RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00182
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070528

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Helicopter Mechanic, medically separated for “right cubital tunnel syndrome,” “right carpal tunnel syndrome,” “left knee pain,” and “chronic right shoulder pain,” rated 10%, 10%, 0% and 0%, respectively, with a combined disability rating of 20%.

CI CONTENTION:  The CI requested consideration of all conditions.  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 – 20070427	VARD – 20090616	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Cubital Tunnel Syndrome	8716	10%	No VA Placement	
Right Carpal Tunnel Syndrome	8725	10%	Right Carpal Tunnel Syndrome Claimed as Right Wrist Condition	8615	10%	20090512	
Left Knee Pain	5099-5003	0%	Left Knee Meniscus Tear	5259	0%		
Chronic Right Shoulder Pain	5099-5003	0%	Right Shoulder Condition	5203-5201	NSC		
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

Right Cubital Tunnel Syndrome.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the left-handed CI’s right cubital tunnel syndrome (ulnar nerve) condition was revealed by electrodiagnostic studies in February 2005 and May 2006, which were performed to evaluate complaints of right upper extremity numbness and tingling.  The CI declined a surgical option, and conservative treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “right upper extremity ulnar neuropathy at the elbow” for PEB adjudication.  The MEB NARSUM examination on 4 October 2006 (8 months prior to separation) noted complaints of pain in the right medial elbow area radiating to the 4th and 5th fingers.  He reported difficulty performing fine motor activities due to right upper extremity cubital and carpal (see below) tunnel syndromes.  Physical examination showed decreased light touch sensation in the distribution of the ulnar nerve.  There was evidence of ulnar nerve irritation at the right elbow (positive Tinel’s sign).  Although there was no muscle atrophy, there was some decreased strength of the muscle controlling little finger adduction, as well as decreased grip strength.  At the MEB examination (recorded on DD Forms 2807 and 2808) dated 9 February 2007 (4 months prior to separation), the CI reported numbness in his right arm and hand.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the right cubital tunnel syndrome condition 10%, coded 8716 (ulnar nerve neuralgia), citing ‘mild’ incomplete neuralgia.  After an examination almost 2 years after separation, the VA (for unknown reasons) did not rate the right cubital tunnel syndrome.  The ulnar nerve coding pathway stipulates that “moderate” incomplete paralysis justifies a 20% rating for the non-dominant upper extremity, while “mild” warrants 10%.  Board members noted there was numbness and some little finger weakness directly attributable to the ulnar nerve; and ulnar neuropathy may have contributed to some weakness of grip.  Ultimately, the Board concluded the evidence was most accurately depicted by the “mild” descriptor, and a 10% rating was supported.  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 right cubital tunnel syndrome condition.  

Right Carpal Tunnel Syndrome.  This median nerve condition was discovered at the same time as the cubital tunnel syndrome, during electrodiagnostic studies performed to evaluate numbness and tingling.  The CI declined a surgical option, and conservative treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “right upper extremity median neuropathy at the wrist” for PEB adjudication.  At the MEB examination the CI reported numbness in his right arm and hand.  The MEB NARSUM examination reported difficulty performing fine motor activities related to the carpal tunnel syndrome (and cubital tunnel syndrome, above), but no other specific historical details were provided.  Physical examination showed decreased light touch sensation in the distribution of the median nerve, and evidence of median nerve irritation at the right wrist (positive Tinel’s sign).  Although there was no muscle atrophy, there was some decreased strength of the muscles controlling thumb abduction, as well as decreased grip strength.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the right carpal tunnel syndrome condition 10%, coded 8725 (posterior tibial nerve neuralgia), citing ‘mild’ incomplete neuralgia; however, the PEB’s coding choice refers to a nerve in the leg; the relevant neuralgia code in this case is 8715 (median nerve neuralgia).  The VA also rated the right carpal tunnel syndrome condition 10%, and used an appropriate 8615 code (median nerve neuritis), citing ‘mild’ incomplete neuritis as a rationale.  The rating was based on a VA C&P examination almost 2 years after separation, which was not probative to the time of separation.  The median nerve coding pathway stipulates that “moderate” incomplete paralysis justifies a 20% rating for the non-dominant upper extremity, while “mild” warrants 10%.  Board members considered there was numbness and some thumb weakness attributable to the median nerve; and median neuropathy may have contributed to some weakness of grip.  The Board concluded the evidence was most accurately depicted by the “mild” descriptor and a 10% rating was supported.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded there was insufficient cause to recommend a change in the PEB adjudication for the right carpal tunnel syndrome condition.  
Left Knee Pain.  According to the STR and the MEB NARSUM, the CI underwent left knee arthroscopy in July 2005 for debridement of a medial meniscus injury occurred while on a helicopter.  Debridement of redundant tissue (medial plica) was also performed, and chondromalacia (softening) of the trochlear cartilage of the knee joint was noted.  At the time of surgery, all knee ligaments were noted to be intact.  Following surgery further treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “left knee trochlear chondromalacia status post medial meniscus debridement” for PEB adjudication.  At a physical therapy (PT) evaluation on 15 September 2006 (8 months prior to separation) the CI complained of 4/10 left knee pain severity.  The pain was described as dull, and was aggravated by climbing stairs, walking long distances, running or squatting; it was alleviated by rest.  Examination showed left knee flexion of 110 degrees after repetition (normal 140) and extension of 0 degrees after repetition (normal 0).  Gait was normal, but tenderness and painful motion were present.  The MEB NARSUM examination (8 months prior to separation) reported the left knee prevented running, rucking or road marching. The examiner rendered a diagnosis of left knee trochlear chondromalacia status post medial meniscus debridement.  An X-ray on 2 November 2006 showed mild degenerative changes in the left knee.  A repeat examination by PT on 8 February 2007 (4 months prior to separation) found left knee flexion of 120 degrees and extension 0 degrees, both after repetition.  The anterior cruciate ligament was intact.  At the MEB examination the CI reported that the knee prevented him from running long distances.  Examination showed painful motion.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the left knee pain condition 0%, coded analogously to 5003 (degenerative arthritis).  The VA rated the left knee pain condition 0% coded 5259 (cartilage, semilunar, removal of symptomatic), based on a VA C&P examination almost 2 years after separation, which was not probative to the time of separation.  There was no limitation of flexion or extension that supported a rating under the VASRD diagnostic codes for limitation of motion (5260 or 5261).  The examinations proximate to separation did not record 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) to support a rating under the respective codes.  There was no fracture, non-union, or malunion of the femur or tibia to support consideration under the respective codes for knee impairment related to long bone conditions (5255, 5262); however, there was evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45).  The 5259 code (cartilage, semilunar, removal of, symptomatic) was also applicable in this case, and provided an alternate route to a 10% rating.  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 pain condition, coded 5099-5003.

