RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01581
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20090204

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Trainee, medically separated for “left (non-dominant) long finger, limitation of motion” and “ring and small fingers limitation of motion,” rated 0% each, with a combined disability rating of 0%.

CI CONTENTION:  The CI requested review of all conditions.   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 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 condition(s) 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 - 20081217	VARD - 20090916	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left (Non-Dominant) Long Finger, Limitation of Motion	5229	0%	Torn Volar Plate with Lost Function of Three Fingers, Left Hand	5229	0%	STR	
Ring and Small Fingers Limitation of Motion	5230	0%					
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Left (Non-Dominant) Long Finger, Limitation of Motion.  According to the service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s left long finger condition (she is right-hand dominant) began in 16 June 2008 after falling on her left hand, hyperextending the left 3-5th metacarpophalangeal joints (MPJ.)  There was stiffness, swelling and pain.  X-rays of the left hand showed no fractures, dislocations or bony lesions.  Severe pain and swelling of the left hand persisted despite conservative treatment.  She was referred to Orthopedics who referred her to the Hand Surgeon for further assessment.  The CI was diagnosed with a torn volar plate of all three metacarpophalangeal (MCPs) (3-5) and indicated no surgery could be done and stiffness was permanent.  She reported she was unable to grip, do push-ups or move her digits.  The injury occurred in the second week of training but she was not pulled from training until the seventh week.  On 27 October 2008 she was seen in the emergency room (ER) for pain and swelling.  On 17 November 2008 magnetic resonance imaging (MRI), showed inflammation of one of the flexor tendon of the third digit.  She was referred for more rehabilitation.  

At the 21 October 2008 MEB examination (recorded on DD Forms 2807-1 and 2808), 4 months prior to separation, the CI reported injury to her left hand during training.  She was taking a narcotic-like pain medication (tramadol) and an over the counter medication.  The examiner noted the CI was being discharged with a left hand fracture but review of x-rays were all negative for fracture.  

The 20 November 2008 MEB NARSUM examination, 3 months prior to separation, noted complaints of left long finger MCP stiffness and pain.  Physical examination showed skin was intact on the left hand.  She had mild swelling about the long finger MPJ.  It was mildly tender with increased pain with attempted forced flexion or extension.  Sensation was intact.  Proximal and distal interphalangeal joints were normal and had normal range of motion (ROM.).  The left long finger MCP range of motion (ROM) was 0-35 degrees (normal 100) with pain on attempted flexion past that point.  She did not hyperextend.  Grip strength was measured in 3 different positions using a handgrip strength monitor.  It was decreased in all 3 positions by greater than 50% relative to the grip strength for the right hand.  A diagnosis of left long finger MCP pain and stiffness was rendered, occurring in the line of duty and service aggravated.  The examiner noted she needed continued therapy and may need surgery in the future.  Joint motion had slightly increased in the last 2 months but not to the point she could perform Soldier in training duties.  He opined there would be slight improvement with time and therapy.  The CI met criteria for Regulations which stated contracture of joints with marked loss of function and not remediable by surgery and conditions individually or in combination result in interference of satisfactory performance of duty.  She was not able to complete basic training due to her injury.  There was no VA Compensation and Pension (C&P) evaluation in evidence proximate to separation.   

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left finger limitation of motion condition 0%, coded 5229 (index or long finger, limitation of motion), citing gap of less than one inch between fingertip and palm.  The VA also rated the left finger condition 0% coded 5229 (index or long finger, limitation of motion), based on the STR, citing limitation of motion that did not show evidence warranting a compensable evaluation.  The VA did note the presence of a hand injury with a loss of function of the long finger.  

MRI showed a torn volar plate of the third MCP.  Examination showed swelling of the third digit with pain on flexion and extension.  The examination had shown both active and passive motion of all three joints of the fingers.  Grip strength of the left hand was reduced greater than 50% in three different positions as compared to the right hand.  She required continued treatment with a possible need for surgery in the future.  The panel noted that the 5229 code used by the PEB captured the disability in evidence.  There was no limitation of flexion or extension that supported a rating under the VASRD diagnostic codes for limitation of motion (5229).  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 for the long finger condition.  

Ring and Small Finger Limitation of Motion.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s ring and small finger condition began in June 2008 after falling.  She had mild swelling about the ring and small finger MCP joints, which were tender and showed increased pain with forced flexion or extension.  Sensation and vascular supply were intact.  Neuroimaging showed a partial to almost complete tear of the flexor digitorum profundus tendon of the fifth digit and a partial tear of the extensor digit.  

The 20 November 2008 MEB NARSUM examination noted complaints of stiffness and pain.  She was unable to grip a weapon, do push-ups, or grip other objects.  Physical examination showed her ring finger was the stiffest with ROM from 0 to 22 degrees.  Small finger ROM was 0 to 50 degrees (normal 100).  She had mechanical blocks to flexion and there was pain with forced flexion.  Grip strength of the left hand was as described above.  She occasionally took narcotic-like medication and over the counter medication.  Physical examination noted mild swelling about the long, ring and small finger MCP, all of which were mildly tender and had increased pain with forced flexion or extension.  Sensation and vascular supply was normal.  Proximal and distal interphalangeal joints were normal with a normal ROM.  The MCP of her long, ring and small finger were stiff with mechanical blocks to flexion.  ROM of the left long finger MCP was flexion to 35 degrees active and passive.  There was pain with attempted flexion past that point.  The ring finger was the stiffest with ROM to 22 (normal 100) degrees of active ROM and the small finger had a ROM to 52 degrees.  There was pain with any attempted forced flexion.  Grip strength was measured with a Jamar handgrip strength monitor in three different positions.  The grip strength was less than 50% of that of the right hand in all three positions.  There were no pertinent findings about the wrist. 

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the ring and small finger limitation of motion condition 0%, coded 5230 (ring or little finger, limitation of motion).  The VA also rated the ring and small finger condition 0% coded 5229 (index or long finger, limitation of motion), based on the STR, citing limitation of motion that did not show evidence warranting a compensable evaluation.   

The PEB combined the ring and small finger conditions into a single unfitting condition characterized as: “Ring and Small Fingers Limitation of Motion”, coded 5230 (any limitation of motion rated at 0%)  In this case, the ring and small finger were considered to fail retention standards; and both were implicated by the NARSUM.  Neither was profiled (left hand fracture was profiled) Members agreed therefore that both the ring and the small finger should be conceded as reasonably separately unfitting.  

The fingers had neuroimaging evidence of a tear of the volar plate at the 3rd-5th MCP with limitation of motion.  The panel noted that the 5230 code used by the PEB captured the disability in evidence.  The examination had shown both active and passive motion of all three joints of the fingers.  Both were reduced, but motion was present and had been on previous examinations.  The panel considered the evidence and found no better coding option than the 5230 code used by the PEB.  Under this code, a 0% rating is the highest rating possible.  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 for the ring and small finger limitation of motion condition.  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 for the ring and small finger condition.  

BOARD FINDINGS:  In the matter of the long finger condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the ring and small finger condition and IAW VASRD §4.71a, the panel 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 20150622, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170008543, XXXXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found your separation disability rating and your separation from the Army for disability with severance pay to be accurate.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed), and I accept its recommendation.  I regret to inform you that your application to the DoD PDBR is denied.  

	This decision is final.  Recourse within the Department of Defense or the Department of the Army is exhausted; however, you have the option to seek relief by filing suit in a court of appropriate jurisdiction.

Sincerely,					      
						      					
Enclosure