RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	      CASE:  PD-2015-00270
BRANCH OF SERVICE:  Army                                                                  SEPARATION DATE:  20030216 

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4, Medical Specialist, medically separated for “….left (non-dominant) thumb…” with a disability rating of 0%.  

CI CONTENTION:   “The Department of Veteran Affairs gave me a rating of a combined total of 60%.”  The CI’s complete submission is at Exhibit A.

SCOPE OF REVIEW:  The panel’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 panel’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 panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The panel’s assessment of the PEB rating determinations is based on 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 panel 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 panel 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 - 20021230	VARD - 20030306	
Condition	Code	Rating	Condition	Code	Rating	Exam	
…Left (Non-Dominant) Thumb…	5228	0%	Surgical Residuals, Left Thumb	5299-5224	10%	20021125	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:    

Left Thumb Pain.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI injured his left (non-dominant) wrist and thumb in 1993 (6 years prior to enlistment).  He underwent several surgeries that resulted in an arthrodesis (fusion) of the carpometacarpal (CMC) joint (the union of the metacarpal bone of the thumb with the trapezium bone of the wrist, contributing to the motion and flexibility of the thumb).  Soon after enlistment he reported an inability to do push-ups and was granted a P2 profile.  The pain and limitations worsened during service as noted in STR clinical entries of non-specific limitation of range of motion (ROM) and painful motion.  There was X-ray confirmation of an intact CMC fusion and mild degenerative changes.  

The 12 September 2002 NARSUM examination, 5 months before separation, documented that the condition had “deteriorated” since enlistment, but did not characterize the pain; and, noted the profile limitations to physical fitness testing along with an inability “to perform his duties as an Infantry medic.”  The physical examination (PE) recorded crepitus with motion (without mention of pain) and listed thumb joint ROM measurements that indicated some limitations, but were not applicable to VASRD rating.  Upon PEB request, the MEB orthopedist provided examination findings applicable to VASRD rating criteria as elaborated below.  The examiner stated, “Able to oppose thumb and all digits.  No gap.”  

A 25 November 2002 VA Compensation and Pension (C&P) examination, 4 months after separation, documented “complains of constant pain in the left hand and wrist with inability to do pushups, grip or lift.”  The PE recorded, “The left thumb is fused.  However, the veteran is able to do finger opposition and has strong [5/5] digital musculoskeletal strength of all fingers ... and there is a strong and equal bilateral grasp.”  Specific ROM measurements were listed that documented 0% motion at the CMC and moderate limitations at all other thumb joints (again, not constituting VASRD-ratable criteria).

The panel directed attention to its rating recommendation based on the above evidence.  The PEB’s 0% rating was under code 5228 (thumb, limitation of motion) citing “able to oppose all fingers ... no gap between fingers and thumbs.”  The 0% (minor and major) rating criteria of code 5228 are “with a gap of less than one inch (2.5 cm.) between the thumb pad and the fingers, with the thumb attempting to oppose the fingers.”  The higher ratings are premised on the degree of measured gaps when present.  The VA rated under code 5299-5224 (analogous to ankylosis of the thumb) and opined that the C&P evidence satisfied the 10% criterion (minor and major) of favorable ankylosis (unfavorable ankylosis confers 20%).  Members noted that the PEB code and rating were quite specific for the condition and accurately matched the evidence with the rating language.  Conversely the VA rating for favorable ankylosis was subject to challenge in that ankylosis was confined to the CMC articulation only, not to the entire joint.  Members ultimately agreed that code 5228 was specifically aligned with the clinical features of this case and the analogous application of code 5224 or any alternate code was not sufficiently justified by VASRD §4.20 (analogous ratings). The applicable code 5228 provides explicit criteria for which the minimum 10% rating was not satisfied by unequivocal evidence.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded that there was insufficient cause to recommend a change in the PEB adjudication of the left thumb condition.

PANEL FINDINGS:  In the matter of the left thumb condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  There were no other conditions within the panel’s scope of review for consideration.  The panel, 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 20150413, 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

10 Apr 2017

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for 
XXXXXXXXXXXXXXXXXX, AR20170004772 (PD-2015-00270)

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