RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03556
BRANCH OF SERVICE:  MARINE CORPS	SEPARATION DATE:  20051215

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Refrigerator Mechanic), medically separated for “Overall Effect” for left wrist and right knee conditions.  The left wrist and right knee conditions could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS).  He was placed on limited duty (LIMDU) and referred for a Medical Evaluation Board (MEB).  “Other joint derangement, not elsewhere classified” and “forearm and nonunion of fracture” were forwarded to the Physical Evaluation Board (PEB) IAW SECNAVINST 1850.4E.  No other condition was submitted by the MEB.  The Informal PEB adjudicated “left wrist ulnar styloid fracture non-union surgically treated with excision non-union fragment”, “right knee patellofemoral syndrome [PFPS]” and “left wrist lunotriquetral instability” as unfitting based on “Overall Effect”, rated 0%, with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The CI made no appeals and was medically separated.  

CI CONTENTION:  His conditions continue to worsen and negatively impact his daily activities.  He was not evaluated for post-traumatic stress disorder (PTSD).  His complete submission is at Exhibit A.

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e. (2).  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/Naval 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 20050819	VA* (1 Day Pre-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Wrist Ulnar Styloid Fracture Nonunion Surgically Treated w/ Excision Nonunion Fragment	OE	0%	Status Post Left Wrist Fracture w/Open Reduction &
Internal Fixation 	5215	10%	20051214
	
Left Wrist Lunotriquetral Instability							
Right Knee PFPS			Right Knee Condition	5257	NSC		
Other MEB/PEB Conditions x 0 (Not in Scope)	Other x 7 	
RATING:  0%	COMBINED RATING:  40%	
*Derived from VA Rating Decision (VARD) dated 20060405 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:  The PEB combined left wrist ulnar styloid fracture nonunion surgically treated with excision nonunion fragment, left wrist lunotriquetral instability and right knee PFPS as a single unfitting condition, un-coded, and rated 0%.  This approach by the PEB reflected its judgment that the constellation of conditions was unfitting, but that individually each condition alone was not considered unfitting, hence the “overall effect.”  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.  If the Board judges that two or more separate ratings are warranted in such cases, it must first satisfy the requirement that each “unbundled” condition was unfitting in and of itself.  Thus, the Board must maintain the prerogative of separate fitness recommendations in this circumstance, with the caveat that its recommendations may not produce a lower combined rating than that of the PEB.

Left Wrist Nonunion Fracture and Instability.  In June 2004, the CI fractured his left wrist after a car fell from a jack and rolled over his left hand.  Initial X-rays revealed a fracture of the left ulnar styloid process.  He received conservative treatment consisting of pain medications, restrictions, casting, and eventual occupational therapy (OT).  Due to persistent pain and weakness, the CI underwent a surgical arthroscopy of the left wrist and removal of a nonunion fragment of the left ulnar styloid process on 1 February 2005.  Three months after surgery, OT reported that his grip strength and active range-of-motion (ROM) of the wrist was increasing.  The CI began his second LIMDU on 16 March 2005 (9 months prior to separation).  At the MEB examination 19 August 2005 (4 months pre-separation), the CI reported a sharp and persistent pain about his left wrist with any type of twisting or turning activities.  His physical examination (PE) revealed tenderness about the left wrist.  There was comparison grip strength weakness measured as 120 pounds on the right and 86 pounds on the left.  The examiner’s opinion included, “[The CI] has a functional ROM of the left wrist but non-functional grip strength.”  At the VA Compensation and Pension (C&P) examination 14 December 2005 (1 day prior to separation), the CI reported constant left wrist pain that causes difficulty with pushing, pulling and lifting.  The PE revealed left wrist was limited and had painful motion.  There was no evidence of heat, redness, swelling, effusion, drainage, abnormal movements, instability, or weakness of the left wrist.  The goniometric 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.

Left Wrist ROM
(Degrees)	MEB ~4 Mo. Pre-Sep	VA C&P 1 Day Pre-Sep	
Dorsiflexion (70 Normal)	55 	50	
Palmar Flexion (80)	60	80	
Ulnar Deviation (45)	30	45	
Radial Deviation (20)	20	20	
Comment	tenderness; weakness 	painful motion	
§4.71a Rating	0%-10%	10%	

The Board directed attention to its rating recommendation based on the above evidence.  The Board members first considered and agreed that probative value (PV) in this case be apportioned to the VA examination due to it being 1 day before the CI’s separation date.

