RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-03161
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070709

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Parachute Rigger, medically separated for “bilateral hand and bilateral lower extremity exertional compartment syndrome pains” with a disability rating of 0%.   

CI CONTENTION:  “Review all conditions.”  The CI also 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 - 20070601	VARD - 20080619	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Hand And Bilateral Lower Extremity Exertional Compartment Syndrome Pains	5099-5003	0%	Compartment Syndrome, Right Lower Extremity, Muscle Group XI and XII	5311	10%	20080312	
			Compartment Syndrome, Right Lower Extremity, Muscle Group XI and XII	5311	10%		
			Status Post Carpal Tunnel Release, Right Wrist (Major) 	8515	10%		
			Status Post Carpal Tunnel Release, Left Wrist (Major)	8515	10%		
Type 1 Diabetes	Not Unfitting	Diabetes Mellitus, Type I	7913	20%		
Hypertension	Not Unfitting	Hypertension 	7101	10%		
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  80%	

ANALYSIS SUMMARY:  

Bilateral Hand [Pain] and Bilateral Lower Extremity Exertional Compartment Syndrome.  The panel first discussed and agreed that the PEB’s written disability description as listed on DA FORM 199 was vulnerable to misinterpretation in relating the diagnosis of “exertional compartment syndrome” to the CI’s both hands vice the diagnosis of “bilateral hand pain”.

The PEB combined the right and left hand pain and the right and left lower extremity exertional compartment syndrome as a single unfitting condition analogously coded 5099-5003 (arthritis, degenerative) and rated 0%.  The 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 or implied adjudication that each condition was separately unfitting.  The panel’s initial charge in this case was therefore directed at determining if the PEB’s approach of 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 that the condition would not cause the member’s referral into the DES or finding of unfit because of physical disability.  When the panel recommends separate fitness recommendations as in this circumstance, its recommendations may not produce a lower combined rating than that of the PEB.  The evidence for the right and left hand pain exertional compartment syndromes and right and left lower extremity compartment syndromes is separately presented with attendant recommendations regarding separate unfitness and individual component ratings.

Bilateral Hand Exertional Compartment Syndrome Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI developed numbness and tingling in both hands upon repetitive use in September 2003.  In August 2006, the CI received a provisional diagnosis of bilateral carpal tunnel syndrome (CTS) which was confirmed by electro-diagnostic studies performed on 5 September 2006.  Despite surgical intervention to both upper extremities, his bilateral wrist pain remained and he was referred for MEB with three diagnoses; one of which was CTS.

On 2 March 2007, 4 months prior to separation, occupational therapy measured wrist range of motion (ROM) as palmar flexion of 74 degrees on the left (normal 80) and 72 degrees on the right with painful motion bilaterally.  Dorsiflexion measured 63 degrees on the left (normal 70) and 55 degrees on the right with bilateral painful motion.    

The 30 April 2007 MEB NARSUM examination, 2 months prior to separation, noted complaints of bilateral hand pain with resulting inability to fire a weapon, workout, or perform pushups.  Physical examination (PE) revealed tenderness about both CTS surgical scars (left greater than right) and a slight decrease in grip strength comparison with left at 4/5 and right at 5/5.  “[The CI] is able to do flexion/compression tests without abnormalities.  [The CI] does not have any thenar (base of thumb) atrophy or wasting.  [The CI] is intact to light touch in all distributions and median nerve function is preserved throughout [the CI’s] hand.”  There was no comment concerning the presence of painful motion.           

At the 12 March 2008 VA Compensation and Pension (C&P) evaluation, 8 months after separation, the CI reported intermittent episodes of tingling, numbness, and weakness of the thumb, index, and middle fingers, of both hands.  Symptoms occurred as often as three times per day each with a duration of five minutes.  An extensive PE of both upper extremities was normal.
  
The panel directed attention to its rating recommendation based on the above evidence.  Utilizing the same analogous VASRD code of 5099-5003 (degenerative arthritis) the PEB bundled both wrists into a single condition and rated 0% whereas the VA separately rated each wrist at 10%; citing slight and intermittent pain and incomplete, mild paralysis of hand movements; respectively.  The panel first considered if each wrist, having been de-coupled from the combined PEB adjudication, remained independently unfitting and ratable.  

The panel agreed that the CI’s inability to fire a weapon or perform push-ups would be of similar issue if either hand, separately considered, demonstrated such painful parameters and therefore, concluded that the disability confined to either wrist/hand would have rendered the CI incapable of performing his occupational duties and that each hand be considered separately unfitting.  

In regards to rating the separately unfitting hand conditions, all panel members further agreed that the progressive improvement of minimal physical symptoms pre-separation to normal physical findings post-separation would support no positive impairment rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends separate disability ratings of 0% for the right hand/wrist condition and 0% for the left hand/wrist condition; both coded as 5099-5003.  However, although the panel recommends separate hand conditions with separate and independent impairment ratings, the overall combined rating for the hands remained unchanged at 0%.  Therefore, providing no additional rating benefit to the CI, there was no reason to recommend a change the PEB’s coding scheme.

