RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01554
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20020415

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Indirect Fire Infantryman, medically separated for “chronic pain, bilateral wrists and neck,” with a disability rating of 10%.

CI CONTENTION:  The CI requests review of all conditions.  A 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 - 20020313	VARD – N/A	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Pain, Bilateral Wrists and Neck	5099-5003	10%	No VA Examination in Evidence	
Chronic Right Medial Neuropathy at the Wrist	Not Unfitting		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  N/A	

ANALYSIS SUMMARY:  

Right Wrist Condition.  The PEB combined the right wrist, left wrist, and neck conditions as a single unfitting condition coded analogously to 5003 (arthritis, degenerative) and rated 10%.  The 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 right wrist, left wrist, and neck conditions are presented separately, with attendant recommendations regarding separate unfitness and rating in the rating discussion. 

According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the bilateral wrist pain began prior to entering the Army.  A nuclear medicine bone scan of hands and wrists was normal.  A 13 August 1999 bilateral upper extremity electrodiagnostic (EDX) study (electromyogram [EMG]/nerve conduction velocity [NCV]) revealed a very mild right wrist median nerve sensorimotor neuropathy (peripheral nerve irritation or injury).  A 6 January 2000 orthopedic surgery encounter noted 2 years of progressive right wrist pain with numbness and tingling in the index and middle fingers.  There was no improvement with steroid injections and wrist splints.  The history, examination, and EDX were consistent with right carpal tunnel syndrome ([CTS] median nerve compression in wrist carpal tunnel causing numbness and tingling of palm side of thumb and fingers [sparing little finger]).  

On 28 January 2000 the CI underwent a right carpal tunnel release.  There was no intraoperative findings of significant hyperemia (excess blood engorgement) or compression on the median nerve.  The 2 June 2000 orthopedic surgery right wrist examination revealed a well-healed incision with negative Phalen (wrist volar flexion compresses median nerve and elicits pain, tingling, and numbness in the hand and fingers) and Tinel (percussing volar carpal tunnel over median nerve elicits pain, tingling, and numbness in the hand and fingers) tests.  The 5 September 2000 physical medicine encounter revealed positive Phalen and Tinel tests.”  On 21 November 2000 occupational therapy (OT) measured range of motion (ROM).  Right wrist active dorsiflexion (extension) was 30 (70 normal), palmar flexion was 20 (80), radial deviation was 15 (20), and ulnar deviation was 15 (45) degrees.  At the 5 September 2001 orthopedic surgery follow-up, the CI complained of having trouble with gripping with pain radiating up into the arms.  Bilateral wrist active ROM was dorsiflexion was 45 (70), palmar flexion was 30 (80), radial deviation was 20 (20), and ulnar deviation was 20 (45) degrees.  

During the 7 December 2001 MEB examination (recorded on DD Forms 2807-1 and 2808), 4 months prior to separation the examiner documented normal grip strength and bilateral wrist tenderness with palpation and ROM.  The 4 February 2002 MEB NARSUM, 1 month before separation, recounted the history and interventions above.  The CI complained of bilateral, slight, constant, ventral surface, wrist pain.  He reported associated numbness and tingling in the 2nd, 3rd, and 4th fingers (median nerve distribution).  The CI “reports dropping objects with both hands if they are of any weight.”  The bilateral wrist examination documented the Phalen and median nerve compression tests were positive.  Strength, deep tendon reflexes (DTRs), and sensation were normal except for “light touch and pin prick which were slightly decreased from C4 down to T1 on the left.”  The examiner recounted the findings of the bone scan, X-rays, and EDX.  The diagnoses listed bilateral wrist pain (constant and slight) and chronic right wrist median neuropathy (constant and slight).  

