RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01399
BRANCH OF SERVICE:  ARMY 	SEPARATION DATE:  20041107

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Petroleum Supply Specialist, medically separated from the Temporary Disability Retired List (TDRL) for “cervical degenerative disc disease [DDD]” and “status post left cubital tunnel decompression surgery and right carpal tunnel decompression surgery with residual pain in both forearms,” rated 10% and 0%, respectively, with a combined disability rating of 10%.  

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 it reasonably reflects the severity of the disability at the time of separation.  

RATING COMPARISON:  

SERVICE PEB - 20041007	VARD - 20011218	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Cervical DDD	5237	10%	No VA Examination Proximate to Separation in Evidence	
S/P Left Cubital Tunnel Decompression and Right Carpal Tunnel Decompression Surgery with Residual Pain in Both Forearms	5099-5003	0%		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40% 	

ANALYSIS SUMMARY:  

Cervical DDD.  According to the service treatment record (STR) and Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s neck condition began in 1994 after a fall.  An MRI in 1999 showed disc bulges at C5-6, but there was no surgical indication.  The CI was placed on TDRL effective 23 December 2000.  In 2002, the CI noted onset of pain that radiated from her neck into her shoulder, arm and hand.  A cervical spine MRI from April 2003 showed mild to moderate narrowing of the right neural foramen, but electrodiagnostic studies in May 2004 were normal.  

The 26 January 2004 MEB physical examination, recorded on DD Forms 2807-1 and 2808, 9 months prior to separation, showed pain with range of motion (ROM) testing, but measurements were not recorded.  The 19 March 2004 MEB NARSUM PE, 8 months prior to TDRL removal, showed reduced sensation over the thumb, index finger, and middle finger in both hands, but reflexes and strength were normal.  ROM measurements using an inclinometer were forward flexion of 60 degrees (normal 45) and combined ROM of 205 degrees (normal 340).  There was pain in all planes of motion.  There was no VA Compensation and Pension evaluation proximate to TDRL removal in evidence.
  
The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the neck condition 10%, coded 5237 (cervical strain), citing pain with ROM.  The panel agreed a 10% rating, but no higher, was justified for limitation of combined ROM greater than 170 degrees but not greater than 335 degrees, reported on the NARSUM examination proximate to TDRL removal.  There was no muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour, thus the next higher 20% rating was not justified on this basis.  The panel considered whether a higher rating (§4.7) was achieved by using the alternate rating formula based on incapacitating episodes due to intervertebral disc syndrome (IVDS).  Although the CI had IVDS, there were no incapacitating episodes requiring physician-prescribed bed rest to warrant consideration of rating under that formula.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded there was insufficient cause to recommend a change in the PEB adjudication for the neck condition.  

Status Post Left Cubital Tunnel Decompression and Right Carpal Tunnel [Syndrome] with Residual Pain in Both Forearms.  Panel members first noted that although the PEB adjudicated status post right carpal tunnel decompression surgery with residual pain, the CI did not have surgery on the right wrist.  The PEB combined the status post left cubital tunnel decompression and right carpal tunnel [syndrome] as a single unfitting condition coded 5099-5003 and rated 0%.  The approach by the PEB commonly reflected its judgment that the constellation of conditions was unfitting, and there was no need for separate fitness adjudications or implied adjudication that each condition was separately unfitting.  The panel’s initial charge in this case was directed at determining if the PEB’s approach of combining these conditions under a single rating was justified in lieu of separate ratings.  When considering a separate rating for each condition, the panel considers each bundled condition to be reasonably justified as separately unfitting unless a preponderance of evidence indicates the condition would not cause the member to be referred into the DES or be found unfit because of physical disability.  When the panel recommends separate fitness recommendations in this circumstance, its recommendations may not produce a lower combined rating than that of the PEB.  The evidence for the bilateral upper extremities is presented together below.  Members agreed each condition was reasonably considered separately unfitting and that separate coding and rating is applicable for each upper extremity condition.

According to the STR and MEB NARSUM, the right-hand dominant CI’s left cubital tunnel syndrome began in late 1998 without reported trauma.  Electrodiagnostic studies demonstrated bilateral carpal tunnel syndrome and left cubital tunnel syndrome with compression of the ulnar nerve at the elbow.  Decompression of the left arm peripheral compressive neuropathyies was carried out in September 1999 when the CI underwent left carpal tunnel release along with left elbow decompression of the ulnar nerve with anterior submuscular ulnar nerve transposition.  Postoperatively the CI continued to have difficulty with left arm pain along with paresthesias (tingling) and anesthesias (numbness) in the left hand as well as paresthesias and anesthesias in the right hand and fingers.  Since she did not have a very successful result with the left side surgery, operative treatment of the right side was held.  Repeat electrodiagnostic studies in March 2000 continued to demonstrate a compression neuropathy, but with significant improvement from her preoperative situation.  Examination of the left upper extremity in October 2000 revealed well-healed surgical scars over the left elbow and palmar aspect of the left wrist.  Two-point discrimination was intact to 5 mm in all five digits and there was no atrophy in the forearm or hand, although the CI had a positive Tinel’s sign (indicative of nerve irritation) at the elbow and wrist.  Provocative testing was positive for carpal tunnel syndrome and examination of the right upper extremity revealed findings consistent with carpal tunnel syndrome.  She had full ROM of her elbows, wrists and all digits bilaterally in her upper extremities.  An interim TDRL examination in November 2001 indicated the CI still had diffuse bilateral forearm pain, right more than left.  She also had thenar atrophy on the left side and decreased light touch in the median nerve distribution bilaterally.  A subsequent interim TDRL examination in August 2002 revealed mild atrophy at the thenar eminences on both sides.  Median nerve irritation was present bilaterally.  Two-point discrimination for the entire left hand was diminished and two-point discrimination on the right was diminished for the thumb, index and middle fingers at 4 mm.  The interim TDRL examination in October 2002 revealed no atrophy of the left hand or wrist.  The right upper extremity was not addressed.  

