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

XXXXXXXXXX
XXXXXXXXXX
XXXXXXXXXX

Dear XXXXXXXXXX:

		Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2017-02719.

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 not appropriate under the guidelines of the Veterans Affairs Schedule for Rating Disabilities.  Accordingly, the Board recommended modification of your assigned disability rating without re-characterization of your separation with severance pay. 

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding, accept their recommendation and direct that your records be corrected as set forth in the attached copy of a Memorandum for the Chief of Staff, United States Air Force.  This will not result in any change to your separation documents or the amount of severance pay you are entitled to.  Disability severance pay is computed the same regardless of a rating of 0, 10 or 20 percent.

						

RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXX	CASE:  PD-2017-02719
BRANCH OF SERVICE:  Air Force	SEPARATION DATE:  20070720

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

CI CONTENTION:  In addition to the wrist conditions, the CI requested review of additional conditions not identified by the Medical Evaluation Board (MEB) and Physical Evaluation Board (PEB).  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 PEB to be unfitting for continued military service, and when specifically requested by the CI, those conditions identified by the 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 - 20070529	VARD - 20080623	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Wrist Pain 	5003	10%	Right Wrist Synovitis	5215-5020	10%	20070716	
			Ulnar Neuropathy, Left Elbow (Claimed as Left Wrist Numbness)	8599-8515	10%	20070725	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

Bilateral Wrist Pain.  The PEB combined the right and left wrist conditions under a single disability rating, coded 5003 (degenerative arthritis) and rated 10%.  This approach by the PEB not uncommonly reflected its judgment that the constellation of conditions was unfitting, and there was no need for separate fitness adjudications.  The panel noted that “bundling,” the combining of two or more major joints, may be permissible under the VASRD 5003 rating requirements, and that this approach does not compromise the VASRD §4.7 directive to choose the higher of two valid ratings.  The panel’s initial charge in this case was therefore directed at determining if combining conditions under a single rating was justified in lieu of separate ratings.  When considering a separate rating for each condition, the panel considers each bundled condition to be reasonably justified as separately unfitting unless a preponderance of evidence indicates the condition would not cause the member to be referred into the DES or be found unfit because of physical disability.  When the panel recommends separate fitness recommendations in this circumstance, its recommendations may not produce a lower combined rating than that of the PEB.  

According to the service treatment record and MEB narrative summary (NARSUM), the right-handed CI fractured the left navicular (wrist) bone in 2002 and underwent right arthroscopic debridement and synovectomy (inflamed tissue around the joint is removed) in September 2006.  Despite treatment, the CI continued to have bilateral hand and wrist pain with crepitus, but no further surgery was indicated.  A follow-up orthopedic examination on 13 April 2007, noted continued right wrist discomfort interfering with heavy lifting, carrying or push-ups.  Physical examination revealed right hand grip strength to be 25 Kg (bilaterally symmetric) with lateral and jaw chuck pinch strength less than the non-dominant left wrist measurements (slight weakness).  Right wrist Tinel’s sign (irritated nerve test) was negative and distal sensation and capillary refill were normal.  Bilateral wrist range of motion (ROM) is charted below.  The 24 April 2007 MEB NARSUM examination, 3 months prior to separation, noted complaints of bilateral hand pain with crepitus.  Physical examination showed crepitus and decreased bilateral wrist ROM.  Neurologic examination was grossly normal.  The 15 March 2007 MEB physical therapy (PT) ROM examination was referenced and charted below.  At the 21 June 2007 family practice separation examination, 1 month prior to separation, physical examination documented bilateral wrist pain and crepitus with movement.  

