DVA