RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXX	CASE:  PD-2016-00870
BRANCH OF SERVICE:  Navy	SEPARATION DATE:  20040504

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Damage Controlman, medically separated for “degenerative joint disease [DJD] of his right thumb metacarpophalangeal [MCP] joint” with a disability rating of 20%.  

CI CONTENTION:  No specific contention was made.  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 Medical Evaluation Board (MEB), but determined by the PEB 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.  The panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections when appropriate.  The panel’s assessment of the PEB rating determination is based on review of medical records and all available evidence relevant to application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards for 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, which operates 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 disability at the time of separation.  

RATING COMPARISON:  

SERVICE PEB – 20040129	VARD - 20050208	
Condition	Code	Rating	Condition	Code	Rating	Exam	
DJD of Right Thumb MCP Joint	5299-5003	20%	Residuals S/P Multiple Surgeries with Retained Hardware/Scar, Right Thumb	5010-5224	10%	20050208	
Status Post (S/P) Right MCP Volar Plate Tenodesis…, Right Thumb Metacarpal Joint Ligament Reconstruction and S/P Right First Dorsal Compartment Release	Cat II					
		Residual Neuropathy, S/P Injury Right Upper Extremity	8599-8516	10%	20050208	
		Residual Hyperextension Injury Right Wrist	5215	10%	20050208	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

DJD, Right Thumb MCP Joint.  According to the service treatment record and MEB narrative summary (NARSUM), the CI’s right (dominant) thumb condition began in April 2001 after falling.  In October 2001, he had a right thumb first dorsal compartment release for tenosynovitis, and then a right carpometacarpal (CMC) joint reconstruction in August 2002.  On 17 May 2003, he underwent a volar plate advancement for the right thumb, but continued to have pain and used a splint as needed.  He reinjured his thumb in a fall in October 2003.  

The 27 October 2003 MEB NARSUM examination, 6 months prior to separation, noted CI complaints of right thumb pain.  Physical examination revealed a well-healed incision and no pain at the CMC joint; however, there was tenderness along the volar aspect of the MCP joint.  Range of motion (ROM) was -2 degrees to 45 degrees for the thumb MCP joint, and 0-98 degrees for the thumb interphalangeal (IP) joint.  Grip test measurements from a 21 October 2003 evaluation were referenced and showed significant weakness (positions #1, 2, and 3 on right hand of 16, 21, and 13 kg; and left hand of 34, 49 and 40 kg).  The physician stated that the CI had “continued difficulty with fine motor manipulation” due to DJD of the MCP joint as demonstrated by surgical evaluation and imaging to include a nuclear scan.  

A 10 March 2004 orthopedic note included risks and benefits of a fusion of the right MCP joint, and another note on 24 March 2004 documented surgery on 15 March 2004 for a “left” thumb MCP arthrodesis (erroneous as the rest of the record showed surgery was performed on the right hand).  Examination on 28 April 2004 revealed a fixed MCP joint and IP ROM of 0-40 degrees.  

At the 8 February 2005 VA Compensation and Pension (C&P) general and neurologic examinations, 9 months after separation, the CI reported right hand and thumb pain, with significantly decreased function and ROM, and increased pain with repetitive motion (carrying 10-20 ponds, or clerical work).  He also had decreased sensation over the thumb and palmar aspect, and intermittently wore a thumb immobilizer.  Physical examination showed well-healed scars with tenderness over a palpable screw.  There was “good motion of right fingers, right hand, and right wrist.”  The right thumb MCP joint was tender with a favorable fusion at 30 degrees, without further flexion; it did not extend to 0 degrees and was tender.  The IP joint was normal with flexion to 90 degrees and extension to 0 degrees.  The CI could only cross his thumb over the hand to come 2 cm from touching the base of the small finger, and he could not touch the ulnar side of his hand with the thumb.  Grip strength was significantly decreased to between 11-16 kg on the right compared to an average of 45 kg on the left.  The right wrist also had some limited ROM, primarily during ulnar and radial deviation, with painful motion.  Neurologic evaluation documented loss of sensation over both digital nerves in the palmar sensory branch of the median nerve.  The neurologist diagnosed neuropathy affecting both right thumb digital nerves and the palmar sensory branch of the median nerve.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right thumb condition 20%, analogously coded as 5003 (degenerative arthritis).  The PEB also listed associated diagnoses (Category II) of “status post right metacarpophalangeal volar plate tenodesis and advancement, right thumb metacarpal joint ligament reconstruction and status post right first dorsal compartment release.”  Panel members noted that these were the underlying surgical procedures which were performed for, or resulted in, the Category I unfitting diagnosis of DJD of the right thumb MCP joint.  The procedures were not separate disability conditions for which a rating could be assigned.  However, the PEB was prior to (and so did not mention) the thumb arthrodesis surgery in March 2004.  

The VA rated the right thumb condition 10%, analogously coded 5010-5224 (arthritis, due to trauma-thumb, ankylosis), based on the C&P examination, citing favorable fusion of the MCP joint, grip weakness, and pain.  The additional VA ratings for the right wrist and right upper extremity (hand/thumb) neuropathy are not specifically in scope for the panel’s adjudication, but are noted in the rating comparison chart as indicators of functional loss due to, or associated with, the CI’s thumb condition.  

Although the 20% rating is the highest available VASRD rating under codes 5003 or 5224, the note under code 5224 states:  “also consider whether evaluation as amputation is warranted and whether an additional evaluation is warranted for resulting limitation of motion of other digits or interference with overall function of the hand.”  The panel therefore deliberated whether evaluation as an amputation was reasonable, and considered the NARSUM examiner’s assessment of significant grip weakness, difficulty with fine motor control, and limited ROMs (before fusion surgery); as well as the VA examiner’s detailed evaluations of functional loss and disability following pre-separation surgical fusion of the right thumb MCP joint.  The panel adjudged that the interference with overall function of the right hand due to the CI’s thumb condition, and associated surgeries, warranted analogous rating equivalent to 5152 (thumb, amputation of) at the MCP joint or through the proximal phalanx (30%).  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 30% for the right thumb condition, coded 5199-5152.  

BOARD FINDINGS:  In the matter of the right thumb condition, the panel recommends a disability rating of 30%, coded 5199-5152 IAW VASRD §4.71a.  There are no other conditions within the panel’s scope of review for consideration.  

The panel recommends 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 the date of medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Degenerative Joint Disease of Right Thumb Metacarpophalangeal Joint--Status Post Right Metacarpophalangeal Volar Plate Tenodesis and Advancement, Right Thumb Metacarpal Joint Ligament Reconstruction and Status Post Right First Dorsal Compartment Release	5199-5152	30%	

MEMORANDUM FOR DEPUTY COMMANDANT (Manpower and Reserve Affairs) COMMANDER, NAVY PERSONNEL COMMAND

Subj:	PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS

Ref:	(a)	DoDI	6040.44		
	(b)	PDBR	ltr dtd	21	Sep	18	ICO	XXXXXXXXXX		

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

a.	XXXXXXXXXX: Placement on the Permanent Disability Retired List with a 30 percent rating (increased from 20 percent) effective date of discharge.

3.	Please take action to implement these decisions and provide notification to the above individuals once those are complete.