RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXX	CASE:  PD-2016-00902
BRANCH OF SERVICE:  Navy	SEPARATION DATE:  20020405

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Pharmacy Technician, medically separated for “bilateral cubital tunnel syndrome” with a disability rating of 20%.  

CI CONTENTION:  A lengthy contention was submitted requesting the PDBR do a review for fairness of his disability adjudication.  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 - 20020102	VARD - 20020627	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Cubital Tunnel Syndrome	5299-8616
5299-8616	10%+
   10%	Cubital Tunnel Syndrome Right Hand	8516	10%	20020129	
			Cubital Tunnel Syndrome Left Hand	8516	0%	20020129	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Bilateral Cubital Tunnel Syndrome.  According to the service treatment record and MEB narrative summary (NARSUM), the right-handed CI’s bilateral carpal tunnel condition began in early 2001 while he was serving as a pharmacy technician performing repetitive twisting of bottle caps.  An EMG and nerve conduction test performed on 26 September 2001 revealed no abnormal electrophysiological findings on the upper extremities.  

During the 29 October 2001 MEB examination (recorded on Standard Forms 88 and 93), 5 months prior to separation, the CI reported bilateral carpal tunnel syndrome with pain, numbness, and tingling of the hands up to the elbows which lasted for 4-6 hours after activity.  He indicated the right arm also swelled and he lost sleep due to his illness.  He was on limited duty and had been wearing a brace and a splint at night for 7 months.  Physical examination revealed bilateral carpal tunnel syndrome with positive tests (Tinel’s and Phalen’s) for nerve irritation.  There was decreased motor strength of the hand (4+/5) with paresthesias of bilateral hands and forearms.  

The 26 November 2001 MEB NARSUM examination, 4 months prior to separation, noted CI complaints of bilateral (right worse than left) paresthesias at the small and ring fingers and part of the middle finger.  He had nighttime symptoms that awakened him on a regular basis.  Physical examination revealed bilateral positive tests for nerve irritation at the cubital tunnel, flexor carpi ulnaris, for the ulnar nerve, and at the wrist for the median nerve.  There were positive hyper flexion tests at the elbows with paresthesias at the small and ring fingers.  The motor intrinsic examination (spread the fingers [or reverse]) on the right was weaker (4+/5) than the left (5/5).  Grip strength was 16 kg on the right and 30 kg on the left.  Thenar strength and sensory examinations were normal bilaterally.  Elbow range of motion (ROM) was 0-125 degrees on each side (normal 0-145), with no mention of painful motion.  The examiner indicated that the CI failed conservative treatment to include splinting at the elbow, as well as at the wrist, even with nocturnal use; and that “his weakness is such that continued use of the extremities in the current capacity may exacerbate his symptoms to the point where even with the submuscular transposition (surgery), his strength may not return.”  

At the 29 January 2002 VA Compensation and Pension (C&P) examination, 2 months before separation, the CI reported bilateral cubital tunnel syndrome with the right worse than the left.  There was numbness from both elbows down with pain and in the elbows down into the fingers with numbness and tingling.  He had numbness and tingling into the fourth and fifth fingers.  Physical examination showed “there is some weakness, especially in the right hand.”  There was no hand atrophy or wasting and no intrinsic muscle weakness in the right hand that was noted on previous examinations.  Both elbow had painful motion with normal ROM.  EMG of both upper extremities was normal.  There was positive Tinel and Phalen signs of the right elbow.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral cubital tunnel syndrome condition 20%; specifying 10% for the right wrist and 10% for the left wrist, each analogously coded 5299-8616 (ulnar nerve, neuritis).  The VA rated the right cubital tunnel condition 10%, coded 8515 (ulnar nerve, paralysis of), based on the C&P examination, citing positive Tinel and Phalen signs of the right elbow and slight painful motion of the right elbow and weakness of the right hand.  The VA rated the left cubital tunnel condition 0%, coded 8515, based on the C&P examination, citing a non-compensable evaluation for the left since the examination showed weakness and subjective complaints of numbness and tingling on the left elbow and the fourth and fifth fingers.  

The panel considered the tenants of VASRD §4.123 (neuritis, cranial or peripheral) with the maximum rating for neuritis not characterized by organic changes as “moderate;” and the clarification under §4.124a 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 ….”  

The NARSUM and VA examinations clearly identified the ulnar nerve as impacted, and both examinations noted neuritis as well as decreased strength in the hands and/or elbows, with the dominant right hand having more significant weakness.  The panel considered that the NARSUM’s measured grip strengths with a more detailed examination had a higher probative value for rating at separation than the C&P examination.  Normal male age-adjusted grip strengths (reference Physiotherapy 92(1):11-15·- March 2006) compared to the NARSUM measurements are:  right grip strength 16 kg (normal 44.3-63.6) and left grip strength 30 kg (normal 41.1-58.9).  

The panel adjudged that there was insufficient evidence that the left cubital tunnel met the next higher “moderate” rating level under codes 8616 or 8516.  The panel next deliberated if the decreased right (dominant) hand grip strength and neuritis symptoms more closely approximated the disability picture of a “moderate” incomplete paralysis for the ulnar nerve.  Given the dominant hand grip weakness of less than 40% of the normal, as well as neuritis in the ulnar and median nerves, the panel adjudged that the right ulnar nerve condition more nearly approximated the disability picture of a “moderate” incomplete paralysis for the ulnar nerve.  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 cubital tunnel syndrome condition, coded 8616-8516, and no change in the 10% disability rating for the left cubital tunnel syndrome condition.  

BOARD FINDINGS:  In the matter of the bilateral cubital tunnel syndrome condition, the panel recommends a disability rating of 30% for the right cubital tunnel syndrome condition, coded 8616-8516, and no change in the 10% disability rating for the left cubital tunnel syndrome condition; both IAW VASRD §4.124a.  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	
Right Cubital Tunnel Syndrome	8616-8615	30%	
Left Cubital Tunnel Syndrome	5299-8616	10%	
COMBINED	40%	

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: