RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-01698
BRANCH OF SERVICE:  army 	SEPARATION DATE:  20040405

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E6, Human Resources Specialist, medically separated for “bilateral carpal tunnel” and “right knee arthritis,” rated 10% and 0%, respectively, with a combined disability rating of 10%.  

CI CONTENTION:  “I had 2 surgeries on my right knee due to work in the Army.”  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 - 20040218	VARD - 20041013	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Carpal Tunnel	8799-8715	10%	Right Carpal Tunnel Syndrome With Cubital Tunnel Syndrome	5307-8616	10%	20040616	
Left Carpal Tunnel	8799-8715	0%	Left Carpal Tunnel Syndrome with Cubital Tunnel Syndrome	5307-8616	10%	20040616	
Right Knee Arthritis	5003	0%	Residuals Of Right Knee ACL. Surgery With Degenerative
Joint Disease	5010-5257	0%	20040616	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS: 30%	

ANALYSIS SUMMARY:  

Right and Left Carpal Tunnel.  The PEB DA Form 199 noted bilateral carpal tunnel; however, it assigned separate ratings for unfitting right carpal tunnel 10%, and unfitting left carpal tunnel 0%.  Both the right and left carpal tunnel syndrome (CTS – median nerve compression at the wrist) conditions are discussed together below for administrative efficiency.  

According to the service treatment record (STR) and MEB narrative summary (NARSUM), the right hand dominant CI underwent right carpal tunnel repair in October 2001.  The surgery was unsuccessful as demonstrated on electrodiagnostic testing in March 2002.  The report indicated there was mild right CTS, unchanged from the June 2001 study which was prior to surgery, and mild bilateral cubital tunnel (ulnar nerve compression at the elbow) syndrome.  The left was unchanged from the June 2001 study; the right was a new finding.  There was a median to ulnar nerve anastomosis (Martin-Gruber anastomosis) noted bilaterally, a variant of normal anatomy which was also noted on the 2001 study.  The CI declined repeat surgery on the right hand.  The 3 December 2003 physical therapy evaluation measured range of motion (ROM) for the MEB.  Right wrist ROM after three repetitions was palmar flexion (PF) of 84 degrees (normal 80) and dorsiflexion (DF) of 70 degrees (normal 70); left wrist ROM (noted to be the “unaffected” joint) was PF 85 degrees and DF 79 degrees.  

The 12 January 2004 MEB NARSUM examination, 3 months prior to separation, noted complaints of needing to frequently release fingers and decrease elbow flexion which impaired repetitive motions such as firing a weapon, standing at parade rest, or donning respiratory protective equipment or helmet.  The CI reported referred pain to her neck and upper extremities.  Physical examination showed the bilateral upper extremities were normal to inspection.  There was no atrophy of the hands (hypothenar or thenar eminence).  There was a negative Tinel’s sign at the right wrist, but a positive Tinel’s sign over the pronator teres (median nerve compression at the elbow or proximal forearm).  Tinel’s sign [presumably at the wrist] was negative on the left, but positive over the cubital tunnel, greater on the left than right.  Muscle strength of the upper extremity was graded 5/5 including wrist flexion and extension, except for mild weakness (graded 4+/5) of the flexion of the ulnar fingers (digits 4 and 5) and very mild weakness (graded 5-/5) of finger opposition, digits 1-5.  The MEB NARSUM examiner indicated the CI had right greater than left carpal tunnel with residual pain in the right hand despite surgical release.  

At the 16 June 2004 VA Compensation and Pension (C&P) examination, 2 months after separation, the CI reported CTS for 10 years.  She reported numbness, tingling, and weakness in all fingers and the medial arm bilaterally.  The CI’s functional impairment was described as the inability to grip with full strength.  The CI was noted to be right-hand dominant.  Physical examination of the right wrist showed a well-healed scar that was tender.  The left wrist was normal in appearance.  Right and left wrist ROM was the same with DF of 45 degrees and PF of 50 degrees, with pain at end ROM.  The right and left wrist ROM was noted to be additionally limited by pain, but not fatigue, weakness, lack of endurance, or incoordination.  No additional loss of wrist ROM with repetition was documented.  There were positive Tinel’s and Phalen’s signs at the wrists bilaterally.  Reflexes were normal.  Grip strength was graded 4/5 bilaterally.  Decreased sensation was noted of the medial elbow and forearm and whole hand.  The examiner stated there was median and ulnar neuritis.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right carpal tunnel condition 10%, and the left carpal tunnel condition 0%, both coded 8799-8715 (median nerve neuralgia), an analogous code for CTS, citing “muscle testing 4+/5.”  The VA separately rated the left and right wrist condition 10% each, coded 5307-8616 (muscle group VII injury [includes finger flexors] - ulnar nerve neuritis), based on the C&P examination, citing mild incomplete paralysis of finger and wrist movements.  

