RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01981
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070701

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Military Police, medically separated for “Raynaud’s disease affecting bilateral hands” with a disability rating of 10%.

CI CONTENTION:  “Review 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 panel 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 - 20070514	VARD - 20070727	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Raynaud’s Disease 	7117	10%	Raynaud’s Phenomenon, Bilateral Hands	7117	0%	20070620	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Raynaud’s Disease.  According to service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI had a history left hand trauma from a firecracker explosion, requiring extensive surgical repair in 2000.  At the 30 November 2006 family practice appointment, the CI complained of left hand 5/10 pain and numbness.  It documented “has injury to his left hand ... large m80 firecracker blew up in his left hand in 2000; had a hand surgeon do the repair ... since then has pain in the left index finger medial tip (neuroma? [reactive tumor of disorganized axons] at scar site?) ... but now having paresthesia [abnormal sensation, tingling, burning, prickling] and pain of the left thumb, index long and ring fingers.”  The physical examination documented “over all the left hand is colder to touch than the right at finger tips.”  The left hand examination revealed some clubbing (pathological enlargement of digits from pulmonary or cardiovascular diseases) of the nails distally with no atrophy (wasting).  The 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 were positive.  Grip strength, deep tendon reflexes (DTRs), and sensation were normal except for decreased pin prick sensation over the median nerve distribution.  The assessment listed carpal tunnel syndrome ([CTS] compression of the median nerve in the wrist carpal tunnel causing numbness and tingling of the palm side of the thumb and fingers [sparing little finger]) and reflex sympathetic dystrophy ([RSD] chronic extremity pain, swelling, limited range of motion, vasomotor instability, skin changes, and patchy bone demineralization following injury).  

A 3 January 2007 left upper extremity nerve conduction study ([NCS] nerve impulse velocity) revealed normal median and ulnar nerve motor and sensory function and was interpreted as normal.  At the 3 January 2007 physical medicine and rehabilitation (PM&R) evaluation the CI complained of left hand pain for 5 years with a history of left hand trauma from a firecracker explosion, requiring extensive surgical repair.  The physical examination revealed no pain with hand motion, no motor dysfunction, and no sensory abnormalities.  The examiner recounted the findings of the NCS and documented “No electrodiagnostic evidence to suggest carpal tunnel type entrapment neuropathy.”  The PM&R physician started a trial of the anticonvulsant Neurontin for off-label treatment of neuropathic (sensory nerve injury pain) pain.  

At the 13 February 2007 PM&R follow-up the CI denied significant improvement in pain with Neurontin.  The evaluation recorded difficult to localize left palmar hand pain and hyperesthesia (abnormal increased sensitivity to stimulation).  The physical examination documented “Appearance of the hands was abnormal somewhat blanched after cold weather exposure.”  The bilateral hand examination revealed tenderness, pain with hand motion, no weakness, and no decreased response to tactile stimulation.  The assessment listed RSD and the PM&R physician converted the Neurontin to another anticonvulsant, Lyrica.  The 27 March 2007 physical profile listed cold intolerance and Raynaud’s disease (recurrent finger and toe vasospasm in response to cold or stress).  

The 18 April 2007 MEB NARSUM, 3 months before separation, recounted the history and interventions.  The CI complained of bilateral (L>R) hand pain with exposure to cold weather.  Pain was 1-2/10 at best, and 7-8/10 at worst.  The Lyrica did help to some degree, but did not significantly alleviate his symptoms.  The CI noted he was unable to hold or fire his weapon, or do other basic military police tasks, in cold weather due to his hand pain.  The physical examination revealed the fingertips (L>R) were cold and both hands (L>R) appeared mottled or somewhat blanched.  The bilateral hand examination revealed left fingertip ulceration (sparing thumb), mild finger (L>R) tenderness, and pain with hand motion.  Pulses and sensation were normal except for a slight decrease to light touch in the left fingertips.  The examiner recounted the findings of the normal NCS.  The diagnoses listed bilateral hand (L>R) cold intolerance and Raynaud's disease.  

A 9 May 2007 email for the PEB from the MEB NARSUM physician documented “Using full precautions to prevent cold exposure, SPC Gutierrez still has 2-3 episodes meeting the definition of ‘characteristic attack’ per week during the winter months but during the summer months, only has 2-3 per month.”  

The 21 June 2007 VA Compensation and Pension (C&P) examination, 1 week before separation, documented the CI “developed pain, fingers of bilateral hands turning blue, and numbness every time he was exposed to cold.”  He reported “pain, pins and needles sensation, numbness, and whitening of the fingers of bilateral hands on cold exposure.”  Exacerbations of sharp 7/10 pain lasted 1 to 30 minutes.  Symptoms were exacerbated by shifting from warmer to colder temperatures and relieved by warming and medication (Lyrica).  The bilateral hand examination revealed finger clubbing with no pallor, cyanosis (bluish discoloration from insufficient oxygen), edema (excess tissue fluid swelling), ecchymosis (bruising), erythema (redness), tenderness, or other deformity.  Strength, pulses, sensation, and DTRs were normal and pathologic reflexes were absent.  The diagnosis listed Raynaud's phenomenon with symptoms on cold exposure.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under the 7117 code (Raynaud’s syndrome), citing Raynaud's disease affecting bilateral hands with characteristic attacks occurring two to three times per week.  The VA assigned a 0% rating under the 7117 code (Raynaud’s syndrome), citing a non-compensable evaluation is assigned unless characteristic attacks occur one to three times a week.  Panel members agreed that the disability more closely approximated the 10% (characteristic attacks occurring one to three times a week) than the 20% (characteristic attacks occurring four to six times a week) rating under 7117 (Raynaud’s syndrome).  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 Raynaud’s disease.  

BOARD FINDINGS:  In the matter of the Raynaud’s disease condition and IAW VASRD §4.71a, the panel unanimously 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 modification or re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150712, w/attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170010013, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX

	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