RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03984
BRANCH OF SERVICE:  ArmY	BOARD DATE:  20150526
SEPARATION DATE:  20080122

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an activated National Guard E-2 (Basic Trainee) medically separated for a right wrist condition.  The condition could not be adequately rehabilitated to meet the physical requirements of basic training.  However, the profile allows for an alternate aerobic event to satisfy physical fitness standards.  He was issued a permanent U3 profile and referred for a Medical Evaluation Board (MEB).  “Right wrist injury with arthritis” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other condition was submitted by the MEB.  
The Informal PEB adjudicated right dominate wrist pain as unfitting, rated 0% with cited application of the US Army Physical Disability Agency (USAPDA) pain policy.  The CI made no appeals and was medically separated.

CI CONTENTION:  “Please consider all conditions.”

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:

Service IPEB – Dated 20080102	VA* - - Based on Service Treatment Records (STR)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Wrist Pain (Dominate)	5099-5003	0%	Residuals, Right Schapoid Fracture	5215-5010	0%	STR	
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 0	
RATING:  0%	RATING:  0%	
*Derived from VA Rating Decision (VARD) dated 20080910 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Right Dominate Wrist Pain.  In March 2007, the CI caught his right wrist between another solider and a door which resulted in local pain.  Initially diagnosed as a wrist sprain, subsequent radiographs revealed abnormalities consistent with a possible fracture/dislocation.  Despite right arm immobilization, his wrist pain continued.  In July 2007, the CI underwent a diagnostic right wrist arthroscopy which revealed synovitis (inflammation of the lining surrounding a joint) without boney fracture or disruption.  Although post-surgical occupational therapy did improve his overall wrist range-of-motion (ROM), the examiner commented that the CI would require “another 6 months before he would be able to return to basic training.”  The CI was permanently profiled and referred to a MEB.

At the MEB narrative summary examination on 20 March 2007; 10 months prior to separation, the CI’s chief complaint was “right wrist pain” and reported the inability to perform push-ups or lifting greater than 30 pounds.  His examination revealed tenderness, stiffness, and decreased painful motion of the right wrist.  His diagnosis was right wrist injury with arthritis.  Additional radiologic imaging performed on 18 June 2007 (7 months prior to separation) revealed no boney abnormality.  His permanent profile of October 2007 listed right wrist injury as the sole diagnosis and the commander’s statement noted that the CI’s injury prevented [him] from performing many physical exercises and activities.  An occupational therapy encounter dated 1 November 2007 indicated slight weakness in the right wrist as compared to the left wrist (grip strength of 60 pounds versus 70 pounds).

A VA examination was not available for review, but a VARD (proximate to separation) indicated that the right wrist condition was rated at 0%, citing the absence of objective medical evidence of painful or limited motion.  It was additionally noted that the CI “failed to report” for a previously scheduled C&P examination.

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 Wrist ROM
(Degrees)	NARSUM
~10 Mo. Pre-Sep
(20070320) 	OT
~3 Mo. Pre-Sep
(20071101) 	VA C&P
~12 Mo. Post-Sep
(20090128) 	
Dorsiflexion (70 Normal)	notable decrease	(65) 61/65/65	50	
Palmar Flexion (80)	--	(70) 70/70/70	55	
Ulnar Deviation (45)	Intact	(30) 30/30/30	32	
Radial Deviation (20)	Intact	(20) 20/17/18	24	
Comment	Painful motion	Painful motion; tenderness	Painful motion	
§4.71a Rating	10% (PEB 0%)	10%	10% (VA 10%)	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the right wrist condition at 0% using VASRD code 5009-5003 (analogous to degenerative arthritis) and cited the USAPDA pain policy.  The VA also rated the condition at 0% with dual codes 5215-5010 (wrist; limited motion and traumatic arthritis) and cited the absence of medically evident disabilities.  Clearly there was decreased right wrist ROM on both prior to and after separation examinations, but none were compensable under VASRD criteria for the wrist limitation of motion disability codes.  The Board deliberated if the record provided reasonable doubt as to concede either painful motion IAW VASRD §4.59, limited motion §4.71, or functional loss §4.40 and discussed the CI’s subjective limitation of activities.  In this case, both painful motion as well as functional loss would yield a maximum of 10%.  Functional loss was evidenced by slight weakness in grip strength.  The VASRD §4.40 states “weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as seriously disabled.”  Absent surrounding nerve and or muscle damage, Board members alleged that the degree of right hand weakness (grip strength) was primarily related to subjective pain on use versus a secondary medical condition and therefore, considered “seriously disabled” as per §4.40.  Additionally, the Board discussed and acknowledged that the wrist (as a whole) is a multifaceted joint with articulations with the radius and ulna bones of the arm and therefore, considered alternate coding pathways under the arm codes.  All members concurred that the close anatomical connections to the arm bones had no bearing in this case for the surgically diagnosed synovitis pathology was completely and exclusively contained within the wrist bones.  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.

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 right wrist was operant in this case and the condition was adjudicated independently of that policy by the Board.  In the matter of the right wrist condition, the Board unanimously recommends a disability rating of 10% coded 5099-5003 IAW VASRD §4.71a.  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	
Right Wrist Pain	5099-5003	10%	
RATING	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140917, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB

06 JUL 2016

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, AR20160002833 (PD201403984)

1 . 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,
accept the Board's recommendation to modify the individual's disability rating to 10%
without re-characterization of the individual's separation. This decision is final.

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.

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:

CF:
( ) DoD PDBR
()DVA