RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00528
BRANCH OF SERVICE: Army 	SEPARATION DATE:  20030813

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Paralegal Specialist, medically separated for “heat injury” and “pain right wrist,”  rated 0% and 0%, respectively, with a combined disability rating of 0%. 

CI CONTENTION:  The CI’s condition continues to worsen and affect daily activities. His 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 - 20030522	VARD - 20041015	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Heat Injury	7999-7900	0%	Heat Injuries	8999-8911	NSC	STR	
Pain Right Wrist	5099-5003	0%	Fracture, Right Wrist Arm	5201-5215	NSC	STR	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  NSC	

ANALYSIS SUMMARY:  

Heat Injury.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI suffered his first heat injury approximately 3 years prior to referral for an MEB.  The anterior hypothalamus (preoptic nucleus) carefully maintains a core temperature of 98.6°F ± 1.8°F.  During exercise, multiple mechanisms (evaporation, radiation, convection, and conduction) act to dissipate excess heat generated by skeletal muscle.  On 21 May 2001, during a division run the CI developed low back pain at 2 miles.  At the 4-mile mark, he developed marked confusion and passed out.  The CI was taken to the first aid station and his body core temperature was 105.3°F.  He was treated with cooling and intravenous (IV) fluids.  Labs revealed biomarkers of muscle injury (elevated creatine kinase) associated with rhabdomyolysis (syndrome of muscle necrosis and release of intracellular muscle constituents) and hepatic injury (elevated transaminases).  The CI was diagnosed with heat stroke (exertional heat illness with hyperthermia, end organ [kidney/liver/muscle] damage, and significant neurologic manifestations).  A 25 March 2002 specialty care consult for the MEB reported the second heat injury episode occurred in August 2001 following a 4-mile road march with ruck sack.  The CI completed the march without difficulty but experienced profuse sweating, dizziness, and nausea.  He was taken to the aid station for IV hydration and was diagnosed with heat exhaustion (exertional heat illness with hyperthermia and without end organ [kidney/liver/muscle] damage or significant neurologic manifestations).  The third episode of heat injury occurred in November 2001 following a 20-kilometer ruck march.  The CI experienced dizziness and fatigue, required IV hydration, and was diagnosed with heat exhaustion.  The 24 April 2003 NARSUM, 4 months before separation, recounted the history of heat injuries (heat stroke x1 and heat exhaustion x2) and interventions.  The CI reported that if he did any physical training, he felt very lightheaded and got nauseous.  He denied any use of herbal supplements, ephedra, medications, or alcohol the day before any of these heat injuries.  The CI reported he had hydrated well before these episodes.  He was never hospitalized overnight for his heat injuries and took no medications.  The examiner recounted the lab findings from the date of the heat stroke.  The diagnosis listed heat stroke.  The examiner documented, “Sgt. Cochran has had one episode of heat stroke.  He is now symptomatic with any physical training.  His condition will not improve.  It is difficult to predict if he will have another episode.  Exposure to elevated temperatures and work in hot or even warm weather may cause another episode that could possibly lead to serious sequelae and might be fatal.  This may be true for the rest of his life.”

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 0% rating under an analogous 7900 code (hyperthyroidism) citing heat injury with no residuals and no evidence of residual enzyme elevations.  The VA chose an analogous 8911 code (epilepsy, petit mal) but did not service connect the heat injuries based on unavailability of service medical records, and noting the CI failed to report for the scheduled VA C&P examination.  There was no tachycardia, which may be intermittent, and tremor, or continuous medication required for control consistent with the 10% rating under 7900.  There was no confirmed diagnosis of epilepsy with a history of seizures consistent with the 10% rating under 8911.  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 heat injury condition.  

Right Wrist Pain.  According to STRs and the MEB NARSUM, the right-hand dominant CI sustained a right wrist injury with a fall on an outstretched hand while doing pugil stick training on 28 March 2002.  A 28 March 2008 left wrist X-ray revealed a comminuted (multiple fragments or splinters) distal radial intra-articular fracture.  On 4 April 2002 the CI underwent right distal radius fracture closed reduction and percutaneous pinning.  A 15 April 2002 left wrist computed tomography study revealed a lower radial articular surface step-off and fracture fragments diastasis (separation of normally joined parts).  Because there was inadequate reduction and persistent comminution, on 18 April 2002 the CI underwent a right distal radius fracture open reduction internal fixation (ORIF).  Post-operative right wrist X-rays showed malleable plate, screw, and K-wire fixation across a distal radial fracture with grossly anatomic alignments.  On 9 July 2002 occupational therapy (OT) measured left wrist active range of motion (ROM) as dorsiflexion of 50 (70 normal), palmar flexion of 30 (80), ulnar deviation of 5 (45), and radial deviation of 10 (20) degrees.  Left forearm active ROM was supination of 80 (85) and pronation of 85 (80) degrees.  On 15 November 2002 left wrist active ROM measured by OT was dorsiflexion of 55 (70), palmar flexion of 60 (80), ulnar deviation of 20 (45), and radial deviation of 10 (20) degrees.  Left forearm active ROM was supination of 60 (85) and pronation of 80 (80) degrees.  The 18 April 2003 MEB examination (documented on DD Forms 2807-1 and 2808) noted decreased ROM and a 3-inch surgical scar to the palmar side of the right wrist.  The NARSUM recounted the history and interventions.  The CI complained of persistent right wrist pain and inability for complete utilization or ROM.  Under physical examination, the author documented, “General physical examination … on 24 April 2003 was remarkable for decreased [ROM] of his right wrist.”  The author cited the right wrist ROM performed by OT on 15 November 2002.  The diagnosis listed right wrist decreased ROM.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 0% rating under an analogous 5003 code (arthritis, degenerative) citing right wrist pain after fracture, no pain medication noted, decreased ROM which does not rise to a ratable level in the VASRD.  The VA did not service connect the right wrist injury under the 5201-5215 codes (arm, limitation of motion of-wrist, limitation of motion of) based on unavailability of service medical records and noting the CI failed to report for the scheduled VA C&P examination.  While the CI underwent a right distal radius fracture ORIF, there was no radius or ulna flail false joint (5210), significant loss of bone substance, marked deformity, nonunion, or malunion (5211 and 5212), or impairment of supination or pronation (5213) for consideration under the respective codes.  Physical examinations, and diagnostic imaging, did not demonstrate the characteristic anatomical deformities of wrist ankylosis, unfavorable palmar flexion, ulnar deviation, or radial deviation (5214) for consideration under the respective code.  The limitation of motion (5215) in the proximate examinations did not attain a minimum rating.  The Board agreed there was evidence of painful motion with functional loss supporting a 10% rating (based on §4.40, §4.45, and §4.59).  

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, coded 5099-5003.  

BOARD FINDINGS:  In the matter of the heat injury condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  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.  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	
Heat Injury	7999-7900	0%	
Pain Right Wrist …	5099-5003	10%	
COMBINED RATING	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150601, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB										

MEMORANDUM FOR Commander

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXXXXXX, AR20160018745 (PD201500528)

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