RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01024
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20040524

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Aerospace Control and Warning System Craftsman, medically separated for “reflex sympathetic dystrophy in left upper extremity (right-hand dominant)” with a disability rating of 20%.  

CI CONTENTION:  “Review all conditions.”  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 - 20040308	VARD - 20050131	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Reflex Sympathetic Dystrophy in Left Upper Extremity 	8715	20%	Reflex Sympathetic Dystrophy, Left Upper Extremity	5309-5308	20%	20040902	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Reflex Sympathetic Dystrophy in Left Upper Extremity.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s reflex sympathetic dystrophy condition began in November 2002 after jamming her left index finger playing basketball.   X-rays of the left hand and wrist demonstrated no fracture.  After a cast was removed, pain continued with swelling and increased sensitivity of the finger and dorsal hand along the shaft of the second metacarpal.  By March 2003 the pain extended from the base of her index finger metacarpal across the volar and dorsal aspects of her wrist into the radial forearm at times.  Orthopedic examination revealed a normal appearing left wrist and hand.  There was no evidence of edema, synovitis (inflammation), or swelling.  She had a full range of motion (ROM) of the wrist, but complained of pain with dorsiflexion and palmar flexion.  She was slightly tender along the first extensor tendon and had tenderness of the snuffbox and dorsal scaphoid along with diffuse tenderness.  She was also slightly tender along the index finger extension tendon, but the tenderness seemed to be out of proportion to the depth of palpation.  She had negative forearm compression testing as well as a negative carpal tunnel compression test and a negative Tinel’s test (to determine nerve irritation) of the cubital tunnel.  A bone scan revealed symmetric bilateral uptake.  Magnetic resonance imaging (MRI) post arthrogram dated 7 May 2003 revealed no tear of the TFCC (triangular fibrocartilage complex) or intercarpal ligaments and there was no obvious avascular necrosis seen.  On 12 May 2003 the CI received injections of anesthetics and a steroid into the radial scapholunate region and radial scaphoid region.  Electrodiagnostic studies were normal.  Because of pain and paresthesias of the left upper extremity a possible complex regional pain syndrome (CRPS) was considered in July 2003.  Occupational therapy treatment for the chronic left wrist pain was uncomfortable and was discontinued. An MRI of the cervical spine dated 18 July 2003 demonstrated early disc degeneration to a variable degree throughout the cervical spine without any focal disc abnormality or area of acquired stenosis (narrowing).  No cord impingement or nerve root impingement was appreciated.  A trial of Neurontin (gabapentin for nerve pain), prednisone (a steroid), and Feldene (piroxicam, a nonsteroidal anti-inflammatory drug (NSAID)) was prescribed on 29 July 2003.  On 22 August 2003 the CI’s condition was considered to be probable reflex sympathetic dystrophy (RSD) in the left upper extremity based on increasing pain in the left hand and intermittent swelling and sweating in the affected extremity not responsive to injections in the wrist, medications, or occupational therapy.  Pain management treatment consisted of a left stellate ganglion block followed 6 days later by pulsed radiofrequency denervation and a stellate ganglion block on 3 September 2003. After the procedure she had the same degree of pain in her left arm.   No further interventional pain procedures were done; however, a Lidoderm (lidocaine, an anesthetic) patch was prescribed for application to the dorsal left hand for 12 hours each day.  Neurosurgical evaluation indicated that a sympathectomy or a spinal stimulator had a less favorable chance of helping her; nevertheless, the procedures were offered to her.  However, she elected to continue with medication, which included Baclofen for spasticity and Vicodin (hydrocodone, a narcotic, and acetaminophen, a pain reliever).  Subsequently, a trial of MS Contin (morphine, a narcotic) was instituted for pain control.

The 16 February 2004 MEB NARSUM examination, 3 months prior to separation, noted complaints of pain in the left upper extremity, shoulder and neck.  Physical examination showed the CI’s neck was quite stiff and she had globally limited ROM especially to left rotation and flexion.  She had trigger points over the occipital notch bilaterally.  Neurological evaluation revealed normal cranial nerves II-XII.  The sensory examination was limited to the left upper extremity which exhibited marked hyperesthesia with minimal warmth and swelling of the left digits compared to the right.  The CI wore a wrist splint that was snug.  Strength in the unaffected extremity was normal and it was very difficult to test the affected extremity secondary to her extreme sensitivity to touch.  Deep tendon reflexes in the right upper extremity were normal.  Despite the medications, the pain related to the reflex sympathetic dystrophy persisted.  