Bilateral Lower Extremity Exertional Compartment Syndrome.  According to the STR and NARSUM, the CI’s bilateral lower extremity exertional compartment syndrome pains began in March 2006 during a 4-mile brigade run where he experienced severe, bilateral tibial (shin bone) pain.  Over a short period of time, physical exertion resulted in bilateral lower leg pain at ¾ to 1 mile with walking or marching and ½ mile with running.  The CI was referred to sports medicine on 30 November 2006 where testing was positive for bilateral compartment syndrome.  Surgical intervention was not a viable option.  A bone scan performed on 14 December 2006 indicated a mild degree of degenerative changes and possible stress changes about both lower extremities.  

At the 26 February 2007 MEB examination (recorded on DD Forms 2807-1 and 2808), 5 months prior to separation, the CI’s PE documented the following: “Bilateral lower legs; No edema or erythema.  Pulses intact 2+ bilateral feet and pain with palpation (tenderness) along the anterolateral border of bilateral tibias.”

The 30 April 2007 MEB NARSUM examination, the CI endorsed complaints of bilateral leg pain with an inability to run for more than ½ mile without excruciating pain in the lower extremities.  PE noted that, other than a fascial defect (small area of muscle herniation) on the left leg, both lower extremities were normal, to include ROM of the knees and ankles.  The CI’s permanent profile dated 22 May 2007 noted, “…own pace and distance of activity” under the heading of ‘functional limitations’.     

At the C&P examination, the CI reported localized bilateral lower leg pain described as squeezing, burning and cramping which was aggravated with activity and relieved with rest with an occurrence of once a day with a duration of 1 hour.  The CI additionally endorsed the inability to run or walk for long distances.  PE of both lower extremities was completely normal.  

The panel directed attention to its rating recommendation based on the above evidence.  Utilizing the same analogous VASRD code of 5099-5003, the PEB bundled both lower extremities into a single condition and rated 0%; where the VA separately rated each lower extremity at 10%; citing slight and intermittent pain and moderate muscle disability respectively.  The panel first considered if each lower extremity, having been de-coupled from the combined PEB adjudication, remained independently unfitting and ratable.

The panel acknowledged that the remarkable PE findings of bilateral lower leg tenderness without evidence of painful motion did not warrant application of VASRD §4.59 (painful motion) for a minimum of 10% as applied unilaterally or bilaterally.  This case revealed minimal to mild pre-separation adverse physical findings which were near equivocal to each lower extremity without a significant level of intensity at the time of separation.  Although it is speculative to conclude that the disability confined to either lower extremity would have rendered the CI incapable of performing within his occupational rating, panel member consensus was that it was also reasonable to surmise that it was the overall effect of both legs that rendered him unfit.  

In regards to rating the bundled lower leg condition, all panel members agreed that the progressive improvement of minimal to mild physical symptoms resolving to normal physical findings prior to separation would support no positive impairment rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3, the panel concluded that there was insufficient cause to recommend a change in the PEB’s adjudication for the bundled bilateral lower extremity pain condition.

Contended PEB Conditions: Type 1 Diabetes and Hypertension.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended conditions as listed above were not unfitting.  Only the diabetic condition was profiled, implicated in the commander’s statement and judged to fail retention standards.  Hypertension was not judged to fail retention standards.    

The CI was originally diagnosed with diabetes in 2006, which presented with polyuria and polydipsia.  The diabetes was not controlled with oral medication alone and thus required insulin that was delivered through an insulin pump that was implanted on 31 July 20006.  The CI had no history of episodic diabetic ketoacidosis.  The vast majority of clinical encounters contained within the case file between April 2006 and January 2007 noted either “good”, “improved” or “ideal” control of the CI’s blood sugar.  The diabetes was considered stable and well controlled, but required both long and short acting insulin as well as oral medication.  On 13 December 2006, the CI was “approved” for re-enlistment into active service noting the Commander’s determination of qualification as, “soldier is fully qualified for requested [re-enlistment] action.”   

The MEB NARSUM examination listed laboratory studies from 05 February 2007 (5 months prior to separation) noting normal urinalysis, fasting blood glucose of 168, hemoglobin A1C of 6.8 and normal blood pressure.  The post-separation C&P examination revealed no additional adverse physical findings other than those previously listed under other conditions.  

All panel members first agreed that the evidence of being found “fully qualified” for re-enlistment just 4 months after receiving an insulin pump coupled with consistent normal blood pressures clearly supported that there was no performance-based evidence from the record that either of the contended conditions significantly interfered with satisfactory duty performance at or near separation.  Therefore, after due deliberation, the panel concluded there was insufficient cause to recommend a change in the PEB’s fitness determination for either of the contended conditions, so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the bilateral hand/wrist pain condition, the panel recommends no change in the PEB’s adjudication.  In the matter of the bilateral lower extremity exertional compartment syndrome and IAW VASRD §4.71a, the panel recommends no change in the PEB’s adjudication.  In the matter of the contended Type 1 Diabetes and Hypertension conditions, 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.  

The following documentary evidence was considered:

	

[AR NUMBER], XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX

	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.

Enclosure