RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-00619
BRANCH OF SERVICE:  army	SEPARATION DATE:  20050504

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, M1 Armor Crewman, medically separated for “left cubital tunnel syndrome with left carpal tunnel syndrome” and “chronic neck pain with osteophytes,” each rated 10%, with a combined 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 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 - 20050316	VARD - 20060103	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Cubital Tunnel Syndrome with Left Carpal Tunnel Syndrome 	8599-8516	10%	Left Cubital Tunnel Syndrome with Left Carpal Tunnel Syndrome	8516-8515 	60% 	20050727 	
Chronic Neck Pain with Osteophytes	5299-5237	10%	Degenerative Osteoarthritis Cervical Spine	5242	10%	20051221	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  80%	

ANALYSIS SUMMARY:

Left Cubital Tunnel Syndrome with Left Carpal Tunnel Syndrome.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI developed pain and sensory symptoms in his non-dominant left upper extremity (LUE) during a 2003 deployment to Iraq.  Electrodiagnostic testing (EMG) identified “mild to moderately severe” cubital tunnel and carpal tunnel syndromes on the left.  All STR entries were directed at the LUE, although several mentioned right upper extremity (RUE) symptoms that were characterized as minor.  With regards to the LUE, there was STR documentation of ROM limitation and painful motion of the elbow, although several entries described grossly normal ROM of all LUE joints.  There was no indication in STR of guarded positioning of the elbow as described below in the VA examination; and, although there was documentation of joint tenderness, there was no indication of the exquisite sensitivity to touch (hyperesthesia) described in the VA findings.  Multiple STR entries documented non-specific LUE weakness with decreased grip strength.  A more detailed examination graded strength as “4/5 in flexors and 3-4/5 in extensors.”  An occupational therapist recorded a very low measurement for left grip strength (6 pounds), but this was so incongruent with the rest of the clinical evidence (including EMG findings) that it was suggestive of voluntary guarding and of little probative value for validly quantifying grip strength.  

The 3 November 2004 MEB NARSUM examination, 6 months prior to separation, documented complaints of constant slight burning pain at the left wrist, which radiated to the elbow with extreme tenderness at the left elbow and numbness of the left fourth and fifth fingers.  The examiner noted that the LUE symptoms and strength were improving with therapy and were “much more severe than” the RUE symptoms.  The NARSUM noted functional limitations of dropping objects from the left hand, interference with keyboard work, and “very minimal lifting ability with the left hand alone.”  Physical examination recorded LUE strength as 4/5 for both flexors and extensors and intact sensation to monofilament testing.  There was decreased left elbow flexion of 115 degrees (normal 145) due to “significant pain.” Although there was only “mild” pain with pronation and supination, the examiner noted “moderate to severe” tenderness of the left elbow over the ulnar nerve.  

A 15 December 2004 neurology consultation, 5 months before separation, documented an improving clinical course, with some motor and sensory deficits that were confined to the left hand and wrist.  Reflexes were normal and motor strength proximal to the wrist was intact.  There was no note of hyperesthesia or guarding.  The neurologist opined that surgery (possible ulnar transposition) would only be indicated “if there [was] worsening of motor changes.”

At the 27 July 2005 general VA Compensation and Pension (C&P) evaluation, 3 months after separation, the CI complained of “left hand and wrist” pain rated 3/10 and present “about 2 hours a day,” along with constant numbness of the “entire” LUE.  Documented functional limitations were interference with using a keyboard, dropping things from the left hand and difficulty carrying with the left hand.  Of note, the C&P examination for the neck (5 months later, details below) documented that the CI was a full-time student with no time loss for medical reasons.  The VA examiner stated that the LUE physical examination was “extremely difficult” because of diffuse hyperesthesia.  The elbow was guarded in partial flexion and pronation and did not permit active or passive ROM at the elbow (5 degrees leeway in flexion, none in supination).  The VA examiner noted findings of fasciculations (muscle twitching) and skin color lability that were not corroborated by service examiners, and postulated a diagnosis of reflex sympathetic dystrophy (also known as complex regional pain syndrome (CRPS)).  No motor testing was documented other than “markedly decreased” left hand grip.  Reflexes were symmetric and sensation was intact to “light touch, temperature, and 2-point discrimination.”  The examiner opined that “the major disability is from the ulnar [i.e., cubital] tunnel syndrome.”  

In addition to the left cubital tunnel syndrome, the MEB submitted bilateral carpal tunnel syndrome as a separate condition that failed retention standards.  The neurology consultant, opined that the cubital tunnel syndrome failed retention standards, but specified only that there was “no evidence of motor changes on examination” with regard to the carpal tunnel syndrome.  The PEB’s DA Form 199 decision subsumed the bilateral carpal tunnel submission with the unfitting LUE condition, without stipulating a separate fitness determination.  The profile was for “arm pain with numbness” and the commander’s statement was equally non-specific with regard to RUE involvement.  Later in the clinical course a left arm cervical radiculopathy was diagnosed, but it will not be addressed further since it would pyramid (VASRD §4.14) with the rated neuropathies and was not submitted by the MEB or adjudicated by the PEB.

The panel directed attention to its rating recommendation based on the above evidence.  Members first addressed the RUE component of the bilateral carpal tunnel syndrome that was subject to a separate VASRD rating as conferred by the VA.  It was agreed that it was within scope (as defined above) since it was submitted by the MEB and subsumed in the PEB rating.  In order to recommend service rating for the RUE condition, however, it must be reasonably justified as separately unfitting; and, members agreed that there was insufficient performance-based evidence for doing so.  There was no NARSUM evidence for any objective RUE neurological deficits or significant functional impairment, and the above neurology opinion was a compelling argument that the RUE carpal tunnel syndrome was not associated with any potentially unfitting impairment.

The panel then turned to deliberation of an appropriate rating recommendation for the unfitting LUE neuropathies.  The PEB’s 10% rating under code 8599-8516 (analogous to incomplete paralysis of the ulnar nerve) did not cite a rationale, but the applicable criterion is “mild” nerve impairment.  Code 8516 offers ratings (minor) of 20% for “moderate” and 30% for “severe” impairment.  The VA‘s 60% rating, based on the C&P evidence, was under code 8516-8515 (incomplete paralysis of the ulnar nerve and median nerve).  Code 8515 offers ratings (minor) of 20% for “moderate” and 40% for “severe” impairment.  The VA rating decision did not clarify how it arrived at a rating higher than the maximum for either code.  It could only be surmised that ratings were added from each code, although it was noted the only combination yielding 60% would be “moderate” cubital tunnel plus “severe” carpal tunnel.  Members agreed, however, that the closely related cubital and carpal neuropathies could not be functionally isolated for separate disability ratings without violation of VASRD §4.14.  

The panel therefore concluded that its recommendation should be premised on the criteria from only one of the involved nerves.  Although as a “severe” rating the carpal tunnel (wrist) code was favorable (40% vs 30%), the collateral clinical evidence indicated that the elbow (cubital tunnel) was the dominant source of pain, and it was the dominant disability in the VA examiner’s opinion.  Members thus agreed that code 8516 was the most applicable to this case for the determinant rating scale.  The appropriate code based on the above logic is 8515-8516 indicating that both nerves were subsumed under rating criteria of 8516.  Members further agreed that separate (or alternate) ratings premised on VASRD §4.71a joint codes for ROM limitation was not justified, concluding that there was no clinically identified joint pathology and that any ROM limitation was a consequence of the neuropathies.  Only the latter constituted an unfitting condition within the panel’s scope of review, and ROM limitation due to the same pain would be subsumed in the same rating.

Having so concluded, the panel turned to deliberation of the fairest rating of the LUE neuropathies under the above criteria.  In that regard, there was a disparity in the severity of the disability as portrayed by the service evidence versus the VA evidence, and members considered the probative value of the conflicting evidence.  It was possible that the acuity had worsened by the time of the C&P examination with the development of CRPS, as suggested by the fasciculations and skin color lability reported by that examiner, but members agreed that it would be overly speculative to conclude that this should influence the recommendation for service rating.  There was no service diagnosis of CRPS or STR evidence indicating its presence.  Members also considered that the service neurology consultation was the only specialty evaluation in evidence and was nearly as temporally probative to separation as the C&P examination by a general provider.  Furthermore, there was a disconnect in the C&P evidence between the stated severity (pain 3/10 for 2 hours a day, numbness) and the joint guarding, etc.; and, the C&P examiner did not provide objective findings for motor strength.  Members therefore agreed that the service neurology and NARSUM evidence carried the determinant probative value for the panel’s recommendation.  