Electrodiagnostic studies during active duty indicated the CI had a normal nerve variant in both forearms known as a Martin-Gruber anastomosis.  This was described as a communication between the median and ulnar nerves in the forearm.  This nerve variant can cause confusion in diagnosis of CTS because of unusual patterns of symptoms, as well as confusion in interpreting electrodiagnostic studies.  The CI had symptoms of both the right and left arms and hands with positive clinical examination for bilateral peripheral neuropathies of both upper extremities documented at both the MEB NARSUM and VA examinations.  Mildly decreased strength of the hands was noted at the MEB NARSUM examination, and at the VA examination there was positive clinical testing of CTS of both the right and left wrists, mild weakness of grip strength bilaterally, and decreased sensation in both forearms and hands.  The rating criteria of 8715 is subjective with a 10% rating for mild CTS and 30% rating for moderate CTS (dominant upper extremity) and 20% for moderate CTS (non-dominant upper extremity).  Based on the evidence above, the panel majority agreed there was evidence to support a 10% rating under 8799-8715 (or 8699-8615) for mild bilateral CTS.  There was no evidence of moderate CTS of either extremity manifested by such things as weakness sufficient to cause dropping of objects or sensory loss which impaired the use or safety of the arms or hands.  There was no higher rating than 10% supported by the evidence for the CTS of either arm.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel majority recommends a disability rating of 10% for the left carpal tunnel condition, coded 8799-8715; however, the panel concluded that there was insufficient cause to recommend a change in the PEB adjudication for the right carpal tunnel condition of 10%.  

Right Knee Arthritis.  According to the STR and MEB NARSUM, the CI underwent right knee surgery in 1988 while in high school for a torn anterior cruciate ligament (ACL).  She entered the Army with a waiver in 1993 and injured her knee in basic training.  She recovered from this injury but there was suspicion of a partial tear of the ACL graft.  She underwent a MEB and was found fit for duty with a P3 profile.  In 1995 the graft tore completely after a slip and fall on ice.  After a year of healing she underwent another surgery for ACL reconstruction.  In 1999 orthopedic re-evaluation showed a failed reconstruction.  Subsequently, the CI had multiple arthroscopies.  On 10 July 2003, right knee arthroscopy showed patellofemoral chondromalacia and knee joint degenerative joint disease.  At the 3 December 2003 physical therapy ROM evaluation, 4 months before separation, right knee ROM after three repetitions was flexion 127 degrees (normal 140) and extension 0 degrees (normal 0).  Painful motion was not addressed.

The 12 January 2004 MEB NARSUM examination, 3 months prior to separation, noted complaints of chronic anterior knee pain, aggravated by cold weather.  The CI reported she could not get up from sitting or prone positions without help and could not squat or kneel.  Physical examination showed a mildly antalgic gait.  On inspection of the lower extremities, there was a well healed anterior knee scar, with mild to moderate right knee effusion.  There was no muscle atrophy.  There was tenderness of the lateral knee, without evidence of instability.  Knee flexion and extension were normal, with twenty repetitions.  Muscle strength was normal and the CI could toe and heel walk.  Reflexes and sensation of the lower extremity were normal.  

At the 16 June 2004 VA C&P examination, 2 months after separation, the CI reported right knee pain, stiffness, and a limp.  She reported constant knee pain with no incapacitating episodes in the past year.  The CI’s functional impairment was described as inability to squat or sit for long periods without having a limp for a while, and inability to run.  She did not use a cane or crutch for ambulation.  Physical examination showed a normal gait.  The right knee had a surgical scar and arthroscopy scars that were not tender.  There was lateral joint line tenderness and crepitus but no evidence of instability or meniscal damage.  Right knee ROM was 140 degrees flexion and 0 degrees extension with pain at end ROM.  The knee ROM was noted to be additionally limited by pain, but not fatigue, weakness, lack of endurance, or incoordination.  No additional loss of knee ROM with repetition was documented.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right knee condition 0%, coded 5003 (arthritis, degenerative), citing only one joint involved.  The VA rated the right knee condition 0%, coded 5010-5257 (arthritis, due to trauma, substantiated by X-ray findings - knee, other impairment of), based on the C&P examination, citing a 10% pre-service deduction and no evidence of residual instability or limitation of motion.  

There was no limitation of motion which supported a rating under the diagnostic codes for limitation of flexion or extension (5260, 5261).  However, there was imaging evidence of arthritis with painful limited motion for 10% rating under 5003.  There was no history or evidence of dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258), or history of surgery to remove a meniscus (5259) to support a rating under those codes.  There was no fracture, nonunion, or malunion of the femur or tibia to support consideration under the respective codes for knee impairment related to long bone conditions (5255, 5262).  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the right knee condition, coded 5003.  

BOARD FINDINGS:  In the matter of the right carpal tunnel condition and IAW VASRD §4.124a, the panel recommends no change in the PEB adjudication.  In the matter of the left carpal tunnel condition, the panel majority recommends a disability rating of 10%, coded 8799-8715 IAW VASRD §4.124a.  The single voter for dissent recommends no change and did not elect to submit a minority opinion.  In the matter of the right knee arthritis condition, the panel recommends a disability rating of 10%, coded 5003 IAW VASRD §4.71a.  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 the date of medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Right Carpal Tunnel	8799-8715	10%	
Left Carpal Tunnel	8799-8715	10%	
Right Knee Arthritis	5003	10%	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160913, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20180005414, 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, XXXXXXXXXXXXXXXXXX.

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

Sincerely,					      
Enclosure