RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00266
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20090427

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Infantryman, medically separated for “right (dominant) wrist pain and stiffness secondary to non-union of a scaphoid fracture resulting in “arthritis,” and “low back pain,” rated 10% each, with a combined disability rating of 20%.

CI CONTENTION:  His conditions continue to worsen and impact his daily life.  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 – 20090113	VARD - 20090723	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right (Dominant) Wrist Pain and Stiffness Secondary to Non-Union of a Scaphoid Fracture Resulting in Arthritis	5099-5003	10%	Status Post Surgery of Fracture Right Scaphoid Bone with Limitation of Motion, Pain and Scarring	5299-5215	10%	20090622	
Low Back Pain	5237	10%	Intervertebral Disc Syndrome 	5242	20%		
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Right (Dominant) Wrist Pain and Stiffness Secondary to Non-Union of a Scaphoid Fracture Resulting in Arthritis.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the right hand dominant CI first injured his right wrist at age 15.  He apparently did well until he reinjured it in February 2006 during basic training.  X-rays showed an old non-healed fracture of one of the wrist bones (navicular).  This was treated initially with a cast and then surgically with a bone graft in October 2006.  The non-union persisted (these records are not in evidence).  Surgical revision was then done on 11 July 2007.  This was complicated by loose hardware (a screw backed out) as was noted on 17 September 2007.  This was apparently removed although these records are not in evidence either.  X-rays on 13 November 2007 showed a persistent fracture line.  Repeat X-rays on 17 January 2008 noted good alignment and post-operative changes.  An orthopedic follow-up on 25 February 2008 recorded that the X-rays showed a healed navicular bone (AKA scaphoid) and early signs of arthritis.  The range of motion (ROM) was limited to about 16% of the left side in flexion and extension.  Formal ROM measurements were obtained in occupational therapy (OT) for the MEB process on 17 September 2008 and are charted below.  The ROM was limited by pain and did not change with repetition.  The MEB forwarded right wrist pain for PEB adjudication.  

At the MEB NARSUM examination dated 14 October 2008, 5 months prior to separation, the CI reported pain and limitations with activity.  The examiner noted tenderness over the wrist and decreased ROM.  The OT measurements (below) were cited.  

At the VA Compensation and Pension (C&P) general evaluation performed on 22 June 2009, 2 months after separation, the CI reported continuous pain and limited ROM.  He denied the use of a splint, swelling, or warmth.  The pain was aggravated by activity.  He was on disability for his wrist and back (below) from the state and was not working.  On examination, the scar was well healed and non-tender.  Motion was mechanically limited, but pain free.  The examination of the wrist was otherwise unremarkable.  Motor function and sensation were intact.  

The ROM examinations 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)	Orthopedics ~ 14 Mo. Pre-Sep 	MEB ~7 Mo. Pre-Sep	VA C&P ~2 Mo. Post-Sep	
Dorsiflexion (70 Normal)	11 (16% of left)	25	30	
Palmar Flexion (80)	13 (16% of left)	30	40	
Ulnar Deviation (45)	---	20	25	
Radial Deviation (20)	---	2	5	
Comment	5 months after final surgery	12 months after final surgery.  Painful motion	21 months after final surgery	
§4.71a Rating	10%	10%	10%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the right wrist condition 10%, coded 5099-5003 (analogous to degenerative arthritis), noting that the limitation in motion was non-compensable.  However, loss of function and painful motion supported a 10% rating IAW §4.10 (functional impairment), 4.40 (functional loss), 4.45 (the joints), and 4.59 (painful motion).  The VA also rated the wrist 10%, coded 5299-5215 (analogous to limitation in motion of the wrist) citing loss of function.  The Board found no route to a higher rating.  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 wrist condition.

Low Back Pain.  According to STR and the MEB NARSUM, the first record in evidence for low back pain (LBP) is a primary care note dated 26 October 2007, in which the CI reported aggravation of LBP for which he had first been seen 6 months earlier (this record is not in evidence).  The CI was referred to physical therapy (PT).  An X-ray dated 16 November 2007 showed degenerative disc disease (DDD) at multiple levels.  This was confirmed on an MRI 10 days later which also noted that the “spinal canal and neural foramina are patent in all visualized levels.”  The next record is an orthopedic evaluation on 13 March 2008.  He reported that he injured his back while lifting a “water buffalo” and noted abnormal sensations in both legs, as well as persistent pain.  He expected to separate from the military in 10 months.  He took no particular medications for his pain.  The gait was normal and neurological abnormalities were not recorded.  He could forward flex to 12-16 inches from the floor (about near normal).  On X-ray, DDD was again noted as well as suspicion of an old wedge compression fracture at L1.  This had not been noted on prior imaging.  He was referred to pain management and seen on 29 April 2008.  He was noted to have a painful gait and limited lumbar flexion and extension (not thoracolumbar).  Motor function was normal.  Reflexes were symmetric.  Increased sensation was present over the left thigh.  The CI was then seen in PT on 2 September 2008 for ROM measurements as charted below.  Pain was reported in some planes.  The MEB also forwarded LBP for PEB adjudication.  

At the MEB NARSUM examination, the CI reported that he could only walk about 50 feet before the development of pain.  He noted the onset of pain after hooking up a “water buffalo” to a truck during basic training.  He reported that PT had made the pain worse.  The examiner referenced the DD Form 2808 Report of Medical Examination, dated 18 August 2008, which recorded “low back pain” and a normal neurological examination.  The CI was noted to be 70.5 inches tall and to weigh 255 pounds.  

At the VA C&P evaluation, the CI reported that the LBP initially improved with treatment, but later worsened.  He denied the use of an assistive device, neurological deficit, or incapacitation.  He did endorse pain radiating to his thighs when sitting, but not standing or walking.  On examination, he was noted to weigh 272 pounds.  He rose slowly from the waiting room chair, but had a symmetric gait without the use of an assistive device.  The use of his arms to get up from a chair was not recorded.  No comment was made on difficulty getting on and off the examination table.  Neither tenderness nor spasm were present.  The ROM was reduced and painful as charted below.  The neurological examination was normal.  There were no further entries in the record regarding the back condition until a VA C&P examination on 16 July 2015, remote from separation.  It noted that the CI was not currently being treated for his back condition and that he did not do stretching or PT.  Flexion was reduced to 70 degrees and extension to 20 degrees.  The ROM was otherwise normal as was the neurological examination.  No comment was made on gait, but it was observed that there was no impact on his ability to work.  The ROM examinations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.  

Thoracolumbar ROM
(Degrees)	PT/MEB ~8 Mos. Pre-Sep	VA ~2 Mos. Post-Sep	
Flexion (90 Normal)	80	40	
Combined (240)	220	175	
Comments	ROM limited by pain/ tenderness & spasms present/ normal gait and contour	ROM limited by pain/ no tenderness or spasm/ normal gait and contour	
§4.71a Rating	10%	20%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition at 10%, coded 5237 (lumbosacral strain), citing limitation in motion.  The VA rated the back at 20%, coded 5242 (degenerative arthritis of the spine), citing the limitation in motion noted on the VA C&P examination.  The Board noted that this examination supported a 20% rating and was also the closest examination to separation.  It considered then the probative value of this examination given the totality of the evidence.  The Board noted that there were three clinical visits in evidence for the back condition other than evaluations for the MEB and VA.  The last of these was 12 months prior to separation.  The ROM recorded prior to separation was normal or near normal with the exception of the ROM noted by the pain specialist.  This was limited to the lumbar spine though and does not accurately reflect full thoracolumbar motion.  The VA noted limited flexion secondary to pain.  The limitation is an outlier from prior examinations and greater than would be expected from the objective pathology on imaging.  No recent aggravation was documented.  The gait was normal and neither tenderness nor spasm were present.  An examination remote from separation recorded significantly improved motion without documentation of intervening treatment; in fact, it was noted that the CI was not actively being treated for the back.  Finally, prior to separation, it was noted that the CI took no particular medications for the back.  This is also not typical for someone with pain which causes significant limitation in motion such as documented on the VA examination.  In consideration of the totality of evidence, the Board assigned a higher probative value to the MEB NARSUM examination for rating purposes.  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 back condition.  

BOARD FINDINGS:  In the matter of the right wrist condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the low back 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 20140304, 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

06 MAR 2017

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for 
XXXXXXXXXXXXXXXXXX, AR20170002583 (PD201500266)

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