DCT Z 5 2018

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:

RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXX	CASE:  PD-2016-01553
BRANCH OF SERVICE:  Marine Corps 	SEPARATION DATE:  20040415

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E3, Basic Marine, medically separated for “chronic right wrist extensor tendinitis” with a disability rating of 10%.  

CI CONTENTION:  “Lifetime nerve damage and still limited use of that arm.”  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 - 20040416	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Right Wrist Extensor Tendinitis	5099-5003	10%	S/P Fracture of the Right Wrist with Open Exploration and Cyst Removal	5215-8512	20%	20040521	
Status Post (S/P) Dorsal Right Wrist Surgery w/out Clear Etiology of Pain	Cat II					
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Chronic Right Wrist Extensor Tendinitis.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s dominant right wrist condition began in March 2003 after falling on his outstretched hand on approximately day six of basic training.  At a sports medicine examination on 5 March 2003, the CI reported wrist pain for 2 days.  Physical examination showed tenderness of the anatomical snuff box (radial aspect of wrist at base of thumb) and limited wrist ROM.  Wrist X-rays were normal, including navicular series views to rule out a scaphoid fracture (suggested by snuff box tenderness).  At sports medicine follow-up visits, physical examination noted full strength of wrist extension, flexion and grip.  The median, ulnar, posterior interosseous and anterior interosseous nerves were intact.  The CI was casted for thumb tendonitis (De Quervain’s syndrome) without significant improvement.  He underwent steroid injection of the wrist and thumb extensor tendons (second and third dorsal compartments) with full, but temporary relief of his pain for a day.  MRI on 8 June 2003 showed a small ganglion cyst (joint or tendon cyst) about the scaphoid and the CI underwent surgery for removal of the ganglion cyst on 6 October 2003, without relief.  

The 25 November 2003 MEB NARSUM examination, 5 months prior to separation, noted complaints of chronic pain on the top of the right wrist.  The CI reported wrist pain with any lifting, physical exertion or extremes of flexion and extension.  Physical examination showed tenderness over the radial aspect of the wrist and second dorsal extensor compartment tendons and pain with resisted wrist extension, without swelling.  There was no palpable wrist mass or sign of reflex sympathetic dystrophy. There was no sign of instability of the wrist or hand joints, the surgical incision was well healed and non-adherent.  Wrist ROM was palmar flexion (PF) of 35 degrees and dorsiflexion (DF) of 45 degrees.  Sensation was intact.  The CI had full extension of his fingers and was able to make a full fist.  Grip strength of his dominant right hand was decreased compared with the left (usually greater), 12 to 16 kilograms compared to 40 to 44 kilograms.  Wrist X-rays showed no abnormality.  

During the 8 December 2003 MEB examination (recorded on DD Forms 2807-1 and 2808), 4 months prior to separation, the CI reported dysesthesia of the top of the hand and pain with movement of the wrist, especially palmar flexion and push-ups or “overexertion.  He reported he could perform normal routine activities.  Physical examination showed pain with wrist ROM which was reported as “within normal,” except for DF deficit of 5 degrees.  

At the 21 May 2004 VA Compensation and Pension (C&P) examination, 1 month after separation, the CI reported loss of grip strength and loss of ROM of the wrist.  Physical examination showed wrist ROM with PF of 20 degrees and DF of 15 degrees, with pain at both endpoints.  The VA examiner noted there was increased pain with repetitive movements or gripping.  There was decreased sensation over the top of the hand and decreased grip strength on the right.  Wrist X-rays were unremarkable.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right wrist condition 10%, analogously coded 5099-5003 (degenerative arthritis).  The Navy PEB’s Category II diagnosis of “S/P exploratory dorsal right wrist surgery without clear etiology of pain,” is intrinsic to the rated condition and a separate rating cannot be supported IAW VASRD §4.14 (avoidance of pyramiding).  The VA rated the right wrist condition 20%, 5215-8512 (wrist, limitation of motion of-lower radicular group, paralysis of), based on the C&P examination, citing incomplete paralysis of hand movements (mild).  

There was evidence of painful motion causing functional loss supporting the 10% rating (based on §4.59, §4.40 and §4.45) at the MEB Form 2808, MEB NARSUM and VA examinations.  The wrist ROM at the VA examination was also reasonably rated at 10% (after repetition), which is the highest rating for limitation of motion of the wrist available under 5215.  The panel also considered alternatively rating the wrist condition as analogous to a nerve condition.  Serial notes in the STR by sports medicine repeatedly noted no motor loss and no evidence of deficits of the median, ulnar, posterior or anterior interosseous nerves, which have motor components.  Grip strength was decreased on the right compared to the left at the NARSUM and the VA examination, but it is not clear whether this truly represented weakness or was related to pain with wrist movement, consistently reported by the CI.  However, the CI’s complaints of pain of the top of the wrist/hand was possibly consistent with a nerve condition known as Wartenberg’s syndrome, which is an entrapment neuropathy of the superficial branch of the radial nerve, with only sensory manifestations and no motor deficits.  The name cheiralgia (hand pain) paresthetica was suggested because of its similarity to meralgia paresthetica in the thigh, which is an analogous condition involving sensory only manifestations due to entrapment of the lateral cutaneous nerve of the thigh.  However, rating the wrist pain condition analogous to paralysis of the external cutaneous nerve of thigh (8599-8529) would also provide no higher than a 10% rating, which is the highest rating for severe to complete paralysis.  The panel concluded a 10% rating and no higher was supported for the wrist condition.  Although the panel arrived at a 10% rating recommendation using different codes than the PEB, there is no ratings benefit to the CI and therefore no change to the PEB’s coding choice is recommended.  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 right wrist condition.  

BOARD FINDINGS:  In the matter of the right wrist condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  There are no other conditions within the panel’s scope of review for consideration.  Therefore, the panel recommends no modification or re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20161017, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs