RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-01584
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070120

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Parachute Rigger, medically separated for “chronic neck pain” and “bilateral carpal tunnel syndrome (CTS),” rated 10% each, 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 - 20061211	VARD - 20070522	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Neck Pain	5299-5237	10%	Cervical Strain 	5243	10%	20070414	
Intervertebral Disc Degeneration, C5-6, C6-7	Not Unfitting					
Right Carpal Tunnel Syndrome	8799-8715	10%	Carpal Tunnel Syndrome, Right	8515	10%	20070414	
Left Carpal Tunnel Syndrome	Not Unfitting	Carpal Tunnel Syndrome, Left	8515	10%	20070414	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  40% 	

ANALYSIS SUMMARY:  

Chronic Neck Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s neck condition became symptomatic in June 2006 after conducting over 250 parachute jumps.  Cervical spine MRI showed degenerative disc changes with disc bulging at C5-6 and C6-7 with loss of disc hydration at C3-4 and C4-5.  There was no disc herniation, cord stenosis or nerve impingements.  
The 10 September 2006 MEB NARSUM examination, 4 months prior to separation, noted complaints of neck pain and tightness, often radiating to the upper shoulder/trapezius regions.  Physical examination showed 5/5 strength, tenderness and negative axial loading test.  There were several myofascial trigger points in the paracervical and upper trapezius musculature that reproduced symptoms.  A physical therapy (PT) examination on 12 September 2006, 4 months prior to separation, showed a range of motion (ROM) measurements of flexion to 30 degrees (45 normal), with pain, and combined ROM of 275 degrees, with pain.

At the 14 April 2007 VA Compensation and Pension (C&P) examination, 3 months after separation, the CI reported dull, stabbing and burning pain in his neck radiating to the shoulders and causing daily headaches.  Physical examination showed tenderness.  ROM of the cervical spine was forward flexion of 40 degrees and combined ROM of 290 degrees, with painful limitation of motion in all planes.  

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 limitation of motion.  The PEB found the comorbid cervical intervertebral disc degeneration not unfitting.  However, the panel notes that any disability from the intervertebral disc degeneration of the neck is part and parcel of the unfitting neck condition and is properly subsumed into the overall rating of the neck condition.  The VA rated the neck condition 10%, coded 5243 (intervertebral disc syndrome (IVDS)), based on the C&P examination, citing limitation of forward flexion.  The panel majority agreed that a 20% rating, but no higher, was justified for limitation of cervical flexion greater than 15 degrees but not greater than 30 degrees, as reported on the MEB NARSUM examination proximate to separation.  There was no ankylosis, thus the next higher 30% rating was not justified.  There was no documentation of IVDS with incapacitating episodes that required bed rest prescribed by a physician, which would provide for a higher rating under that formula.  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 neck condition, analogously coded 5299-5237.  

Right Carpal Tunnel Syndrome.  According to the STR and MEB NARSUM, the CI underwent electrodiagnostic studies (EMG/NCS) on 5 June 2006, which were consistent with a chronic, moderate grade II CTS on the right.  The 10 September 2006 MEB NARSUM examination, 4 months prior to separation, noted complaints of intermittent tingling and numbness in both hands at night or after prolonged repetitive activities.  Physical examination showed mild decreased sensation to pin prick and temperature in the median dermatomal distribution in both hands.  Negative Tinel's sign at the wrists.  The examiner concluded that the sensory changes were consistent with mild to moderate right CTS.  

