RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00723
BRANCH OF SERVICE:  Army 	
DATE PLACED ON TDRL:  19990428	
DATE REMOVED FROM TDRL:  20040316

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E2, Basic Trainee, medically separated from the Temporary Disability Retired List (TDRL) for “mixed sensori-motor peripheral neuropathy due to frost bite,” with a disability rating of 10%.

CI CONTENTION:  “Review 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 – 19990113/20040303	VARD - 20010226	
Condition	Code	Rating	Condition	Code	Rating
Proximate	
		TDRL
Placement	TDRL Removal			TDRL
Placement	TDRL
Removal	
Demyelinating Peripheral Neuropathy	8199-8105	30%	--	Residuals, Frostbite, R Hand	7122	10%	--	
				Residuals, Frostbite, L Hand	7122	10%	--	
Mixed Sensori-Motor Peripheral Neuropathy due to Frost Bite		--	10%	Residuals, Frostbite, R Foot	7122	10%	--	
				Residuals, Frostbite, L Foot	7122	10%	--	
COMBINED RATING:  30% → 10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:

Mixed Sensori-Motor Peripheral Neuropathy due to Frost Bite.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI developed loss of sensation to his fingers and toes due to a cold weather injury (cold weather injury) or frostbite while in the field from 4 to 6 December 1997.  He was exposed to sub-zero temperatures while both his hands and feet became wet.  He was evaluated in occupational therapy (OT) on 15 December 1997 and noted to have a lack of protective sensation of all the fingertips.  He was also noted to have a waxy/wooden appearance of all fingertips with splinter hemorrhage.  The index fingertips were blackened.  This was thought to be consistent with a CWI.  He began treatment in OT with gradual improvement in function, but had persistent pain and sensory loss.  He was evaluated in neurology on 22 June 1998 and reported continued fingertip numbness and loss of dexterity.  On examination, he was noted to have a distal (towards the fingers and toes; proximal would be towards the shoulder and hips) weakness, greater in both upper extremities (BUE) than both lower extremities (BLE).  He was also noted to have a distal sensory loss.  The addition of a medication for pain was recommended and electrodiagnostic testing (EDX) was scheduled for 8 July 1998.  This confirmed the sensory loss which was noted to be greater for BLE than BUE (different than recorded for the motor examination 3 weeks earlier).  Due to persistent symptoms, the CI was formally removed from training and referred for an MEB for the CWI.  The MEB forwarded “demyelinating peripheral polyneuropathy” for PEB adjudication.

The MEB NARSUM examination was dated 13 August 1998, 9 months prior to separation.  It noted initial improvement in his function and symptoms, but persistent pain in the fingers with hard gripping and a decrease in fine motor skills.  He also reported mild to moderate discomfort of his feet which was relieved by rest.  Significant further improvement was not anticipated.  At the MEB examination (recorded on Special Forms 93 and 88) dated 6 January 1999, 4 months prior to TDRL placement, the CI reported ongoing pain aggravated by activity.  Physical examination revealed fingers and toes that were cool with a slight decrease in sensation.  There was a reduced rapid movement of the fingers as well as strength bilaterally (4/5).  There was no VA Compensation and Pension evaluation performed.  The VA utilized the CI’s STR.

The Board first directed attention to its rating recommendation at TDRL placement based on the above evidence.  The PEB rated the demyelinating peripheral neuropathy 30% at TDRL placement, analogously coded 8199-8105 (Sydenham’s chorea at a moderate level of impairment), citing confirmed electrodiagnostically.  The VA rated each hand and foot frostbite condition 10%, coded 7122 (cold injury residuals), based on the STR.

The Board first considered analogous code 8199-8105 Sydenham’s chorea, which is a post-infectious neurological complication manifested by abnormal movements.  The CI had tissue changes at presentation; however, these changes resolved by TDRL placement.  Board members agreed that code 7122 was the most appropriate code for rating the CI’s CWI residuals.  A rating for each extremity at the 10% level of impairment is supported for pain, numbness, and cold sensitivity.  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 each hand and foot, coded 7122 at TDRL placement.

