RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02078
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20040322

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Administrative Specialist, medically separated for “bilateral cubital tunnel syndrome and right carpal tunnel syndrome” with a disability rating of 20%.  “Bilateral pes planus, symptomatic, was found to exist prior to service (EPTS) and was not rated.

CI CONTENTION:  “VA awarded 40% and the Army only awarded 20%.  I have additional disabilities.”  The 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 - 20040129	VARD - 20040825	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Cubital Tunnel Syndrome with Right Carpal Tunnel Syndrome	8516	20%	Carpal Tunnel Syndrome Right Wrist (Dominant)	8515	0%	20040628	
			Cubital Tunnel Syndrome Left Elbow	8516	0%		
			Cubital Tunnel Syndrome Right Elbow	8516	0%		
Bilateral Pes Planus, Symptomatic	5299-5276	EPTS	Hallux Valgus Right Foot Post Bunionectomy	5280	0%		
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Bilateral Cubital Tunnel Syndrome with Right Carpal Tunnel Syndrome.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s bilateral wrist symptoms began in May 2000 while performing push-ups and sit-ups as described on a Line of Duty form dated 25 August 2003.  Electro-diagnostic studies indicated bilateral upper extremity neuropathies of the ulnar and median nerves which confirmed the diagnoses of bilateral cubital tunnel syndrome and right-sided carpal tunnel syndrome.  Despite extensive Occupational Therapy (OT) rehabilitation, the CI continued to remain symptomatic in both extremities.  

The 5 September 2003 MEB NARSUM examination, 7 months prior to separation, noted a chief complaint of “pain in both wrists and forearms.”  It was documented that her right wrist pain improved, but the left wrist pain persisted.  Additionally, she endorsed bilateral elbow pain and numbness of the ring and little fingers of both hands.  Her physical examination (PE) revealed no clinical evidence of a sensory or motor abnormality in either upper extremity.  There was tenderness about the left wrist and decreased range of motion (ROM) of both wrists as indicated in the chart below.  Under the title of ‘present condition’ the examiner documented the following:  “At present, [the CI] is still doing her regular MOS and she favors her right hand in her typing work due to pain on the left hand.”     

At the 28 June 2004 VA Compensation and Pension (C&P) evaluation, performed 3 months after separation, the CI reported “…bilateral elbow pain and numbness whenever she bends her elbows or rests her elbows on a chair support.”  She denied any weakness, fatigue or functional loss from symptoms originating from her elbows.  Her PE revealed full and non-painful motion of both elbows.  Upon repetitive motion, pain was elicited in the right elbow as well as tingling in her little fingers.  In regards to her wrists condition, she additionally complained of continued painful symptoms (left greater than right), aggravated by computer activity and relieved by rest.  Her pain was described as numbness and aching.  Her wrist focused PE revealed normal and non-painful ROM and no additional pain upon repetition.   

The panel directed attention to its rating recommendation based on the above evidence.  The PEB combined the left and right cubital (elbow) tunnel syndrome conditions as a single unfitting condition as well as being combined with the right carpal tunnel syndrome coded 8516 (incomplete paralysis of the ulnar nerve) and rated 20%, citing “mild” impairment.  The VA separately rated the left and right cubital tunnel and right carpal tunnel syndrome all at 0% rated under 8516, citing “no functional loss” of any involved area.    

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 found unfit because of physical disability.  

Panel members first focused on the bilateral cubital (elbow) tunnel syndrome to determine the possibility of separate impairment ratings.  Despite the electro-diagnostic test indicating ulnar neuropathies, the absence of a sensory or motor abnormality in either upper extremity pre-separation coupled with the evidence of full and non-painful ROM of both elbows post-separation would not support any degree of a positive rating if found separately unfitting.  However, all panel members did concede that the additional evidence of pain being elicited by repetitive motion of the right elbow did support a separately unfitting condition and therefore ratable.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a separately unfit determination with a disability rating of 10% (equivalent for “mild” impairment) for the right elbow cubital tunnel condition.  

The panel next considered if the right carpal tunnel syndrome was considered separately unfitting and thus separately ratable.  The ROM examinations in evidence which the panel weighed in arriving at its rating recommendation, with documentation of additional ratable criteria are summarized. 

Right/Left Wrist ROM
(Degrees)	OT/MEB ~6 Mo. Pre-Sep
(20030825) 	VA C&P ~3 Mo. Post-Sep
(20040628) 	
Dorsiflexion (70 Normal)	45/60	70/70	
Palmar Flexion (80)	40/54	80/80	
Ulnar Deviation (45)	15/20	45/45	
Radial Deviation (20)	14/8	20/20	
Comment	Right wrist = “borderline WFL” (within functional limits)	AO	
§4.71a Rating	10%	0%	

All panel members acknowledged that the CI’s PE findings with regards to ROM of both wrist significantly improved to ‘normal’ parameters over the 9 month period from 6 months prior to separation to 3 months after separation.   The combination of the CI’s ability to “…still do her regular MOS” (although favoring her right hand for typing due to left hand pain) prior to separation and her normal examination (to include negative Deluca criteria) after separation provided the panel the necessary evidence to determine that the right carpal tunnel syndrome did not rise to a separately unfitting condition and accordingly a separate disability rating cannot be recommended.  Therefore, all evidence considered, there is not reasonable doubt in the CI’s favor supporting a change from the PEB’s bundling of these conditions at an overall combined 20% rating decision.

Bilateral Pes Planus, Symptomatic.  According to the STR and the MEB NARSUM, the CI developed foot and ankle pain after separate injuries of an ankle sprain upon stepping into a hole and foot pain after an extended road march in summer of 2002.  Noting radiographic findings of chronic instability, the MEB forwarded “chronic foot/ankle pain” and “pes planus,” for PEB adjudication.  

The PEB determined that the bilateral symptomatic pes planus condition existed prior to service and the panel found no evidence to indicate this was not correct.  The condition was specifically cited on the DD Form 199 as, “There is compelling evidence to support a finding that the current condition EPTS and was not permanently aggravated by such service.”  The panel next considered whether or not there was evidence of permanent service aggravation.  A presumption of service aggravation may only be overcome by a preponderance of competent medical evidence and accepted medical principles that the natural progression of a pre-existing condition was clearly unaltered by any consequence of military service. 

The CI’s enlistment PE dated 21 May 1999 clearly documented existing pes planus under the summary of defects and diagnoses.  At the MEB NARSUM examination, the CI was found to have “…severe pes planus with tenderness on the heel region of both feet.”  Despite a physical therapy encounter dated 15 October 2003 which listed a diagnosis of right plantar fasciitis, its PE noted “rigid flat feet; bilateral.”  Two months later an orthotic encounter noted the CI was to be fitted with custom made arch supports.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3, all panel members agreed that although the condition in question may often be a physical precursor for other foot maladies to develop, the condition, in and of itself was not permanently aggravated by service duties and therefore, recommends no change in the PEB’s adjudication.  

BOARD FINDINGS:  In the matter of the bundled bilateral cubital tunnel syndrome with right carpal tunnel syndrome condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the symptomatic bilateral pes planus condition, the panel unanimously recommends no change in the PEB”s adjudication of EPTS without permanent service aggravation.  There are 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 20150728, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170010109, XXXXXXXXXXXXXXXXXX 

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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,