At the C&P examination the CI reported pain, weakness and fatigue of the right wrist.  The examiner noted that the CI wore a brace on his wrist.  The Phalen and Tinel tests were both positive for CTS.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right wrist condition 10%, analogously coded 8799-8715 (neuralgia), citing the US Army Physical Disability Agency pain policy.  The VA rated the right wrist condition 10%, coded 8515 (median nerve paralysis), based on the C&P examination, citing mild incomplete paralysis of hand movements.  There was no ankylosis or limitation of motion of the wrists to justify a rating under VASRD wrist codes (5214, 5215).  There was no paralysis, muscle weakness (grip strength) or muscle atrophy noted to justify a rating under code 8515.  Electrodiagnostic studies were abnormal and there was some mildly decreased sensation.  The VASRD codes 8515 (median nerve paralysis), 8615 (median nerve neuritis) and 8715 (median nerve neuralgia) rely on designations of mild, moderate of severe muscle disability for arriving at the appropriate rating evaluation.  This rating scheme entails a judgment call regarding the severity of muscle disability, especially between the moderate and severe level distinction.  A rigid assessment could require 3/5 or worse strength testing to merit the moderate rating.  More liberal rating applies to any objective motor impairment or atrophy as a threshold for the moderate designation.  In this case, the panel agreed that the CI had primarily a CTS sensory manifestation, ratable under code 8715.  There was no decreased grip strength secondary to pain noted and there was no other motor impairment present at the time of separation.  The panel concluded that the level of impairment due to pain was no more than mild as adjudicated by the PEB and did not cross into the moderate category and therefore, there was no applicable higher rating for the right CTS.  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 CTS condition.

Contended PEB Condition:  Left Carpal Tunnel Syndrome.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended condition was not unfitting.  The left CTS condition was clearly profiled, implicated in the commander’s statement and judged to fail retention standards by the MEB.  The PEB however, disagreed and considered the left wrist to be not unfitting.  There was performance-based evidence from the commander’s statement that both wrists significantly interfered with satisfactory duty performance.  The commander stated that the CI was unable to execute his normal duties of using his hands and wrists to move or carry heavy materials or carry and handle life-saving equipment due to bilateral CTS.  The panel noted that there was little distinction in the severity of symptoms between the left and right wrists.  The panel therefore concluded there was sufficient cause to recommend a change in the PEB fitness determination for the contended left wrist condition and an additional disability rating is recommended.  

The electrodiagnostic studies completed on 5 June 2006 were consistent with a chronic, very mild grade I CTS on the left.  The MEB NARSUM examination noted complaints of intermittent tingling and numbness in both hands at night or after prolonged repetitive activities.  Physical examination showed decreased sensation to pin prick and temperature in the median dermatomal distribution of the left hand.  There was negative Tinel's sign at the wrists.  The examiner concluded that the sensory changes in both hands were consistent with mild to moderate bilateral CTS.  

At the VA C&P examination, the CI reported pain, weakness and fatigue of his left wrist.  The examiner noted that the CI wore a brace on his wrist.  The Phalen and Tinel tests were both positive for CTS.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB found the left wrist condition not unfitting.  The VA rated the left wrist condition 10%, coded 8515 (median nerve paralysis), based on the C&P examination, citing mild incomplete paralysis of hand movements.  There was no ankylosis or limitation of motion of the wrists to justify a rating under VASRD wrist codes (5214, 5215).  There was no paralysis, muscle weakness (grip strength) or muscle atrophy noted to justify a rating under code 8515.  Electrodiagnostic studies were abnormal and there was some mild decreased sensation.  The panel agreed that the CI had primarily a CTS sensory manifestation ratable under code 8715.  There was no decreased grip strength secondary to pain noted and there was no other motor impairment present at the time of separation and his EMG showed only a very mild grade I CTS.  The panel agreed that a 0% rating was justified for impairment due to pain which was no more than mild.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 0% for the left wrist condition, analogously coded 5299-5237.  

BOARD FINDINGS:  In the matter of the neck condition, the panel majority recommends a disability rating of 20%, analogously coded 5299-5237 IAW VASRD §4.71a.  The single voter for dissent recommends no change, but did not elect to submit a minority opinion.  In the matter of the right CTS and IAW VASRD §4.124a, the panel recommends no change in the PEB adjudication.  In the matter of the contended left CTS, the panel agrees it was unfitting and recommends a disability rating of 0%, analogously coded 5299-5237 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	
Chronic Neck Pain	5299-5237	20%	
Right Carpal Tunnel Syndrome	8799-8715	10%	
Left Carpal Tunnel Syndrome	8799-8715	0%	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170228, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record

AR20180007953  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), XXXXXXXXXXXXXXXXXX.

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

Sincerely,					      
Enclosure