RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03547
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050815

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Human Resources Specialist, medically separated for “chronic bilateral wrist pain,” with a disability rating of 10%.

CI CONTENTION:  The CI contends that she was giving a higher rating from the VA.  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 on 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 - 20051110	VARD - 20071109	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Bilateral Wrist Pain	5099-5003	10%	Status Post Ganglion Cyst Removal, Right Wrist	5215	10%	20060105	
			Status Post Ganglion Cyst Removal, Left Wrist	5215	10%	20060105	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Chronic Bilateral Wrist Pain.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s developed bilateral wrist pain without specific trauma.  She was first seen on 24 January 2003 and reported a 5-day history of pain.  She was treated with bracing, duty limitations and medications.  She continued to have pain though and ultimately required surgery on both wrists.  Despite treatment, the bilateral wrist pain 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 “right wrist pain with mild wrist stiffness and easy fatigability” 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.  

Bilateral Wrist ROM
(Degrees)	MEB ~3 Mos. Pre-Sep	VA C&P ~5 Mos. Post-Sep	
	Left	Right	Left	Right	
Dorsiflexion (70 Normal)	70 (75)	70 (75)	62	54	
Palmar Flexion (80)	80 (90)	80 (90)	60	60	
Ulnar Deviation (45)	30	30	35	38	
Radial Deviation (20)	15	10	30	30	
Comment	Pain with activity over 20 minutes	Onset of pain limited motion	
§4.71a Rating	10%	10%	10%	10%	

The narrative summary (NARSUM) was dated 18 May 2005.  She showed good healing and strength.  The range of motion was reduced as charted above.  

At the VA Compensation and Pension (C&P) examination performed on 5 January 2006, 5 months after separation, the CI reported ongoing pain in both wrists with activity, but denied incapacitation.  She was able to garden, push a lawnmower, and brush her teeth.  On examination the general appearance was normal.  She had increased pain with repetition, but no additional limitation in motion was documented.  X-rays were normal. 
 
The Board directed attention to its rating recommendation based on the above evidence.  The PEB combined both wrists as a single unfitting condition, coded analogously to 5003 and rated 10%, with application of the US Army Physical Disability Agency pain policy.  This approach by the PEB not uncommonly reflects its judgment that the constellation of conditions was unfitting and that there was no need for separate fitness adjudications rather than a judgment that each condition was independently unfitting.  The Board also noted that “bundling,” the combining of two or more major joints, may be permissible under VASRD code 5003 rating requirements and that this approach does not compromise the IAW VASRD §4.7 directive to choose the higher of two valid ratings.  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 Disability Evaluation System 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 bilateral wrist conditions are so intertwined that a single discussion is presented.   

The PEB rated the bilateral wrist pain condition at 10%, coded 5099-5003 (analogous to degenerative arthritis), citing the now rescinded US Army pain policy.  The VA rated each wrist at 10%, coded 5215 (limitation in motion), citing pain with motion.  The limitation in motion is not compensable.  Painful motion, IAW §4.59, supported the assignment of the minimal compensable rating for the joint.  In this case, the use of the code 5003 for both wrists at 10% combined satisfies VASRD §4.59.  While each wrist could be considered separately unfitting, this provided no rating advantage to the CI.  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 bilateral wrist condition.  

BOARD FINDINGS:  In the matter of the bilateral wrist pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  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 20140718, w/attachments
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 XXXXXXXXXXXXXXXXXX, AR20160011987 (PD201403547)

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:

Enclosure

CF: 
(  ) DoD PDBR
(  ) DVA