The panel directed attention to its rating recommendation based on the above evidence.  As previously elaborated, the panel must first consider whether the right wrist condition remains separately unfitting, having been de-coupled from a combined PEB adjudication.  The PEB assigned a 10% rating under an analogous 5003 code (arthritis, degenerative) citing slight, constant, bilateral wrist pain, not requiring daily narcotic therapy, and rated IAW USAPDA pain policy.  There was no VA examination in evidence proximate to separation.  While the CI underwent a right carpal tunnel decompression, there was no ulna flail false joint for consideration under 5210 or significant loss of bone substance, marked deformity, nonunion, or malunion for consideration under 5211.  There was no impairment of supination or pronation for consideration under 5213.  Physical examinations, and radiographic imaging, did not demonstrate the characteristic anatomical deformities of wrist ankylosis, unfavorable palmar flexion, ulnar deviation, or radial deviation for consideration under 5214.  The limitation of motion in the proximate (OT and orthopedic surgery) examinations did not attain a minimum rating under 5215.  The panel carefully considered the option of rating both wrists separately, noting that the PEB rated both wrists together.  The panel majority agreed a 10% rating was supported based on VASRD §4.40 (functional loss) or §4.59 (painful motion).  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 right wrist condition, coded 5099-5003.  

Left Wrist Condition.  The left wrist medical analysis from the MEB NARSUM, DD FM 2808 and OT examinations is the same as above.  The OT measured left wrist active dorsiflexion was 35 (70), palmar flexion was 25 (80), radial deviation was 15 (20), and ulnar deviation was 20 (45) degrees.  At the orthopedic surgery follow-up, the CI complained of having trouble with gripping with pain radiating up into the arms.  There was no VA examination in evidence proximate to separation.

The panel directed attention to its rating recommendation based on the above evidence.  As previously elaborated, the panel must first consider whether the left wrist condition remains separately unfitting, having been de-coupled from a combined PEB adjudication.  The PEB assigned a 10% rating under an analogous 5003 code (arthritis, degenerative) citing slight, constant, bilateral wrist pain, not requiring daily narcotic therapy, and rated IAW USAPDA pain policy.  While the CI underwent a left carpal tunnel decompression, there was no ulna flail false joint for consideration under 5210 or significant loss of bone substance, marked deformity, nonunion, or malunion for consideration under 5211.  There was no impairment of supination or pronation for consideration under 5213.  Physical examinations, and radiographic imaging, did not demonstrate the characteristic anatomical deformities of wrist ankylosis, unfavorable palmar flexion, ulnar deviation, or radial deviation for consideration under 5214.  The limitation of motion in the proximate (OT and orthopedic surgery) examinations did not attain a minimum rating under 5215.  The panel agreed a 10% rating was supported based on VASRD §4.40 (functional loss) or §4.59 (painful motion). After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel majority recommends a disability rating of 10% for the left wrist condition, coded 5099-5003.  

Neck Condition.  According to STRs and the MEB NARSUM, the neck condition began approximately 1.5 years prior to referral for MEB.  The 5 September 2000 physical medicine neck examination documented full active ROM and a negative Spurling’s (assesses cervical nerve root compression by a herniated disc) test.  At the 5 September 2001 orthopedic surgery follow-up, the CI complained of upper back/neck symptoms.  The 30 October 2001 cervical spine X-rays were normal.  In the MEB NARSUM the CI reported a history of insidious onset of neck pain beginning in In November 2001.  He complained of intermittent and moderate neck pain which occurred daily.  The cervical spine ROM values were flexion of 50 (45), extension of 75 (45), and combined of 305 (340) degrees.  The cervical compression (assesses cervical nerve root compression by causing cervical radiculopathy) test increased the CI’s “symptoms” and the cervical distraction (assesses cervical nerve root compression by relieving cervical radiculopathy) test neither relieved nor increased the “symptoms.”  The Adson's (assesses for thoracic outlet syndrome accompanied by compression of subclavian artery) and Spurling’s tests were negative.  Strength, DTRs, and sensation were normal except for “light touch and pin prick which were slightly decreased from C4 down to T1 on the left.”  The examiner recounted the findings of the cervical spine X-rays.  The diagnoses listed chronic mechanical neck pain (intermittent and moderate).
The panel directed attention to its rating recommendation based on the above evidence.  As previously elaborated, the panel must first consider whether the neck condition remains separately unfitting, having been de-coupled from a combined PEB adjudication.  The PEB assigned a 10% rating under an analogous 5003 code (arthritis, degenerative) citing slight, constant, neck pain, not requiring daily narcotic therapy and rated IAW USAPDA pain policy.  The STR contained scant information regarding subjective neck complaints, or objective examination/imaging findings, until the MEB NARSUM.  The MEB NARSUM examiner stated the cervical compression increased the patient’s symptoms and “The pain is significantly debilitating in preventing the patient from doing his duty.”  The CI could not perform any physical exercise (push-ups or sit-ups) or wear his Kevlar. 

