RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02501
BRANCH OF SERVICE:  Navy 	SEPARATION DATE:  20040229

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Navy Recruiter Canvasser, medically separated for “status post [left wrist] four-corner fusion and scaphoidectomy” with a disability rating of 10%.

CI CONTENTION:  “Knee pain in right knee.  Left wrist scaphoidectomy four corner fusion.”  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 - 20031110	VARD - 20040223	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Status Post [Left Wrist] Four-Corner Fusion and Scaphoidectomy	5215	10%	Scaphoidectomy and Four-Corner Fusion, Left Wrist	5215	10%	20040123	
Complete Tear, Scapholunate Ligament, Lunotriquetral Ligament, and Capitohamate Ligament, Left Wrist 	Cat II					
[Right] Anterior Knee Pain	Cat III	Residuals, Osteochondroma Removal, Right Lower Femur	7805-5255	0%	20040123	
Status Post Lateral Osteochondroma Excision Right Distal Femur	Cat III					
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Status Post [Non-Dominant Left Wrist] Four-Corner Fusion and Scaphoidectomy.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s left wrist condition began in April 1998 after a fall, which resulted in a FOOSH (fall on an outstretch hand) injury and chronic mid carpal instability.  The right handed CI underwent left wrist surgery (four-corner fusion and scaphoidectomy) in November 1998 for chronic mid carpal instability.  Postoperatively, the CI had decreased motion with palmar flexion 17 degrees (normal 80), extension (dorsiflexion) 30 degrees (normal 70), ulnar deviation 0 degrees (normal 45), and radial deviation 15 degrees (normal 20).  There was also ulnar-sided wrist pain possibly secondary to impingement by staples.  Removal of the surgical staples was performed in April 1999.  Post staples removal and before operative wound closure, dorsiflexion was 20-25 degrees and volar flexion was 25 degrees.  Postoperatively, the CI experienced recurrent pain.  X-rays dated 8 August 2003 demonstrated a prior carpal bone fusion and an absent scaphoid.  

At an 11 August 2003 orthopedic examination, the examiner noted the CI had torn ligaments (scapholunate (SL), lunotriquetral (LT), and capitohamate (CH)) that resulted in the wrist surgery in 1998.  The 12 August 2003 MEB NARSUM examination, 7 months prior to separation, based on the orthopedic examination 1 day earlier, noted complaints of decreased grip strength, loss of range of motion (ROM), decreased stability, inability to do pushups, and swelling of the left wrist after a full day of activity as well as a fear of falling on an outstretched arm.  Physical examination showed the left wrist had multiple well healed scars. The ROM measurements were dorsiflexion 15 degrees, volar (palmar) flexion 15 degrees, ulnar deviation 10 degrees, and radial deviation 10 degrees; and the CI was distally neurovascularly intact.  During the 19 August 2003 MEB examination (recorded on DD Forms 2807-1 and 2808), 6 months prior to separation, the examiner recorded decreased ROM.  Physical examination showed decreased ROM and grip strength of the left wrist and a T-shaped scar of the left wrist.
  
At the 23 January 2004 VA Compensation and Pension (C&P) evaluation, 1 month before separation, the CI reported sensitivity to pressure of the dorsum of the left wrist and limited utility of the left wrist.  Physical examination showed a 3-inch surgical scar of the left wrist dorsally, which was well healed.   Flexion was 30 degrees and extension 30 degrees with no ulnar deviation and 20 degrees of radial deviation.  Supination and pronation were both 75 degrees. 

The panel directed attention to its rating recommendation based on the above evidence.  The Navy PEB rated the left wrist condition 10%, coded 5215 (wrist limitation of motion).  The PEB listed “complete tear, scapholunate ligament, lunotriquetral ligament, and capitohamate ligament, left wrist” as a related diagnoses (Category II) contributing to the disability in this case.  The panel concluded the Category II diagnoses were not separate conditions which could be reasonably justified as separately unfitting; nor would separate ratings be achievable without violation of VASRD §4.14 (avoidance of pyramiding).  The VA also rated the left wrist condition 10%, coded 5215, based on the C&P examination 1 month before separation, citing functional impairment and pain.  Panel members noted that the PEB rated the left wrist condition based on limitation of motion, albeit dorsiflexion was 15 degrees and palmar flexion was 15 degrees 7 months prior to separation; nevertheless at the VA examination, 1 month prior to separation, both dorsiflexion and volar flexion were 30 degrees.  Therefore, there was no route to a higher rating using code 5215.  While the CI had a four-corner fusion, there was insufficient evidence to use code 5214 (wrist ankylosis) in the absence of unfavorable or favorable ankylosis (immobility) of the wrist, although the CI was unable to ulnar deviate his wrist beyond 0 degrees during the VA C&P examination.  However, there was no radius or ulna nonunion with a flair false joint (code 5210), ulna or radius impairment with loss of bone substance, nonunion or malunion (codes 5211 and 5212), or supination and pronation impairment (code 5213) with loss of (bone fusion) or limitation of motion to warrant a higher rating.  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 left wrist condition.  

Contended PEB Navy Category III Conditions:  Anterior Knee Pain and Status Post Lateral Osteochondroma Excision.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended Category III conditions (conditions that are not separately unfitting and do not contribute to the unfitting were not unfitting conditions).  Neither of the aforementioned conditions carried attached duty limitations proximate to separation or were explicitly implicated in the Non-Medical Assessment.  The CI underwent surgery in May 2000 to resect an exostosis (bony protrusion) arising from the distal femur on the lateral aspect of the right knee.  On 5 August 2003 the CI reported right knee pain for 5 years and since the surgery in 2000 he had pain 8/10 (10 being the worst pain) with swelling at the end of the day.  An orthopedic examination dated 11 August 2003 noted the CI had patellofemoral syndrome or chondromalacia patella status post lateral exostosis excision.  The 12 August 2003 MEB NARSUM noted complaints of anterior and lateral knee pain after having undergone an uncomplicated distal lateral femur osteochondroma excision in 2000.  Physical examination showed a well healed scar of the left knee.  There was no laxity, instability, or medial or lateral joint line tenderness, but he did have a positive patellar inhibition (grind) test.  X-rays of the knee were essentially normal, with evidence of possible lateral sclerosis on the femur, consistent with an excision of a benign osteochondral growth (of cartilage and bone at the end of bone near the growth plate).  At the VA C&P examination the CI reported the knee still aches when he went up and down stairs.  He took nonsteroidal anti-inflammatory drugs (Motrin (ibuprofen) and Vioxx (rofecoxib)) as needed.  He was able to do the PRT (physical readiness test), but his knee hurt afterward.  Physical examination showed a 6-inch scar laterally on the right knee, which was well healed and asymptomatic.  The knee examination was normal and there was no subpatellar crepitus (grinding) when the knee was extended against resistance and there was no ligamentous laxity, instability, synovial thickening, warmth or effusion.  

There was no performance-based evidence from the record that either of the conditions 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 either of the contended conditions; and so, no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the left wrist condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the contended anterior knee pain and status post lateral osteochondroma excision, the panel unanimously recommends no change from the PEB determinations as not unfitting.  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 20151027, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

MEMORANDUM FOR DIRECTOR, SECRETARY OF THE NAVY COUNCIL OF REVIEW
               BOARDS 

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS
 
Ref:   (a) DoDI 6040.44

      In accordance with reference (a), I have reviewed the cases listed below and approve the recommendations of the PDBR that the following individual’s records not be corrected to reflect a change in either characterization of separation or in the disability rating previously assigned by the Department of the Navy’s Physical Evaluation Board:

		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXX, former USMC

		
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	     				  Acting