At the 2 September 2004 VA Compensation and Pension (C&P) evaluation, 4 months after separation, the CI reported loss of strength, weakness, and constant pain.  Physical examination showed the CI’s left hand was in a brace, but was otherwise normal.  Examination of muscle Group IX, which are the hand intrinsic muscles on the left side, demonstrated 4/5 strength.  The CI was able to move the joints independently, but with limitation by pain, and she had easy fatigability.  The left wrist ROM measurements were dorsiflexion 0-60 degrees (normal 0-70), palmar flexion 0-60 degrees (normal 0-80), radial deviation 0-20 degrees (normal 0-20), and ulnar deviation 0-30 degrees (normal 0-45).  Neurologic evaluation showed normal motor function, but and increased sensation in the left upper extremity to pinprick.  Reflexes of the left biceps and triceps were 3+ compared to 2+ on the right.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the reflex sympathetic dystrophy condition 20%, coded 8715 (neuralgia of the median nerve).  The VA rated the reflex sympathetic dystrophy condition 20%, coded 5309-5308, (Group IX (intrinsic muscles of hand)-Group VIII (extensors of carpus, fingers, and thumb; supinator) muscle injury, moderately severe), based on the C&P examination 4 months after separation, citing “examination of muscle group IX, which are the hand intrinsic muscles of the left side, were 4/5. It was noted that [the CI was] able to move the joint independently with limitation by pain and easy fatigability.  The range of motion of the left wrist was limited by weakness and lack of endurance.”  

Members noted that the PEB rated the reflex sympathetic dystrophy using a median nerve code, while the VA rated the condition using a muscle code.  The PEB used the median nerve code, which initially had credence since it was the second finger that was injured.  However, in due course, the pain persisted and spread to involve the dorsum of the hand and arm.  Therefore, use of a nerve code 8712 for neuralgia (lower radicular group, incomplete paralysis of), which includes all intrinsic muscles of the hand and some or all of the flexors of the wrist and fingers is more accurate and appropriate and warrants a 30% rating for a moderate disability of her non-dominant extremity.  The use of that code and rating clearly reflects the persistent pain, hyperesthesia, and functional limitations that failed to improve with a myriad of medications, cervical injections, and stellate ganglion blocks.  However, CI elected not to undergo the offered surgical procedures of sympathectomy or spinal nerve stimulator thereby suggesting a severe disability rating at 40% is not warranted; and, the use of a muscle code does not offer a route to a higher rating.  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 reflex sympathetic dystrophy condition, coded 8712.  

BOARD FINDINGS:  In the matter of the reflex sympathetic dystrophy condition, the panel unanimously recommends a disability rating of 30%, coded 8712 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 in Left Upper Extremity (Right Hand Dominant)	8712	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160919, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

SAF/MRB
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD  20762

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2016-01024.

After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was not appropriate under the guidelines of the Veterans Affairs Schedule for Rating Disabilities.  The Board recommended your separation be re-characterized to reflect disability retirement, rather than separation with severance pay.

I carefully reviewed the evidence of record and the recommendation of the Board.    I concur with that finding, accept their recommendation and determined that your records should be corrected.  The office responsible for making the correction will inform you when your records have been changed.

As a result of the aforementioned correction, you are entitled by law to elect coverage under the Survivor Benefit Plan (SBP).  Upon receipt of this letter, you must contact the Air Force Personnel Center at XXXXXXXXXXXXXXXXXX to make arrangements to obtain an SBP briefing prior to rendering an election.  If a valid election is not received within 30 days from the date of this letter, you will not be enrolled in the SBP program unless at the time of your separation, you were married or had an eligible dependent child, in such a case, failure to render an election will result in automatic enrollment.
Sincerely,

XXXXXXXXXXXXXXXXXX
Director
Air Force Review Boards Agency

Attachment:
Record of Proceeding