RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03800
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20030214

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Combat Engineer) medically separated for chronic right thumb pain.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty.  He was issued a permanent P3 profile and referred for a Medical Evaluation Board (MEB).  The “right dominant thumb pain” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other condition was submitted by the MEB.  The Informal PEB adjudicated “chronic right (dominant) thumb pain” as unfitting, rated 10% citing application of the US Army Physical Disability Agency (USAPDA) pain policy.  The CI made no appeals and was medically separated.  

CI CONTENTION:  The applicant believes his service physical exam was not valid.  Additionally, he was not rated for Bipolar Disorder, Massive Depressive Disorder [sic], Fabromyalya [sic] and Progressive Arthritis.  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 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:  

IPEB – Dated 20021223	VA* - (~23 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Right (Dominant) Thumb Pain	5099-5003	10%	Right Thumb Strain	5228	0%	20050131	
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 4 (equals SC, NSC & deferred)	
RATING:  10%	RATING:  20%	
*Derived from VA Rating Decision (VARD) dated 20050208 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY:  

Chronic Right (Dominant) Thumb Pain Condition.  The narrative summary noted the CI injured his dominant right thumb when he fell from a height of approximately 15 feet and broke his fall with his hands in April 2002.  Notes in the service treatment record (STR) indicated after a month, the CI sought treatment with primary care because of increasing pain (21 May 2002).  The CI had pain around the radial aspect of his thumb with tenderness to palpation (TTP) of the thumb/wrist junction and the metacarpophalangeal joint (MCPJ).  Thumb X-rays noted degenerative changes and calcifications possibly due to old traumatic injury, without other hand abnormalities.  He was evaluated by the orthopedic specialist and casted for 4 weeks for sprain of the radial collateral ligament.  When the cast was removed the CI reported pain on the ulnar aspect of his MCPJ and he was diagnosed instead with sprain of the ulnar collateral ligament (UCL) or “gamekeeper’s thumb” and he was placed in a thumb splint and then re-casted.  Thumb stress X-rays noted minimal laxity.  An occupational therapy (OT) visit on 27 August 2002 noted MCPJ flexion of 55 degrees (normal 60)  A follow–up with the orthopedic surgeon 29 October 2002 noted TTP of the ulnar aspect of the thumb, normal sensation, no skin changes, and normal X-rays.  Despite continued OT, the thumb pain failed to resolve and a MEB was initiated.  The DD Form 2808, Report of Medical Examination, dated 15 November 2002 noted TTP and crepitus of the MCPJ with mild laxity.

At the MEB exam 27 November 2002, 3 months prior to separation, the CI reported thumb pain.  The MEB physical exam noted no laxity of the UCL and normal ROM of the carpometacarpal and interphalangeal joints.  There was decreased ROM of the MCPJ, with TTP of both the CMC and MCP joints, without redness, warmth, swelling, or effusion.  There was decreased global sensation of the tip of the thumb and no evidence of nerve compression (negative Tinel’s sign).

At the VA Compensation and Pension (C&P) exam 31 January 2005, 23 months after separation, the CI reported right hand pain and shaking.  He reported no current treatment for the right thumb and no lost work time.  He reported difficulty writing, cleaning the house, and exercising.
The exam noted the CI was right hand dominant.  The CI reported discomfort of the MCPJ.  There was normal thumb motion (flexion and abduction) without redness, warmth, or swelling.  The thumb was able to oppose all fingers.  Grip strength on the right was “slightly reduced.”  Normal strength, sensation, and reflexes of the upper extremities were noted.  Right hand X-rays were normal.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the thumb pain 10%, coded 5099-5003 (analogous to degenerative arthritis) and cited the USAPDA pain policy.  The VA rated the thumb 0%, 24 months after separation.  The Board noted that the initial C&P exam and original VARD are beyond the 12-month period for special consideration of VA post-separation evidence IAW DoDI 6040.44 and therefore has probative value for the Board’s rating recommendation only insofar as the evidence provides information which reflects the status of the thumb condition more proximate to separation.  Members first considered coding according to VASRD 5003 rating criteria for degenerative arthritis, but noted that a “group of minor joints,” in this case defined as multiple joint involvements of the hand, thumb, and finger joints can be rated 10% for limited motion, and the single MCPJ condition by itself did not achieve a 10% rating.  The Board noted that there is a single VASRD code for limitation of thumb motion based upon the ability of the thumb to oppose the fingers-5228.  

At the MEB exam normal CMC and IP joint ROM was noted with “decreased” ROM of the MCPJ, without documentation of the ability of the thumb to oppose the fingers.  However, the earlier OT evaluation noted near normal MCP joint flexion.  Therefore, it seemed unlikely to the Board that the mildly limited ROM of the thumb resulted in a gap between the thumb and fingers of more than an inch, required to meet a 10% rating.  The remaining thumb codes require evidence of ankylosis of one or more thumb joints for rating, which was not present in this case.  However, the evidence indicates that proximate to separation the CI was having difficulty using his dominant hand due to the thumb pain with continued reported difficulties at the remote C&P exam and Members agreed that a 10% rating was supported with consideration of painful motion and functional loss IAW VASRD §4.59 (Painful motion) and §4.40 (Functional loss).  The Board determined that the evidence supports a 10% rating for the thumb condition IAW §4.71a and no higher, and there was no evidence of any other ratable impairment of the hand.  The Board also noted that the PEB’s reliance on the USAPDA pain policy was not detrimental to arriving at the highest rating and therefore no change to the code is recommended.  After due deliberation in consideration of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the thumb condition.  

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 the USAPDA pain policy for rating the thumb condition was operant in this case and the condition was adjudicated independently of that policy by this Board.  In the matter of the thumb 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.  

RECOMMENDATION:  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 20140510, 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 AR20160004327 (PD201403800)

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