RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02121
BRANCH OF SERVICE:  Navy 	SEPARATION DATE:  20080101

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Submarine Nuclear Propulsion Plant Operator Mechanical, medically separated for “malunion of fracture carpal bones scaphoid, left,” rated 30%, with a 10% EPTS (existed prior to service) deduction, and related Category II condition “non-dominant subjective left wrist pain,” for a combined disability rating of 20%.  

CI CONTENTION:  The CI contends for a higher rating.  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 - 20071015	VARD - 20080415	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Malunion of Fracture Carpal Bones Scaphoid, Left (Wrist)	5214	  30%
 -10%
  20%	Residuals Of Surgically Repaired Left Scaphoid Fracture	5215	10%	STR
&
VA Exam	
Non-dominant subjective left wrist pain	Category 2					
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Malunion of Fracture Carpal Bones Scaphoid, Left Wrist.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s left wrist (non-dominant) condition began in approximately 2000.  The CI’s entry physical from 2002 included a history of right wrist fracture with surgery (ORIF) and retained hardware.  The March 2002 orthopedic consult documented a normal appearing left wrist without crepitus or reactive changes.  Range of motion (ROM) was 90-95% in all directions, with normal strength and push-ups without restriction.  The CI received a waiver for Service entry.  The CI’s left wrist was asymptomatic until three years after being in the Service when he developed left wrist pain “after sustaining several small injuries over several months.”  X-ray in May 2006 showed a left scaphoid wrist fracture, favoring chronic or subacute injury, and further imaging (MRI) showed a chronic scaphoid fracture with nonunion, and the CI underwent a second surgical repair (ORIF with vascularized bone graft) on 18 July 2006.  

The 26 and 30 August 2007 MEB NARSUM and addendum examination, 4 months prior to separation, noted complaints of left wrist pain with decreased ROM.  Physical examination showed left wrist tenderness without muscle atrophy.  Strength was decreased (4/5).  The CI performed 15 push-ups but had to stop due to pain.  ROM was dorsiflexion 20 degrees (normal 70) and palmar flexion 50 degrees (normal 80).  The 30 January 2007 diagnostic imaging (CT) showed bone grafting with subtle central trabecular bridging and the 13 June 2007 X-ray showed no significant change.  The diagnosis was “malunion of fracture carpal bones scaphoid left.”  

There was no source VA examination in the record proximate to separation.  However, the April 2008 VARD summarized a VA examination (date not specified) as showing left wrist painful motion with decreased ROM of 50 degrees dorsiflexion and 60 degrees palmar flexion.  There was no weakness or tenderness.  X-ray showed left wrist mild degenerative changes and mild scaphoid sclerosis.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left wrist condition 30%, coded 5214 (wrist, ankylosis), with a 10% EPTS deduction for a combined 20% rating.  The Navy PEB’s Category II diagnosis of non-dominant subjective left wrist pain is intrinsic to the rated condition and a separate rating cannot be supported without pyramiding (VASRD §4.14); thus, it is appropriately subsumed under the same rating.  The VA rated the left wrist condition 10% coded 5215 (wrist, limitation of motion), based on a VA examination, citing painful motion.  

The panel carefully assessed the left wrist examinations proximate to service entry to determine the rating for any EPTS deduction IAW VASRD criteria.  An EPTS deduction requires a preponderance of objective medical evidence (clinical history, examination findings, etc. and not personal opinion or speculation) for a determination of the rating percentage (IAW VASRD) at the time of entry into service.  In the absence of a preponderance of objective medical evidence supporting a rating percentage at the time of entry into service, an EPTS deduction cannot be made.  At the time of the entry examinations and orthopedic consultation, there was no painful left wrist motion, and there was insufficient limitation of wrist motion or other evidence of functional loss that would warrant any VASRD rating higher than 0%.  

The panel therefore adjudged that a 0% EPTS deduction was the highest that could be applied to the PEB’s 30% rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 30% for the left wrist scaphoid malunion condition, coded 5214, including a 0% EPTS deduction.  

BOARD FINDINGS:  In the matter of the left wrist scaphoid malunion condition, the panel unanimously recommends a disability rating of 30% (including a 0% EPTS deduction), coded 5214 IAW VASRD §4.71a.  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	
Malunion of Fracture Carpal Bones Scaphoid, Left (Wrist)	5214	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150729, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR DEPUTY COMMANDANT, MANPOWER & RESERVE AFFAIRS
		   COMMANDER, NAVY PERSONNEL COMMAND	
	                          
Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS          

Ref:  (a) DoDI 6040.44
	(b) PDBR ltr dtd 26 Jun 17 XXXXXXXXXXXXXXXXXX  
	(c) PDBR ltr dtd 26 Jun 17 XXXXXXXXXXXXXXXXXX
	(d) PDBR ltr dtd 20 Jun 17 XXXXXXXXXXXXXXXXXX
	(e) PDBR ltr dtd 25 Nov 16 XXXXXXXXXXXXXXXXXX
	(f) PDBR ltr dtd 16 Jun 17 XXXXXXXXXXXXXXXXXX
   (g) PDBR ltr dtd 20 Jun 17 XXXXXXXXXXXXXXXXXX

1.  Pursuant to reference (a), the recommendations of the Physical Disability Board of Review set forth in references (b) through (f) are approved.  The official records of the following individuals are to be corrected as follows:

     a. XXXXXXXXXXXXXXXXXX former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge.

     b. XXXXXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 30 percent rating (increased from 20 percent) effective date of discharge.     

     c. XXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge.

     d. XXXXXXXXXXXXXXXXXX, former USMC: Retroactive placement on the Temporary Disability Retired List for six months beginning date of discharge with a 50 percent combined disability rating and a final rating thereafter of 20 percent.  

     e. XXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 20 percent disability rating (increased from 0 percent) effective date of discharge.

     f. XXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 10 percent disability rating (increased from 0 percent) effective date of discharge.   
     
3.  Please take action to implement these decisions.

	XXXXXXXXXXXXXXXXXX

	Acting,