RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  pd-2016-00823
BRANCH OF SERVICE:  ARMY	SEPARATION DATE:  20040715

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reserve, E5, Motor Transport Operator, medically separated for “right cubital tunnel syndrome” and “chronic low back pain,” rated at 10% each, with a combined disability rating of 20%.

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 - 20040604	VARD - 20050801	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Cubital Tunnel Syndrome	8516	10%	Right Cubital Tunnel Syndrome (Major)	8516	30%	20050519	
Chronic Low Back Pain	5299-5237	10%	Recurrent Low Back Pain	5237	10%	20050708	
Cephalgia	Not Unfitting	Post Traumatic Headaches	9304-8045	0%	20050519	
Cervical Spondylosis	Not Unfitting	Cervical Spondylosis	5242	10%	20050708	
Gastroesophageal Reflux Disease (GERD)	Not Unfitting	GERD	7346	10%	20050428	
Hypertension	Not Unfitting	Hypertension	7101	10%	20050428	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  70%	

ANALYSIS SUMMARY:  

Right Cubital Tunnel Syndrome.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s right (dominant/major) cubital tunnel syndrome (pressure or stretching of the ulnar nerve) began in July 2003 after driving over rough terrain in a military vehicle and striking his head on the roof of the cab.  He developed numbness in his right hand and arm from his fingers to the shoulder and was medically evacuated from theater.  Electrodiagnostic studies (EMG/NCS) on 28 August 2003 and 3 December 2003 showed evidence of a demyelinating ulnar neuropathy at the right elbow, consistent with clinical cubital tunnel syndrome.

The 6 January 2004 MEB NARSUM examination, 6 months prior to separation, noted complaints of right hand pain, numbness and weakness since July 2003.  Physical examination showed the right hand had a slight decrease in the extension of his proximal interphalangeal joints (between fingers and hand) with full passive range of motion (ROM) of flexion and extension.  Static two-point discrimination was 5 mm throughout his digits.  Grip strength on the right was 20 pounds, on the left was 60 pounds.  Reflexes and vascular examination were normal.  The 25 February 2004 MEB NARSUM examination, 5 months prior to separation, noted complaints of right wrist and hand pain and numbness.  Physical examination showed right wrist tenderness with full ROM and no hypothenar or thenar (hand) muscle atrophy.  There was decrease in grip strength noted on orthopedic evaluation of 20 pounds on the right versus 60 pounds on the left.  Consult from orthopedics found ulnar neuropathy, and physical medicine documented electrodiagnostic findings of a demyelinating (damage to the sheath surrounding the nerve) ulnar neuropathy at the right elbow consistent with cubital tunnel syndrome.  The 8 July 2004 civilian physician evaluation, 7 days prior to separation, documented the CI was concerned about the lack of use of his right hand.  Physical examination showed that the right hand showed atrophy to the 3rd and 4th fingers and the CI was unable to open his hand freely.

At the 19 May 2005 VA Neurology Compensation and Pension (C&P) evaluation, 10 months after separation, the CI reported right hand numbness after hitting his head on the roof of a truck he was driving.  Physical examination showed mild weakness of the 1st dorsal interosseous and abductor digiti minimi (hand muscles) of the right hand.  Sensory testing showed diminished pinprick over the dorsum of the right wrist in the distribution of the radial sensory nerve and also decreased pin in the right 4th and 5th fingers.  Reflexes were normal.  The neurologist diagnosis was “right hand numbness and some mild weakness with findings in both ulnar and radial nerve distribution.  The possibility of a C8, T1 radiculopathy is also a possibility.”

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right cubital tunnel syndrome 10%, coded 8516 (paralysis of the ulnar nerve), citing mild incomplete paralysis.  The VA rated the right cubital tunnel syndrome condition 30%, coded 8516, based on the C&P examination 10 months after separation, citing diminished sensation with some weakness for a moderate incomplete paralysis.

The VASRD “Diseases of the Peripheral Nerves” indicates that the term “incomplete paralysis” for 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.”  The panel considered that EMG/NCS and MEB NARSUM evidence indicated principle involvement of the ulnar nerve.  The MEB NARSUM documented significant loss of grip strength (20 pounds vs the non-dominant 60 pounds) that may have approached the severe, incomplete paralysis rating and the civilian examination closest to separation showed muscle atrophy to the 3rd and 4th fingers; however, the post-separation VA examination noted improvement to “mild weakness” with sensory deficit, and there was no muscle atrophy noted.  Given objective evidence of muscle weakness and sensory deficit documented in the record, the panel adjudged that the CI’s right dominate disability picture at separation most nearly approximated the “moderate, incomplete paralysis” (30%) criteria.  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 right (dominate) cubital tunnel syndrome, coded 8516.
Chronic Low Back Pain.  According to the STR and the MEB NARSUM, the CI’s back condition began in October 2003 without any specific injury.  Lumbar spine X-rays in January 2004 lumbar spine, January 2004, showed mild degenerative disease at L2-3 and L3-4 levels.  The CI was not a surgical candidate.  The 25 February 2004 MEB NARSUM examination noted complaints of low back pain.  Physical examination showed tenderness in the lumbar sacral area with heel-toe walk.  Neurologic examination showed normal lower extremity strength, reflexes and sensory findings.  Provocative testing for radiating symptoms was negative.  Thoracolumbar range of motion (ROM) was flexion of 90 degrees (normal) and combined 240 degrees (normal); painful motion was not addressed.

At the 8 July 2005 C&P evaluation the CI reported back pain since traveling in a vehicle and hitting the top of his head on the truck roof when the vehicle dipped in a low spot on the road.  His low back pain was exacerbated by activity without radiating pain.  Physical examination showed a normal gait.  Heel/toe walk was stable.  There was no back spasm, pain, or tenderness.  ROM was flexion to 85 degrees and combined 225 degrees.  There was no additionally loss of ROM due to pain, fatigue, weakness or lack of endurance following repetitive use.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, analogously coded 5299-5237 (lumbosacral strain), citing combined ROM greater than 235 degrees with localized tenderness.  The VA also rated the back condition 10%, coded 5237, based on the C&P examination 12 months after separation, citing limitation of motion.  The panel agreed that a 10% rating, but no higher, was justified for tenderness without limited motion as reported on the NARSUM examination, or for limitation of flexion (greater than 60 degrees but not greater than 85 degrees) or combined ROM (greater than 120 degrees but not greater than 235 degrees) as reported on the VA examination.  There was no documentation of intervertebral disc syndrome (IVDS) with incapacitating episodes which would provide for a higher rating under that formula.  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 back condition.

Contended PEB Conditions:  Cephalgia, Cervical Spondylosis, GERD, and Hypertension.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  None of the conditions were profiled, implicated in the commander’s statement or judged to fail retention standards.  There was no performance-based evidence from the record that any 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 any of the contended conditions and so no additional disability ratings are recommended.

BOARD FINDINGS:  In the matter of the right (dominant) cubital tunnel syndrome, the panel unanimously recommends a disability rating of 30%, coded 8516 IAW VASRD §4.124a.  In the matter of the back condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the contended cephalgia, cervical spondylosis, GERD, and hypertension conditions, 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 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	
Right Cubital Tunnel Syndrome	8516	30%	
Chronic Low Back Pain	5299-5237	10%	
COMBINED	40%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160915, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

AR20170018007, 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 40% 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), XXXXXXXXXXXXXXXXXXX.

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

Sincerely,					      
Enclosure