Based on the above conclusions, panel members agreed that the “severe” (30%) rating was not justified by the objective functional evidence.  Motor strength was reasonably preserved (intact above the wrist per the neurologist, 4/5 in the NARSUM), and objective sensory deficits were only intermittently documented with no indication that they were severe (intact to fine touch in the NARSUM and C&P).  The documented functional limitations appeared to be confined to fine dexterity tasks, reliable grasp, and heavy lifting or carrying with the non-dominant hand.  Members next considered whether this degree of impairment was more fairly characterized as “moderate” (20%) or “mild” (10%) disability.  Especially considering that the neurological severity may have been progressing around the time of separation, the panel majority agreed that reasonable doubt favored a concession that the disability was more fairly characterized as “moderate” for rating.  After due deliberation, considering all of the evidence and conceding VASRD §4.3 (reasonable doubt), the panel’s consensus recommendation is a 20% rating for the LUE neuropathies under code 8515-8516.

Chronic Neck Pain with Osteophytes.  The CI experienced an atraumatic onset of neck pain in 2003 concurrently with the above upper extremity complaints.  Imaging (including MRI and CT) demonstrated diffuse mild degenerative changes without disc bulging.  Surgery was not recommended.  There was STR documentation of cervical ROM ranging from grossly normal to 25-75% reductions in various planes.  The only measured ROM in the STR was dated 12 November 2004, 6 months before separation, and documented flexion of 45 degrees (normal) and combined ROM of 305 degrees (normal 340), without addressing painful motion.  There was STR documentation of a normal spinal contour and there was no documentation of incapacitating episodes.  The 3 November 2004 NARSUM documented neck pain aggravated by wearing Kevlar, jostling in vehicles, and extreme rotation or extension.  Physical examination recorded “mild” tenderness and cited the above ROM measurements.  

The 21 December 2005 orthopedic C&P evaluation, 8 months after separation, documented pain rated 1-2/10 at baseline and 4-5/10 during flares.  The only documented functional limitation was occasional jolts of pain with head turning, and the examiner noted that the condition had not interfered with the CI’s fulltime educational pursuits (referenced above).  Physical examination recorded “slight” tenderness without note of spasm or abnormal contour.  Measured ROM was flexion to 45 degrees with a combined ROM of 325 degrees, specifying no pain with flexion but painful motion in all other planes.  Of note, the examiner stated that flexion (with no initial painful motion) was reduced to 30 degrees (20% rating threshold) with repetition.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the neck condition 10% analogously coded 5299-5237 (cervical strain), citing painful motion and tenderness.  The VA rated the neck condition 10% coded 5242 (degenerative arthritis of the spine), based on the C&P evaluation 8 months after separation, citing limitation of flexion.  
The panel agreed the totality of the STR evidence showed no ROM evidence supporting a rating higher than 10%.  The panel considered whether a 20% recommendation could be supported by conceding determinant probative value to the C&P ROM (flexion to 30 degrees), but members agreed that it could not.  The VA evidence was more temporally remote and the deterioration of painless normal ROM by such an extent with repetition was somewhat clinically incongruous.  There was no evidence for abnormal spinal contour to support a 20% rating, and no documentation of incapacitating episodes that would provide for a higher rating under that formula.  After due deliberation, considering all evidence and with deference to reasonable doubt, the panel concluded that there was insufficient cause to recommend a change in the PEB adjudication of the cervical spine condition.

BOARD FINDINGS:  In the matter of the left upper extremity neuropathies (subsuming right carpal tunnel syndrome), the panel majority recommends a disability rating of 20%, coded 8517-8516 IAW VASRD §4.124a.  The single voter for dissent recommends no change and does not elect to submit a minority opinion.  In the matter of the cervical spine 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.

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 his prior medical separation:

CONDITION	VASRD CODE	PERMANENT RATING	
Cubital and Carpal Tunnel Neuropathies, Left Upper Extremity	8515-8516	20%	
Degenerative Arthritis, Cervical Spine	5299-5237	10%	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170214, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

AR20180004716, 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 30% 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 minus the amount of severance pay you were previously paid at 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, (AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557.

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

Sincerely,					      
Enclosure