RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXX	CASE:  PD-2017-02967
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20040319

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Medical Laboratory Specialist, medically separated for “right wrist pain post fracture with open reduction internal fixation [ORIF]” and “thoracic back pain with multiple thoracic fractures,” 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 – 20031230	VARD - 20040930	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Wrist Pain...	5099-5003	10%	Residuals of Fracture, Right Wrist…	5010	10%	20040729	
Thoracic Back Pain… 	5237	10%	Residuals of Fracture, T2-T5, Status Post Laminectomy and Fixation…	5235	10%	20040729	
Change in Bowel Habits	Not Unfitting	Cauda Equina Syndrome [CES] Manifested By Bowel Urgency	7399-7332	0%	20040729	
Spinal Cord Dysfunction	Not Unfitting	Residuals Of CES, Right Lower Extremity… 	8520	10%	20040729	
		CES, Left Lower Extremity… 	8520	10%	20040729	
		Weakness in Both Legs	5399-5312	NSC	20040729	
Hyperreflexia	Not Unfitting	Included in 8520 (Left and Right) Above	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Right Wrist Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI fractured his right (dominant) wrist in a motorcycle accident in March 2002, and underwent a closed reduction and percutaneous pinning for a comminuted fracture/dislocation of distal radius and fracture of distal ulna.  The right wrist fracture position was found to be unacceptable, and on 5 April 2002 he had an ORIF surgery.  Post-operatively, he performed wrist rehabilitation exercises in occupational therapy.  

During 28 July 2003 MEB examination (recorded on DD Forms 2807-1 and 2808), 8 months prior to separation, the CI reported right wrist pain and limited motion. The examiner noted “extreme limitation of wrist extension (less than 10 degrees) unable to extend enough for pushups.”  The 22 October 2003 MEB NARSUM examination, 5 months before separation, recorded complaints of intermittent right wrist pain and weakness.  An X-ray from 29 September 2003 revealed orthopedic hardware, disuse osteopenia, fractured ulnar styloid, degenerative changes and probable ventral instability pattern.  Physical examination showed a well-healed, non-tender scar along the along the dorsum aspect of distal forearm/wrist and a 6.5-cm zigzag scar along the radiovolar aspect of wrist.  Both scars were non-tender with 1+ edema/thickening, but no redness or hotness.  Measured range of motion (ROM), in degrees, showed dorsiflexion to 42 (normal 70), palmar flexion to 72 (normal 80), ulnar deviation to 22 (normal 45) and radial deviation to 0 (normal 20).  Supination was 64 degrees (normal 85) and pronation was 86 degrees (normal 80).  

At the 29 July 2004 VA Compensation and Pension (C&P) examination, 4 months after separation, the CI reported continued right wrist pain.  Physical examination revealed two well-healed surgical scars and tenderness along the superior aspect of the wrist.  Measured ROM, in degrees, showed dorsiflexion to 50, palmar flexion to 60 with discomfort, ulnar deviation to 30, and radial deviation to 20.  The examiner noted normal flexion of all fingers and the thumb without any difficulty, and normal hand and finger strength, without gross sensory deficit noted in any aspect of the right arm or hand.  

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 (degenerative arthritis), citing pain as frequent and moderate, with likely application of the US Army Physical Disability Agency pain policy.  The VA also rated the wrist condition 10%, but analogously coded 5010 (post-traumatic arthritis), based on the C&P examination, citing painful or limited motion.  Panel members agreed there was no ankylosis of the wrist (5214), nonunion of the radius or ulna (5010-5012), or limitation of dorsiflexion, palmar flexion, pronation or supination that supported a rating higher than 10% under the VASRD diagnostic codes for limitation of motion (5215, 5213).  Evidence of painful motion causing functional loss also supported no higher than a 10% rating (based on §4.59, §4.40 and §4.45).  The panel considered alternative VASRD wrist and forearm analogous codes, but all were less applicable and/or not advantageous to rating.  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 for the right wrist condition.  