Chronic Right Shoulder Pain.  According to the MEB NARSUM, the left-handed CI’s right shoulder pain condition began in October 2002 after falling during physical training.  Radiographic imaging studies in 2006 showed an old, healed fracture of the clavicle and minimal tendinitis.  There was no surgical indication, and conservative treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “chronic right shoulder pain” for PEB adjudication.  At a PT evaluation 8 months prior to separation the CI complained of 7/10 right shoulder pain severity.  The pain was described as throbbing, and was aggravated by lifting; nothing alleviated the pain.  Examination showed right shoulder flexion of 150 degrees after repetition (normal 180) and abduction of 130 degrees after repetition (normal 180).  Painful motion and mild shoulder weakness were present.  The MEB NARSUM examination reported chronic right shoulder pain that was worse with overhead or lifting activities.  Physical examination showed right shoulder tenderness and painful motion, but no ligament laxity.  A repeat examination by PT 4 months prior to separation found right shoulder flexion of 135 degrees and extension 145 degrees, both after repetition.  Limitation of motion was due to pain.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic right shoulder pain condition 0%, coded analogously to 5003 (degenerative arthritis), citing the US Army Physical Disability Agency (USAPDA) pain policy.  The VA did not rate the right shoulder, finding it was not service-connected.  The VASRD §4.71a threshold for rating for range of motion impairment (code 5201, arm limitation of motion) is “at shoulder level” (approximately 90 degrees from the side), and the examinations in evidence demonstrated motion above this level; however, Board members agreed a 10% rating was justified with application of VASRD §4.59 (painful motion).  There was no malunion or recurrent dislocation of the humerus and no dislocation or nonunion of the clavicle or scapula to justify a higher rating under the 5202 (humerus, other impairment of) or 5203 (clavicle or scapula, impairment of) codes.  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 shoulder pain condition, coded 5099-5003.

BOARD FINDINGS:  In the matter of the right cubital tunnel condition and IAW VASRD §4.124a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the right carpal tunnel condition and IAW VASRD §4.124a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the left knee pain condition, the Board unanimously recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a.  In the matter of the chronic right shoulder pain 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.  

The Board recommends that the CI’s prior determination be modified as follows; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Right Cubital Tunnel Syndrome	8716	10%	
Right Carpal Tunnel Syndrome	8715	10%	
Left Knee Pain	5099-5003	10%	
Chronic Right Shoulder Pain	5099-5003	10%	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150302, 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

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXXXXXX, AR20170003445 (PD201500182)

1.  Under the authority of Title 10, United States Code, section 1554(a), I approve the enclosed recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) pertaining to the individual named in the subject line above to re-characterize the individual’s separation as a permanent disability retirement with the combined disability rating of 30% effective the date of the individual’s original medical separation for disability with severance pay.  

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:

	a.  Providing a correction to the individual’s separation document showing that the individual was separated by reason of permanent disability retirement effective the date of the original medical separation for disability with severance pay.

	b.  Providing orders showing that the individual was retired with permanent disability effective the date of the original medical separation for disability with severance pay.

	c.  Adjusting pay and allowances accordingly.  Pay and allowance adjustment will account for recoupment of severance pay, and payment of permanent retired pay at 30% effective the date of the original medical separation for disability with severance pay.

	d.  Affording the individual the opportunity to elect Survivor Benefit Plan (SBP) and medical TRICARE retiree options.

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:      
Enclosure
CF: 
(  ) DoD PDBR
(  ) DVA