The PEB’s proceedings reflected the application of SECNAVINST 1850.4E for rating ‘overall effect’, but its 0% determination was possibly consistent with §4.71a standards based upon on the MEB examination data.  The VA rating decision indicated that its 10% rating was based on ‘painful and limited dorsiflexion’ of the wrist.

Board members deliberated and concluded that the totality of evidence from the service treatment record, provided sufficient evidence that the CI’s left wrist became painful with use (specifically when pushing, pulling and lifting) leading to functional loss which supports a minimal compensable rating with application of VASRD §4.59 (painful motion) or §4.40 (functional loss).  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends that the left wrist condition be found separately unfitting and rated 10%, coded as 5099-5003.

Right Knee Condition.  Absent a history of trauma or injury, the CI was diagnosed with right PFPS after he complained of his knee ‘locking up’ over a weeks’ timeframe in February 2005.  He was initially treated with medications, restrictions, and physical and occupational therapy.  At the MEB examination, the CI reported right knee pain and swelling that was associated with clicking and popping behind the kneecap.  He denied current buckling of the knee.  His painful symptoms worsened with walking, running, maneuvering stairs, squatting, or sitting with his knees bent.  His PE revealed right knee tenderness with evidence of positive patellar grind and compression tests.  The lower extremity neuro-vascular status was intact.  The final diagnosis remained unchanged.  At the VA C&P examination, the CI reported constant right knee pain.  He denied any functional impairment as a result of the right knee condition and he denied having any periods of incapacitation.  His PE of the right knee was completely normal.  The goniometric 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 Knee ROM
(Degrees)	PT ~6 Mo. Pre-Sep	MEB ~4 Mo. Pre-Sep	VA C&P 1 Day Pre-Sep	
Flexion (140 Normal)	FROM	-	140	
Extension (0 Normal)		-	0	
Comment	tenderness	tenderness; 
(+) grind/compression… indicative of PM 		
§4.71a Rating	0%	10%	0%	

The Board directed attention to its recommendation based on the above evidence.  The Joint Disability Evaluation Tracking System, or JDETS, attachment to the PEB’s determination indicates that the original board members had doubts that the right knee was independently unfitting, but that it could contribute to an “overall effect” of unfitness.  The Board’s threshold for countering the disability evaluation system fitness determinations is higher than the VASRD §4.3 (reasonable doubt) standard used for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  Board members agreed that the VA examination clearly was representative of the CI’s condition at the time of separation.  The VA’s completely normal PE did not indicate that the right knee condition would significantly interfere with satisfactory duty performance and was not separately unfitting.  After due deliberation, and in consideration of the preponderance of the evidence, the Board concluded that the right knee condition could not be recommended for additional disability rating. 

BOARD FINDINGS:  IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication.  As discussed above, PEB reliance on SECNAVINST 1850.4E for rating an overall effect of multiple conditions was operant in this case and the conditions were adjudicated independently of that instruction by the Board.  In the matter of the combined effect of the above listed conditions, the Board unanimously recommends that the conditions be adjudicated as follows: unfitting left wrist nonunion fracture and instability condition, coded 5099-5003, rated 10% IAW VASRD §4.71a; and, a not unfitting right knee condition.  There were no other conditions within the Board’s scope of review for consideration.  

RECOMMENDATION:  The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of his prior medical separation:  

CONDITION	VASRD CODE	RATING	
Left Wrist Fracture with Instability 	5099-5003	10%	
Right Knee Condition	Not Unfitting	
RATING	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140728, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR DIRECTOR, SECRETARY OF THE NAVY COUNCIL OF REVIEW
               BOARDS 

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS
 
Ref:   (a) DoDI 6040.44
       (b) CORB ltr dtd 21 Jan 16

      In accordance with reference (a), I have reviewed the cases forwarded by reference (b), and, for the reasons provided in their forwarding memorandums, approve the recommendations of the PDBR that the following individual’s records not be corrected to reflect a change in either characterization of separation or in the disability rating previously assigned by the Department of the Navy’s Physical Evaluation Board:

- XXXXXXXXXXXXXXXXXXXX, former USMC 
- XXXXXXXXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXXXXXXXX, former USMC   
- XXXXXXXXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXXXXXXXX, former USMC 
- XXXXXXXXXXXXXXXXXXXX, former USMC  
- XXXXXXXXXXXXXXXXXXXX, former USMC 
- XXXXXXXXXXXXXXXXXXXX, former USMC 

		XXXXXXXXXXXXXXXXXXXX
		Assistant General Counsel
		(Manpower & Reserve Affairs)