RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX 	CASE:  PD-2017-02498
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050305

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Cannon Crewmember, medically separated for “bilateral pain and weakness in the forearms” with a 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 - 20050214	VARD - 20050525	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Pain and Weakness in the Forearms Secondary to Bilateral Cubital Tunnel Syndrome 	8716	20%	Cubital Tunnel Syndrome Right Arm	8616	30%	20050331	
			Cubital Tunnel Syndrome Left Arm	8616	20%	20050331	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

Bilateral Forearm Pain and Weakness.  The PEB combined the bilateral forearm/elbow conditions under a single disability rating, coded 8716, and rated 20%; however, it broke out a 10% rating for the right forearm and a 10% rating for the left forearm.  Therefore, no further unbundling of the bilateral pain and weakness in the forearms is necessary, since each condition was determined to be unfitting by the PEB and each condition received a separate rating.

According to the service treatment record and MEB narrative summary (NARSUM), the right handed CI’s bilateral forearm condition began in January 2003 during basic training without any history of injury or trauma.  He complained of bilateral medial elbow pain despite occupational therapy and nonsteroidal anti-inflammatory medications, and also had numbness and tingling in the small and ring fingers of both both hands.  Electrodiagnostic testing showed mild right and mild to moderate left compression of the ulnar motor nerves across the elbows.  There was no evidence of bilateral cervical radiculopathy.  Right elbow X-rays showed mild soft tissue swelling posterior to the olecranon.  Grip strength testing on 20 August 2004 showed 46.9 pounds on the left (normal published 82.7-126.3) and 64.2 pounds on the right (normal published 100.4-141.6).  Occupational therapy intervention with multiple modalities did not improve the CI’s symptoms, and he preferred not to have any surgery.  

During the 21 October 2004 MEB examination (recorded on DD Forms 2807-1 and 2808), 7 months prior to separation, the CI reported a “pinched nerve in both elbows” and “numbness and tingling in hands.”  Physical examination revealed swelling above the carpal tunnel of each wrist, but no ecchymoses (black and blue marks).  The MEB NARSUM examination the same day noted complaints of bilateral elbow pain and radicular symptoms in both ring and small fingers which had failed to improve with all conservative measures.  Physical examination showed bilateral elbow range of motion (ROM) from 0-125 degrees; pronation and supination were symmetric at 80 degrees each.  There was bilateral tenderness in the epicondylar groove, positive Tinel’s signs (to determine nerve irritation) at the elbows, and elbow flexion testing was positive on the left and negative on the right.   Bilaterally, there was decreased (4/5) interosseous muscle and abductor digiti minimi muscle strength, but adductor pollicis muscle strength was normal.  The examiner diagnosed chronic bilateral cubital tunnel syndrome (ulnar neuropathy at elbow).  

At the 31 March 2005 VA Compensation and Pension (C&P) examination, 1 month before separation, the CI reported bilateral elbow pain, right worse than left, and numbness and tingling in the small and ring fingers bilaterally.  Physical examination showed bilateral elbow ROM measurements with repetition of 0-135 degrees (normal 0-145), and normal supination and pronation of both forearms without any pain, fatigue, or decreased ROM.  There was tenderness in the epicondylar groove and bilateral positive Tinel’s signs at both elbows.  The examiner noted a moderate amount of physical impairment and interference with activities of daily living and usual occupation.  

At a physical therapy visit on 13 September 2005, 6 months after separation, examination revealed increased pain/numbness/tingling with compression of the cubital tunnel retinaculum and ulnar groove at the elbows into the third, fourth, and fifth digits, which the CI reported as reproducing his symptoms.  Grip strength was 75 pounds in the left hand, and 80 pounds on the right, and motor strength of the third, fourth and fifth digits was slightly decreased.  Sensation was intact to light touch and deep pressure, but, the CI reported his hands and fingers were hypersensitive to cold.  At a VA orthopedic examination on 14 November 2005, 8 months after separation, the CI reported left elbow pain and tingling into his small and ring fingers with increased activity and frequent snapping sensation over the medial aspect of the elbow.  On examination, elbow ROM was full, but there was a positive Tinel’s sign over the left cubital tunnel along with tenderness over the medial epicondyle.  Intrinsic muscles of the hand were intact with normal sensation to light touch.   The examiner assessed left cubital tunnel syndrome with snapping ulnar nerve.  A non-operative approach using a soft splint was recommended.    

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral forearm/elbow condition 20%, coded 8716 (neuralgia).  The VA rated the right elbow condition 30%, and the left 20%, with each coded 8616 (neuritis), based on the C&P examination, citing moderate, incomplete finger and wrist paralysis.  

The panel is cognizant that the right forearm condition was separately unfitting.   The CI was right handed and, 7 months before separation, right grip strength was 64.2 pounds, which increased to 80 pounds 6 months after separation.  Both measurements were well below normal published values, however, electrodiagnostic testing showed mild right compression of the ulnar motor nerves across the elbows.  Members noted a disparity between the electrodiagnostic findings and grip strength tests while intrinsic musculature strength of the third to fifth fingers was mildly decreased.  Furthermore, by 8 months after separation, there was no report of right forearm or elbow pain or weakness during a VA orthopedic visit.  Therefore, the panel determined a rating greater than 10% was not justified.  After due deliberation, considering all 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 the right forearm/elbow condition.  

The panel is likewise cognizant that the left forearm condition was separately unfitting.  Left grip strength measured at 7 months before separation was 46.9 pounds, and 6 months after separation it was increased to 75 pounds.  As with the right hand, these measurements were well below normal published values, but electrodiagnostic testing showed mild to moderate compression of the ulnar motor nerves across the elbows.  Members again noted a disparity between the electrodiagnostic findings and the grip strength testing while intrinsic musculature strength of the third to fifth fingers was mildly decreased.  Left elbow ROM was normal and the strength of the intrinsic muscles of the left hand was mildly decreased.  Sensation was intact, although the CI reported numbness and tingling in the third to fifth fingers.  The VA examiner felt the condition was moderately disabling, which is in concert with the moderate ulnar nerve compression noted during electrodiagnostic testing.  Therefore, the panel majority determined a 20% rating is reasonable for a moderate disability of the non-dominant left forearm, although the minority voter favored a 10% rating.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 20% for the left forearm/elbow condition, coded 8516.  

BOARD FINDINGS:  In the matter of the right forearm/elbow condition and IAW VASRD §4.124a, the panel recommends no change in the PEB adjudication.  In the matter of the left forearm/elbow condition, the panel majority recommends a disability rating of 20%, coded 8516 IAW VASRD §4.124a.  The single voter for dissent recommends no change and did not elect to submit a minority opinion.  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	
Pain and Weakness in the Right Forearm Secondary to Right Cubital Tunnel Syndrome 	8516	10%	
Pain and Weakness in the Left Forearm Secondary to Left Cubital Tunnel Syndrome	8516	20%	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170302, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20190007790, 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.  Inquiries 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