RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00408
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20050421

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Human Resource Specialist, medically separated for “chronic [bilateral] elbow pain and hand numbness due to clinically left and right [bilateral] cubital tunnel syndrome” with a disability rating of 0%.

CI CONTENTION:  Additional unfitting conditions were not considered.  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 - 20050207	VARD - 20050129 	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Bilateral Elbow Pain and Hand Numbness due to Clinically Bilateral Cubital Tunnel Syndrome	5009-5003	0%	Left Cubital Tunnel Syndrome	8516	10%		
			Right Cubital Tunnel Syndrome	8516	0%		
COMBINED RATING: 0%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:

Bilateral Elbow and Hand due to Bilateral Cubital Tunnel Syndrome.  The PEB combined the left and right cubital tunnel syndrome conditions under a single disability rating, coded analogously to 5003 and rated 0% with application of the US Army Physical Disability Agency pain policy and AR 635-40 B24.f.  This approach by the PEB not uncommonly reflected its judgment that the constellation of conditions was unfitting, and there was no need for separate fitness adjudications.  The panel noted that “bundling,” the combining of two or more major joints, may be permissible under the VASRD 5003 rating requirements, and that this approach does not compromise the VASRD §4.7 directive to choose the higher of two valid ratings.  The panel’s initial charge in this case was therefore directed at determining if 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 referred into the DES or be found unfit because of physical disability.  When the panel recommends separate fitness recommendations in this circumstance, its recommendations may not produce a lower combined rating than that of the PEB.

According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s bilateral elbow pain and numbness condition began in August 2004 with an insidious onset.  At the 13 July 2004 orthopedic examination the CI reported a 9-month history of left greater than right elbow pain radiating to the hand.  Physical examination showed positive cubital tunnel Tinel’s and flexion tests (tests for ulnar nerve entrapment).  There was tenderness to palpation of the ulnar nerve just above the wrist.  Muscle strength was normal in the forearm and hand.  The examiner rendered a diagnosis of left cubital tunnel syndrome with ulnar neuropathy and early similar symptom on the right.  Electromyography (EMG) and nerve conduction studies performed on 3 August 2004 were normal.

According to the commander’s statement dated 26 October 2004, pain and numbness in the CI’s left arm impacted her ability to perform duties and prohibited her from taking the Army physical fitness test or qualifying with a weapon.  The 06 January 2005 MEB NARSUM examination, 3 months prior to separation, noted complaints of bilateral pain in the wrist, forearm, and elbow medial and volar surfaces.  The CI described the pain as aching in nature with sharp electrical shock type sensations that occurred with any blunt trauma to the medial aspect of the bilateral elbow.  Physical examination showed the left elbow was tender to palpation over the medial epicondyle and the cubital tunnel. The Tinel’s sign (test for ulnar nerve entrapment) was position at the left elbow and negative on the right.  Left hand light touch was diminished in the ulnar distribution.  Motor strength was normal in both upper extremities.  The CI was right hand dominant.  An EMG test was performed which revealed no evidence of radiculopathy, cubital tunnel syndrome, or carpal tunnel syndrome bilaterally.

At the 29 January 2005 VA Compensation and Pension (C&P) evaluation, 3 months before separation, the CI reported left elbow pain occurred with certain work activities such as typing or bending the arm for too long.  The CI described the pain as sharp, cramping, tingling and numb. The CI stated that she took Indocin, Naproxen or Motrin for the symptoms.  She stated that the “aching pain occurs with periods of prolonged typing, lifting of heavy objects, overuse and sleeping on the arm.” The CI said that the numbness and tingling went into the fourth and fifth fingers.  Physical examination showed the CI was right hand dominant.  Range of motion of the left elbow joint was flexion to 145 degrees (normal 145), extension to 0 degrees (normal 0), supination 85 degrees, and pronation 80 degrees.  ROM was not limited by pain, fatigue, weakness, lack of endurance or incoordination after repetitive use.  Radiological study of the left humerus and wrist were within normal limits.  The examiner opined “cubital tunnel syndrome left arm, ulnar nerve distribution.”

The panel directed attention to its rating recommendation based on the above evidence.  The panel first considered if the right and left cubital condition met the panel’s threshold for separate rating (as elaborated above).  A bilateral condition was profiled and each judged to fail retention standards; however, the only left arm was implicated in the commander’s statement and the preponderance of the STR.

Panel members agreed the evidence reasonably justified that the functional limitations of the left cubital tunnel condition contributed to the CI’s inability to perform her military duties, and accordingly a separate disability rating is recommended.  The panel members concluded that the preponderance of evidence showed the right cubital condition would not have caused the CI to be referred into the DES or to be found unfit.

The PEB rated the right and left cubital tunnel condition 0%; analogously coded 5099-5003 (degenerative arthritis), citing application of the US Army Physical Disability Agency pain policy and AR 635-40 B24.f; rated minimal/constant.  The VA rated the left cubital tunnel syndrome condition 10%, coded 8516, (ulnar nerve, paralysis), and right cubital tunnel syndrome condition 0%, also coded 8516, based on the C&P examination 3 months before separation, citing mild paralysis in the left ulnar nerve distribution, and no subjective complaints or objective findings for the right arm or right elbow.

Panel members agrees that the evidence supports a 10% rating painful motion (elbow flexion test) and mild incomplete, mild paralysis in the left ulnar nerve distribution in the hand under the 5003 and 8516 codes respectively.  The evidence did not support a higher rating under 8516 for moderate incomplete paralysis of the ulnar nerve.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the left cubital tunnel syndrome condition, coded 8516.

BOARD FINDINGS:  In the matter of the bilateral cubital tunnel syndrome condition, the panel unanimously recommends that it be adjudicated for two separate conditions:  In the matter of the left cubital tunnel syndrome condition, the panel unanimously recommends a separately unfit determination with a disability rating of 10%, coded 8516.  In the matter of the right cubital tunnel syndrome condition, the panel unanimously agrees that it cannot recommend a finding of unfit for additional disability rating.  There are 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, effective as of the date of the prior medical separation:

CONDITION	VASRD CODE	PERMANENT RATING	
Left Cubital Tunnel Syndrome	8516	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160620, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170015534, XXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found that your disability rating should be modified but not to the degree that would justify changing your separation for disability with severance pay to a permanent retirement with disability.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed) and I accept its recommendation.  This will not result in any change to your separation document or the amount of severance pay.  A copy of this decision will be filed with your Physical Evaluation Board records.  I regret that the facts of the case did not provide you with the outcome you may have desired.
  
	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. 

	A copy of this decision has also been provided to the Department of Veterans Affairs.

Sincerely,	
Enclosure