RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00599
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20040318

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Infantryman, medically separated for “reflex sympathetic dystrophy, left (non-dominate) upper extremity with a disability rating of 20%.  

CI CONTENTION:  The CI made no specific contention.  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 - 20040202	VARD - 20040709	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Reflex-Sympathetic Dystrophy [RSD], Left Upper Extremity	8799-8713	20%	RSD, Left Wrist and Hand	5308	20%	20040518
20040512	
			S/P Scaphoid Fracture, Left Wrist	5215-5010	10%	20040512	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:

Reflex-Sympathetic Dystrophy (RSD), Left Upper Extremity.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the right-handed CI’s left upper extremity RSD condition began in March 2002 after a motorcycle accident where he fractured his scaphoid bone (wrist).  The May 2003 electrodiagnostic testing of the left ulnar and medial nerves was normal, with no electrodiagnostic evidence of a left ulnar or median neuropathy based on the nerves and muscles, and given continued pain and neurologic findings and symptoms, the CI was diagnosed with complex regional pain syndrome (equivalent of RSD).  

During the 3 December 2003 MEB examination (recorded on DD Forms 2807-1 and 2808), 4 months prior to separation, the CI reported constant severe pain in his left wrist and hand with numbness and burning in his pinky and ring (4th and 5th) fingers.  He indicated that he could not use his left hand for anything, and that the hand and wrist stayed swollen.  He was taking narcotic and non-narcotic pain medications.  Physical examination showed limited left wrist and finger motions due to pain, hypersensitivity of the dorsum of the left hand up to 1/3 of the forearm, with limited sensation to pinprick on the 4th and 5th fingers.  

The 4 December 2004 MEB NARSUM examination, 4 months prior to separation, noted complaints of pain in his left hand.  He could not perform his military duties and indicated that he could not even pick up his ten-month-old child or drive more than thirty minutes because of pain.  Physical examination showed good pulses.  There was hypersensitivity from the dorsum of the left hand up to about the lower third of the left forearm and diminished sensation to touch and pin prick of the 4th and 5th fingers.  There was diminished grip and finger movements of the left hand due to pain.  The formal range of motion (ROM) testing by occupational therapy (OT) showed dorsiflexion to 15 degrees (normal 70) and palmar flexion to 15 degrees (normal 80) with normal pronation and supination of the forearm.  The OT evaluation also documented left grip and pinch strength of zero pounds compared to 120 pounds grip and 19 pounds pinch on the right.  

At the 12 May 2004 VA Compensation and Pension (C&P) Peripheral Nerve evaluation, 2 months after separation, the CI reported intense pain in his left hand and wrist with movement, light touch or any kind of clothing or cold weather precipitating and intensifying his pain.  He had episodes of swelling of the left wrist, and prior brown spots had disappeared. Any kind of lifting or heavy activities also worsen the pain.  He had prior constant numbness of his left little, ring, and middle finger which decreased to occasionally.  Physical examination showed normal left upper extremity muscle strength.  Distal muscles strength evaluation showed the CI “was not able to make a complete handgrip and it shows there is marked weakness of left handgrip due to pain.  Wrist extensors are also 3/5 (movement against gravity but not against resistance).  This is also limited due to intense pain.  He also has weakness of left thumb and all the fingers of left hand.  The movement of fingers, thumb, and wrist is limited due to intense pain.”  Sensory examination documented hyperesthesia to pinprick in the left index finger and decreased pinprick in the left index and left little (4th and 5th) fingers.  C&P examinations from 18 May 2004 showed mild hand weakness, with wrist dorsiflexion over 50 degrees (normal 70) and palmar flexion of 40 degrees (normal 80).  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left upper extremity RSD condition 20%, analogously coded 8799-8713 (neuralgia; all radicular groups), rated as mild.  The VA rated the RSD condition 20%, coded 5308 (muscle group VIII, extension of wrist, fingers, and thumb), based on the C&P examination 2 months after separation, citing severe or moderately severe muscle disability.  The VA also rated the left wrist status post scaphoid fracture condition 10%, analogously coded 5215-5010 (wrist, limitation of motion-degenerative arthritis due to trauma), citing painful motion.  

The panel considered the VASRD provisions of §4.124 and Diseases of The Peripheral Nerves stating:  “The term “incomplete paralysis” with this and other peripheral nerve injuries indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration.  When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree.”  VASRD §4.124 (neuralgia) indicates that it is rated “with a maximum equal to moderate incomplete paralysis.”  VASRD §4.123 (neuritis) indicates that “the maximum rating which may be assigned for neuritis not characterized by organic changes … will be that for moderate.”  The panel deliberated if the CI’s left upper extremity RSD more nearly approximated the maximum 30% (moderate incomplete paralysis) rating criteria.  
The NARSUM examination and peripheral nerve C&P examinations proximate to separation described significant functional loss of the left wrist and hand grip strength, as well as sensory changes, and the panel adjudged that the functional loss and functional weakness better described the moderate (30%) level of disability under code 8713.  Painful motion of the wrist was included in the peripheral nerve rating.  There was no muscle injury for alternate rating under muscle coding.  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 upper extremity RSD condition, coded 8799-8713.  

BOARD FINDINGS:  In the matter of the left upper extremity RSD condition, the panel unanimously recommends a disability rating of 30%, coded 8799-8713 IAW VASRD §4.124a.  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; 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	
Reflex-Sympathetic Dystrophy [RSD], Left Upper Extremity	8799-8713	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160912, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170016284, XXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

	I accept the recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) to re-characterize your separation as a disability retirement with the combined disability rating of 30% effective the date of your medical separation for disability with severance pay.  Enclosed is a copy of the Board’s recommendation and record of proceedings for your information.

	The re-characterization of your separation as a disability retirement will result in an adjustment to your pay providing retirement pay from the date of your original medical separation minus the amount of severance pay you were previously paid at separation.
 
	The accepted DoD PDBR recommendation has been forwarded to the Army Physical Disability Agency for required correction of records and then to the U.S. Defense Finance and Accounting Service to make the necessary adjustment to your pay and allowances.  These agencies will provide you with official notification by mail as soon as the directed corrections have been made and will provide information on your retirement benefits.  Due to the large number of cases in process, please be advised that it may be several months before you receive notification that the corrections are completed and pay adjusted.  Inquiry concerning your correction of records should be addressed to the U.S. Army Physical Disability Agency, (AHRC-DO), 

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

Sincerely,					      
Enclosure