Thoracic Back Pain.  According to the STR and MEB NARSUM, the CI’s back condition also began in March 2002 after the motorcycle accident.  He suffered multiple fractures of T2-T5 including subluxation (T4-6), and displaced fragments which required a laminectomy with secondary application of rods, pins and hardware.  His immediate post-operative course was notable for an episode of subtotal paraplegia of the lower extremities which resolved after 3-4 days.  He underwent extensive rehabilitation but was not able to resume his military duties.  During the MEB examination, the CI reported back pain with bilateral lower extremity paresthesias/tingling down to both feet, and the examiner noted bilateral decreased light touch and pinprick sensation from mid-thighs to feet.  There were hyper-reflexes (4+ of normal 2) in both knees and ankles.  

The MEB NARSUM examination noted CI complaints of constant upper back pain that was moderate in intensity and associated with flare-ups.  Physical examination showed a normal gait, no redness, hotness, or tenderness, and thoracolumbar forward flexion to 80 degrees (normal 90). Thoracic spine X-rays revealed spinal fixation hardware without complication or acute bony abnormality, and no evidence of a lumbar vertebral body fracture, disc herniation, or advanced degenerative changes.  A lumber spine MRI impression was unremarkable.  

At the 29 July 2004 VA Compensation and Pension (C&P) examination, 4 months after separation, the CI reported moderate upper back and shoulder pain.  Physical examination showed a normal gait and the ability to heel and toe walk.  Surgical scars were well-healed and there was mild tenderness of the thoracic and lumbar areas with no noted muscle spasm.  Measured ROM revealed forward flexion to 90 degrees, with discomfort, and a combined ROM of 220 degrees (normal 240).  During repetitive motion there was no sign of fatigability or change in flexion.  The examiner estimated that acute flare-ups would probably cause “about 20% reduction” in flexion.  Thoracic and lumbar spine X-rays revealed the presence of hardware and slight narrowing of L5-S1 consistent with degenerative disc disease.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, analogously coded 5237 (lumbosacral strain), citing foward flexion of 80 degrees and combined ROM of 168 degrees.  The VA also rated the back condition 10%, but analogously coded 5235 (vertebral fracture or dislocation), based on the C&P examination, citing the 10% VASRD spine criteria.  Panel members agreed that a 10% rating, but no higher, was justified for limitation of flexion (greater than 60 degrees but not greater than 85 degrees) or combined ROM (greater than 120 degrees but not greater than 235 degrees), as reported on the orthopedic, NARSUM and VA examinations.  There was no muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour, thus the next higher 20% rating was not justified on this basis.  There was no evidence of intervertebral disc syndrome which resulted in incapacitating episodes requiring physician-prescribed bed rest to warrant consideration of rating under that alternate formula.  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 for the back condition.  

Contended PEB Conditions:  Change in Bowels Habits, Hyperreflexia and Spinal Cord Dysfunction.  The panel’s main charge is to assess the fairness of the PEB determination that the contended conditions were not unfitting.  None of the conditions were profiled or implicated in the commander’s statement, but all failed retention standards and were neurologic and residuals of the CI’s unfitting back condition.  There was no performance-based evidence from the record that any of the conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded there was insufficient cause to recommend a change in the PEB fitness determination for any of the contended conditions, so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the wrist condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the back condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the contended change in bowels habits, hyperreflexia and spinal cord dysfunction, the panel recommends no change from the PEB determinations as not unfitting.  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 20170328, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

	PD-2017-02967

AR20190012136, XXXXXXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found your separation disability rating and your separation from the Army for disability with severance pay to be accurate.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed), and I accept its recommendation.  I regret to inform you that your application to the DoD PDBR is denied.  

	This decision is final.  Recourse within the Department of Defense or the Department of the Army is exhausted; however, you have the option to seek relief by filing suit in a court of appropriate jurisdiction.

.

	PD-2017-02967