The 26 January 2004 MEB physical examination showed decreased strength and decreased sensation in the hands and fingers.  During the 28 January 2004 MEB TDRL NARSUM examination, 9 months prior to separation, the CI complained of pain with active movement, decreased sensation in her thumbs, index fingers and middle fingers and difficulty performing fine dexterity tasks.  Physical examination showed tenderness over both carpal tunnels.  She had a normal Allen’s test (to determine vascular status) bilaterally, a positive compression test bilaterally and positive Phalen and Tinel signs (to determine median nerve irritation) bilaterally.  She had diminished light touch sensation over her thumbs, index and middle fingers of both hands.  The examiner’s diagnoses were bilateral carpal tunnel syndrome with median nerve neuropathy.  He opined that the CI’s condition had not changed and he thought she had reached the static state of pain and was not likely to improve in the future.    

At an occupational therapy evaluation on 23 August 2004, 3 months before separation, the CI reported residual symptoms consisting of constant 8/10 arm pain, right greater than left, and tingling at night in both upper extremities.  She was not wearing wrist braces and was independent with activities of daily living and work.  Active ROM was within normal limits for both upper extremities.  She made a good composite fist with no significant hypothenar atrophy noted.  Two-point discrimination for the median nerve of both the right and left hands was 4 mm each, while for the ulnar nerve was 5 mm on the right and 4 mm on the left.  Grip strength was equal bilaterally at 10, 7, 10 pounds and pinch strength was diminished.  The examiner noted the demonstrated strength was not functional and may have been an indication of magnification.  Further testing was recommended.  On 5 October 2004, 1 month before separation, the CI completed four different upper extremity strength tests.  Electric strength testing showed markedly reduced grip strength in the first percentile (right 45 inch pounds and left 33 inch pounds); first percentile in pinch strength (right 11 inch pounds and left 10 inch pounds); 13th percentile right wrist flexion (40 inch pounds) and fourth percentile left wrist flexion (39 inch pounds); and 20th percentile elbow flexion test (right 63 inch pounds and left 56 inch pounds).  The examiner indicated the CI demonstrated full effort, had no evidence of symptom magnification and had functional strength and active motion of the bilateral upper extremities.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral upper extremity conditions at 0%, coded analogous to 5003 (degenerative arthritis), citing residual pain in both forearms, which presented as numbness and tingling.  Members noted the status post left cubital tunnel decompression and left median nerve radiculopathy (median carpal tunnel) surgery conditions were essentially unchanged since TDRL placement.  The CI had decreased grip and pinch strength as well as diminished wrist and elbow flexion strength on the left along with numbness and tingling.  Therefore, the panel determined that a 20% rating was warranted using code 8599-8511 (middle radicular group) since there was involvement of both the ulnar nerve and median nerve as a result of left cubital and left carpal tunnel surgeries.  Separate codes were considered such as the median nerve code (8515) for the cubital tunnel syndrome instead of the ulnar nerve code (8516).  Nevertheless, panel members noted code 8599-8511 not only captured the full extent of the disability, but was also consistent with TDRL placement coding, and there was no significant change in the clinical status of the left upper extremity from TDRL placement to TDRL removal.  While the CI apparently did not undergo surgery on the right for carpal tunnel syndrome, grip strength and pinch strength were diminished.  Therefore, the panel determined a 10% rating using code 8599-8515 was applicable.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 20% for the left upper extremity condition, coded 8599-8511 and a disability rating of 10% for the right upper extremity condition, coded 8599-8515.

BOARD FINDINGS:  In the matter of the neck condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the left upper extremity condition, the panel unanimously recommends a disability rating of 20%, coded 8955-8511 IAW VASRD §4.124a.  In the matter of the right upper extremity condition, the panel unanimously recommends a disability rating of 10%, coded 8599-8515 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 as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Cervical DDD	5237	10%	
S/P Left Cubital Tunnel Decompression and Left Median Nerve Radiculopathy (Carpal Tunnel Syndrome)	8599-8511	20%	
Right Carpal Tunnel Syndrome	8599-8515	10%	
COMBINED	40%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20161011, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

AR20180001577, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

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 
 
	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.

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

Sincerely,					      
Enclosure