The Board next considered its rating recommendation at the time of removal from TDRL.  The PEB rated mixed sensori-motor peripheral neuropathy due to frost bite 10%, also analogously coded 8199-8105, citing reduced rating for non-compliance.  There was no VA rating at TDRL removal.

The VA Compensation and Pension (C&P) CWI evaluation was performed on 6 September 2000, 16 months after TDRL placement and 42 months prior to TDRL removal.  The CI reported no current treatment, but ongoing pain and tingling in the tips of the fingers and numbness after exposure to cold weather.  Raynaud’s phenomenon (a vascular complication) was reported with cold exposure; this had not been previously documented.  Physical examination of the extremities was normal other than being cool to the touch.  Pinprick and light touch were reduced, but the neurological examination was normal and atrophy was absent.  The VA continued the previous 10% rating for each extremity due to the CWI.  No further VA examinations or ratings for the CWI were in evidence.

On 11 December 2002, repeat EDX studies were performed.  The CI reported decreased fine motor control due to pain and paresthesias (abnormal sensations).  Physical examination revealed normal BUE and BLE strength and reflexes.  Sensation showed a slightly reduced pinprick for the hands; no sensory loss for the feet was recorded.  Repeat EDX testing was only for the left side, but showed some improvement from the 1998 study, but remained abnormal.  He was thought to have a chronic pain problem and intensive pain management was recommended.  The CI was continued on TDRL.  His medications were changed.

The TDRL MEB NARSUM examination on 22 January 2004, 2 months prior to TDRL removal, noted complaints of right greater than left pain in the fingers and numbness on the left.  He had trouble with fine motor control such as writing.  He reported ongoing pain in the feet.  He woke from pain about 3 times a week.  He had discontinued the medications given to him in the pain clinic and only took these sporadically.  In addition, he periodically used an over the counter pain medication (such as aspirin).  He was a student, worked full time in customer service for a health insurance company, and went to the gym 3 times a week.  Raynaud’s phenomenon was not recorded.  Physical examination revealed reduced strength in the hands and fingers to 4+/5 (near normal).  Atrophy was absent and the muscle bulk and tone were normal.  Sensation was reduced distally in BUE and BLE.  The reflexes were reduced, but symmetric.  The skin remained normal to examination.  EDX studies were performed on the more symptomatic right side and remained abnormal.  It was thought that these would never return to normal.  Again, he was thought to primarily have a pain problem.  The management was complicated by non-compliance with recommended treatment.

Board members agreed the CI continued to report pain of all four extremities and demonstrated sensory loss of all four as well.  Motor loss of the fingers and wrists was also shown, albeit slight (4+/5).  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 each hand and foot, coded 7122 at TDRL removal.

BOARD FINDINGS:  In the matter of mixed sensori-motor peripheral neuropathy due to frost bite, the Board unanimously recommends a disability rating of 10% for each hand and foot at the time of placement and removal from TDRL and permanent disability disposition, coded 7122 IAW VASRD §4.104.  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	RATING	
		TDRL	PERMANENT	
Residuals Right Hand Frostbite	7122	10%	10%	
Residuals Left Hand Frostbite	7122	10%	10%	
Residuals Right Foot Frostbite	7122	10%	10%	
Residuals left Foot Frostbite	7122	10%	10%	
COMBINED w/BLF	40%	40%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150602, 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 AR20170000258 (PD201500723)

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 place the individual on the Temporary Disability Retired List (TDRL) at 40% rather than 30% disability rating for the period April 28, 1999 to March 15, 2004 and then following this period recharacterize the individual’s separation as a permanent disability retirement with the combined disability rating of 40%. Under the authority of Title 10,

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 temporary disability 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 day following the six month TDRL period.

      c.  Adjusting pay and allowances accordingly.  Pay and allowance adjustment will account for recoupment of severance pay, provide 40% retired pay for the constructive temporary disability retired period effective the date of the individual’s original medical separation and then payment of permanent disability retired pay at 40% effective the day following the constructive TDRL period.  

      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:

CF: 
(  ) DoD PDBR
(  ) DVA