The ROM values in the MEB NARSUM examination were consistent with the 10% rating (flexion of greater than 30 degrees but not greater than 40 degrees; or a combined ROM of greater than 170 degrees but not greater than 335 degrees of the C-spine).  The higher 20% rating would require (flexion of greater than 15 degrees but not greater than 30 degrees; or a combined ROM of not greater than 170 degrees of the C-spine).  There was no evidence of tenderness, muscle spasm, abnormal spinal contour, or abnormal gait.  Other routes to a rating higher than the PEB’s 10% were considered, but there was no evidence of additional functional loss from repetitive use to warrant application of VASRD §4.45, and no evidence of incapacitating episodes that would justify a minimum rating under the alternative formula for rating intervertebral disc disease.  The panel agreed a 10% rating was supported based on VASRD §4.40 (functional loss) or §4.59 (painful motion).  The panel majority concluded that the evidence provided sufficient grounds for recommending a separate neck disability ratings in this case.  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 neck condition, coded 5237. 

Contended PEB Condition:  Chronic Right Medial Neuropathy.  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 not profiled, implicated in the commander’s statement nor judged to fail retention standards.  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.  

BOARD FINDINGS:  In the matter of the wrist condition and IAW VASRD §4.71a, the panel majority recommends a disability rating of 10% for the right wrist and 10% for the left wrist, coded 5099-5003 IAW VASRD §4.71a.  In the matter of the neck condition, the panel majority recommends a disability rating of 10%, coded 5237 IAW VASRD §4.71a.  In the matter of the contended chronic right medial neuropathy at the wrist condition, the panel unanimously agrees that it cannot recommend it for additional disability rating.  The single voter for dissent recommended no change and did not elect to submit a minority opinion.  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; 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	PERMANENT RATING	
Chronic Pain, Right Wrist	5099-5003	10%	
Chronic Pain, Left Wrist	5099-5003	10%	
Chronic Pain, Neck	5237	10%	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150622, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170008522, XXXXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXXXX:

	I accept the recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) to re-characterize your separation as a disability retirement with the combined disability rating of 30% effective the date of your medical separation for disability with severance pay.  Enclosed is a copy of the Board’s recommendation and record of proceedings for your information.

	The re-characterization of your separation as a disability retirement will result in an adjustment to your pay providing retirement pay from the date of your original medical separation minus the amount of severance pay you were previously paid at separation.
 
	The accepted DoD PDBR recommendation has been forwarded to the Army Physical Disability Agency for required correction of records and then to the U.S. Defense Finance and Accounting Service to make the necessary adjustment to your pay and allowances.  These agencies will provide you with official notification by mail as soon as the directed corrections have been made and will provide information on your retirement benefits.  Due to the large number of cases in process, please be advised that it may be several months before you receive notification that the corrections are completed and pay adjusted.  Inquiry concerning your correction of records should be addressed to the XXXXXXXXXXXXXXXXXXXXX.

	A copy of this decision has also been provided to the Department of Veterans Affairs.

Sincerely,					      
Enclosure