RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-02070
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20090928

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Water and Fuel Systems Maintenance Journeyman, medically separated for “right wrist pain” with a disability rating of 10%.  

CI CONTENTION:  No specific contention made.  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 - 20090616	VARD – 20091106 & 20100429	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Persistent Right Wrist Pain	5099-5003	10%	Ligament Reconstruction, Right Hand/Wrist 	5215	10%	20090529
&
20100218	
			Nerve Injury to the Dorsal Cutaneous Branch of the Ulnar Nerve, Right Wrist	8516	10%		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

Persistent Right Wrist Pain.  According to the service treatment record (STR) and the MEB narrative summary (NARSUM), the right-hand dominant CI underwent right wrist surgery (scapholunate ligament reconstruction) in January 2008, revision in July of 2008 and pin removal in September 2008.  Follow-up for chronic wrist pain with orthopedics and pain specialists, including neuroactive medications, electrical stimulation (TENS unit), and stellate ganglion blocks, were ineffective.  

The 12 March 2009 MEB NARSUM examination, 6 months prior to separation, noted complaints of right wrist pain.  Physical examination showed right wrist range of motion (ROM) of 30 degrees dorsiflexion (normal 70) and palmar flexion of 20-25 degrees (normal 80) with radial and ulnar deviation maintained.  There was “good grip and pinch strength.”  Numbness of the ring and little finger was reported.  There was “no notice of pain with firm hand shake on leaving appointment.”  Diagnostic imaging showed decreased bone through carpal bones and the lunate, swelling over the carpal joints and a metallic suture anchor.  Bone scan on 9 February 2009 showed areas suggestive of trauma.  The working diagnosis per the pain specialist was Reflex Sympathetic Dystrophy (RSD).  

At the 20 May 2009 VA Compensation and Pension (C&P) evaluation, 4 months prior to separation, the CI reported right wrist and forearm pain, weakness and stiffness and tingling in his hand.  The ROM was 60 degrees of dorsiflexion and 20 degrees of palmar flexion with pain on repetitive motion.    

The orthopedic hand surgeon consult on 1 June 2009, indicated complaints of right wrist pain with numbness over the dorsal ulnar aspect of the right hand.  Pain was 2-3/10 daily and located focally over the scaphoid on the volar (palm) side of the wrist with some radiation into the hand, and some global pain.  Electrodiagnostic testing on 17 June 2009 was normal.   

At the 18 February 2010 C&P evaluation, 5 months after separation, the CI reported no right wrist palmar flexion and pain with other wrist motions radiating up the forearm.  Physical examination showed painful ROM of 48 degrees dorsiflexion and 10 degrees palmar flexion.  Grip strength was decreased to 74 pounds (left 105 pounds).  There was hyperesthesia on the dorsal surface of his right hand in a pattern that included his fourth and fifth fingers and extending proximally to his wrist.  Although electrodiagnostic testing was normal, there was physical evidence of nerve injury to the dorsal cutaneous branch of the ulnar nerve with a diagnosis of chronic complex regional pain syndrome.  Physical examination showed well healed surgical scars with right wrist ROM of 5 degrees palmar flexion and 30 degrees of dorsiflexion.  There was altered sensation to light touch over the small finger and the dorsum of the ring finger.  Capillary refill was brisk (normal vascular test).  

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 (arthritis, degenerative), citing pain with decreased ROM.  The VA rated the right wrist condition 10%, coded 5215 (wrist, limitation of motion), based on the C&P examination, citing pain and limitation of motion.  The VA also rated the right wrist condition as nerve injury to the dorsal cutaneous branch of the ulnar nerve condition 10%, coded 8516 (ulnar nerve, incomplete paralysis), based on the C&P examination, citing sensory deficits noted to the right hand/wrist (to include pain and hyperesthesia).  

There was a working diagnosis of RSD (analogous to a peripheral nerve condition) and complex regional pain syndrome was in the differential diagnoses, either of which would include wrist pain and other symptoms.  There was no weakness noted prior to separation and no unfitting sensory loss to the right upper extremity.  Any peripheral nerve rating would therefore be no greater than 10%, and ideal coding at separation would be analogous to 8716 (neuralgia, ulnar nerve, incomplete paralysis).  There was no limitation of wrist motion which supported a rating under diagnostic code 5215 for limitation of dorsiflexion less than 15 degrees or palmar flexion limited in line with forearm.  There was no unfitting weakness or sensory loss proximate to separation and the principle unfitting condition was wrist pain.  Given that peripheral nerve rating at 10% would include pain and painful motion of the wrist/hand, two separate ratings cannot be supported without pyramiding (VASRD §4.14).  The PEB’s use of analogous coding to 5003 was reasonable since there was wrist surgery with evidence of painful motion noted in multiple examinations with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45).  Changing the coding of the 10% rating would be of no benefit to the CI.  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 20170301, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record

SAF/MRB
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD 20762

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

		Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2017-02070.

After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was appropriate.  Accordingly, the Board recommended no re-characterization or modification of your separation.

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding and their conclusion that re-characterization of your separation is not warranted.  Accordingly, I accept their recommendation that your application be denied.

						Sincerely,

								XXXXXXXXXXXXXXXXXX
								Director
								Air Force Review Boards Agency

Attachment:
Record of Proceedings