At the 16 July 2007 VA Compensation and Pension (C&P) general examination, 4 days before separation, the CI reported bilateral wrist pain, popping and swelling.  The right wrist pain had paresthesias (burning and prickling sensation).  The right hand was weak and all right-hand fingers were numb most of the time.  The left-hand fingers had occasional paresthesias with repetitive use.  The examiner found no bilateral wrist, hand or finger muscle atrophy; coordination was intact.  Right hand strength was slightly decreased at 4+/5 especially with grip and thumb/index finger pinching.  Right hand sensation was decreased to light touch and sharp-dull discrimination.  The left hand was normal.  Bilateral wrist and elbow Tinel's signs were negative.  Bilateral wrist Phalen's sign (for carpal or cubital tunnel syndrome) was negative.  Bilateral wrist ROM elicited painful motion as charted below.  

At the 25 July 2007 C&P neurology peripheral nerve examination the CI reported bilateral hand (right greater than left) pain, weakness and numbness.  He had bilateral pain with manipulative activities, dropped items and was not able to use tools.  He had difficulties holding groceries with the right hand.  Physical examination showed normal bilateral hand muscle bulk and tone.  Left hand strength was normal, but right hand strength was 4+/5 with pain on manual motor testing/give-way weakness.  Right hand sensation was decreased at the right upper extremity to light touch, pinprick, and temperature in a gloved distribution to the level of the wrist.  Fine motor movements were slowed on the right in comparison to the left.  Reflexes were symmetric and normal.  Tinel's sign elicited an aching sensation in the right hand.  Phalen's sign was negative.  

The ROM examinations in evidence, which the panel weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.  

Bilateral Wrist ROM
(Degrees)	PT/MEB ~4 Mo. Pre-Sep	Ortho ~3 Mo. Pre-Sep	VA C&P general
4 Days Pre-Sep	
	Left	Right	Left	Right	Left 	Right	
Dorsiflexion (70 Normal)	64/63/65	60/63/58	65	50	65	60	
Palmar Flexion (80)	60/64/60	70/65/68	65	50	80	70	
Ulnar Deviation (45)	35/40/41	39/38/45	35	25	45	40	
Radial Deviation (20)	32/36/35	26/27/28	30	30	20	20	
Comment	Normal strength	Right hand weakness and give-way	Right and left hand painful motion	
§4.71a Rating	0% + 0%	0% + 10%	10% + 10%	

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral wrist condition 10%, coded 5003, as discussed above.  The VA rated the right wrist condition 10%, dual coded 5212-5020 (limitation of wrist motion-synovitis), based on the C&P general examination, citing painful motion of a major joint.  The VA rated the left wrist 10% analogously coded 8599-8515 (median nerve, paralysis), based on the C&P neurology peripheral nerve examination, citing mild incomplete paralysis of left hand movements that are “symptomatic.”  

The panel first considered whether each wrist condition remained separately unfitting, having been decoupled from the combined PEB adjudication.  The profile made no distinction between the left or right upper extremity.  Bilateral wrists and hands were implicated by the commander’s statement.  The bilateral wrists were implicated by the MEB NARSUM and judged to fail retention standards.  Members agreed that each wrist was reasonably justified as separately unfitting.  Panel members agreed there was no ankylosis of either wrist.  There was no limitation of motion which supported a rating under the diagnostic code for limitation of wrist motion (5215) for either wrist.  However, there was satisfactory STR and VA evidence of painful motion with functional loss to support a 10% rating (based on §4.59, §4.40 and §4.45) for each wrist.  Pain was the predominant symptom and alternative rating under peripheral nerve codes (VASRD §4.124a) would be no higher than 10% for either wrist.  However, an additional 10% rating for pain was not supported for either wrist IAW §4.14 (avoidance of pyramiding).  After due deliberation, and considering all the evidence, the panel recommends a disability rating of 10% for the right wrist condition and 10% for the left wrist condition, each coded 5099-5020.

BOARD FINDINGS:  In the matter of the bilateral wrist condition, the panel recommends that each joint be separately adjudicated as follows: an unfitting right wrist condition coded 5099-5020 and rated 10%, and an unfitting left wrist condition, coded 5099-5020 and rated 10%, both IAW VASRD §4.71a.  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, effective the date of medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Right Wrist Pain 	5099-5020	10%	
Left Wrist Pain	5099-5020	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170402, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record