RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00328
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20061029

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Signal Support Systems Specialist, medically separated for “chronic bilateral wrist pain” with a disability rating of 10%.  

CI CONTENTION:  “Please review all of my Veteran’s Affairs medical issues that were aggravated/initiated by military service.”  His 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 review of disability ratings assigned 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 or non-compensable.  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 determination 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 conditions at the time of separation.  The panel has neither the role nor the authority to compensate for progression or complications of service connected conditions after separation.  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 - 20060817	VARD - 20070709	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Bilateral Wrist Pain	5099-5003	10%	Right Wrist Pain	5024-5215	10%	20070426	
			Left Wrist Pain	5024-5215	10%		
Left Knee Patellofemoral Pain Syndrome	Not Unfitting	Patellofemoral Pain Syndrome, Left Knee	5260	10%		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  70%	

ANALYSIS SUMMARY:  

Chronic Bilateral Wrist Pain.  The PEB combined the bilateral wrist conditions as a single unfitting condition analogously coded 5099-5003 and rated 10%, with application of the USAPDA pain policy AR 635-40 B24.f.  This approach by the PEB not uncommonly reflected its judgment that the constellation of conditions was unfitting, and there was no need for separate fitness adjudications or implied adjudication that each condition was separately unfitting.  The panel also noted that “bundling,” the combining of two or more major joints, may be permissible under the VASRD 5003 rating requirements, and that this approach does not compromise the VASRD §4.7 directive to choose the higher of two valid ratings.  The panel’s initial charge in this case was therefore directed at determining if the PEB’s approach of combining conditions under a single rating was justified in lieu of separate ratings.  When considering a separate rating for each condition, the panel considers each bundled condition to be reasonably justified as separately unfitting unless a preponderance of evidence indicates the condition would not cause the member to be referred into the DES or be found unfit because of physical disability.  When the panel recommends separate fitness recommendations in this circumstance, its recommendations may not produce a lower combined rating than that of the PEB.  The evidence for the bilateral wrist conditions are presented, with attendant recommendations regarding separate unfitness, and separate rating if indicated.  

According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s left wrist condition (pain with weight-bearing) began insidiously in January 2003.  All clinical entries through September 2005 addressed the left wrist.  Right wrist pain began in January 2006.  Radiographic (X-ray) evaluations in January 2004 and January 2006; MRI in February 2004 and April 2006, and arthrogram in March 2004, showed no evidence of fracture, dislocation, arthritic, or inflammatory changes, nor evidence of muscle or tendon tears, ligament damage, or tenosynovitis.  A bone scan in May 2006 showed evidence of early degenerative changes of the left wrist (at the radiocarpal joint).  

At a 5 June 2006 orthopedic clinic visit, 5 months prior to separation, the physical examination showed tenderness of the radiocarpal joint, pain in the dorsal wrist (scaphoid area) with ulnar and radial deviation and no evidence of instability.  Left wrist range of motion (ROM) showed dorsiflexion of 60 degrees (normal 70), and palmar flexion of 70 degrees (normal 80).  Right wrist ROM showed dorsiflexion of 70 degrees, and palmar flexion of 80 degrees.  

At the June 2006 MEB examination (documented on DD Forms 2807-1 and 2808), 4 months before separation, the CI reported constant pain of the left wrist and intermittent pain of the right wrist that occurred with extension, daily chores, pushing, twisting, and driving.  The physical examination showed pain over the dorsal mid wrist (scapholunate area) that increased with flexion, left greater than right.  

At the 12 July 2006 MEB NARSUM examination, 4 months before separation, the CI reported pain and stiffness of the bilateral wrists (left greater than right), worsened with driving, washing, and lifting.  The physical examination showed tenderness at the dorsal wrist (left greater than right), pain-limited motion, and no effusion.  Left wrist ROM showed dorsiflexion of 25 degrees and palmar flexion of 40 degrees.  Right wrist ROM showed dorsiflexion of 50 degrees and palmar flexion of 35 degrees.  

At the 26 April 2007 VA Compensation and Pension (C&P) examination, 6 months after separation, the CI reported constant pain over the bilateral wrists, with flares that occurred 2 to 3 times per month, causing 6 hours of incapacitating pain.  Right and left wrist ROM showed dorsiflexion of 70 degrees and palmar flexion of 80 degrees.  Painful motion was present bilaterally after repetition with no further decrements in ROM.  No other abnormalities were noted.  

The panel directed attention to the rating recommendation based on the above evidence.  The PEB bundled the bilateral wrist condition and rated 10%, under analogous code 5099-5003 (degenerative arthritis), citing normal studies with abnormal bone scan, and the USAPDA pain policy.  The VA assigned a separate 10% rating for each wrist rating using the analogous code 5024-5215 (tenosynovitis; wrist, limitation of motion) citing functional limitations due to pain.  

The panel first considered if the left and right wrist pain, having been de-coupled from the combined PEB adjudication, each remained independently unfitting as established above.  In this case, both wrists were considered to fail retention standards; both were implicated by the NARSUM and the commander’s statement, and, both were profiled.  The CI was on a permanent profile with significant limitations that would have resulted from either condition alone.  All members agreed that the left and right wrist pain, as isolated conditions, would have each rendered the CI incapable of continued service for his MOS and accordingly merit separate service ratings.  

The panel considered the evidence for the painful motion of the bilateral wrists to support a disability rating of 10% for each wrist, analogously coded 5215-5003.  There was no evidence of ankylosis (5214) nor evidence of more significant limitations of motion at the wrist (5215) to support a higher rating.  There was no evidence of a “moderately severe” disability in extension of the wrist and fingers that would support a higher rating under 5308.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the left wrist and 10% for the right wrist conditions.  

Contended PEB Conditions:  Left Knee Patellofemoral Pain Syndrome.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended condition was not unfitting.  The contended condition was profiled; however, the condition was not implicated in the commander’s statement, and the PEB adjudicated the condition as not unfitting.  There was no performance-based evidence from the record that the condition significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the contended condition and so no additional disability rating is recommended.  

PANEL FINDINGS:  In the matter of the chronic bilateral wrist pain condition, the panel unanimously recommends separate disability ratings as follows:  10% for the right wrist and 10% for the left wrist conditions, coded 5215-5003 IAW VASRD §4.71a.  In the matter of the contended left knee patellofemoral pain syndrome condition, the panel unanimously recommends no change from the PEB determination as not unfitting.  There were no other conditions within the panel’s scope of review for consideration.  The panel recommends that the CI’s prior determination be modified as follows, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	RATING	
Left Wrist Degenerative Joint 	5215-5003	10%	
Right Wrist Degenerative Joint	5215-5003	10%	
RATING w/BLF	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150514, w/attachments
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, AR20170003456 (PD201500328)

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 20% 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