RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW
NAME:  XXXXXXXXXXXXXXXX	CASE: PD-2017-04231
BRANCH OF SERVICE: ARMY	SEPARATION DATE: 20041130

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Motor Transport Operator, medically separated for “chronic bilateral hand pain, rated as slight/constant” with a disability rating of 10%.

CI CONTENTION:  Review of all conditions requested.  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 - 20041004	VARD - 20041116	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Bilateral Hand Pain…	5099-
5003	
10%	Left Middle Finger Condition…	5299-5229	0%	
20041026	
			Left Ring Finger Trigger Condition…	5299-5230	0%		
			S/P Pulley Release, Right Ring Finger…	5299-5230	0%		
COMBINED RATING: 10%	COMBINED RATING OF ALL VA CONDITIONS: 20%	

ANALYSIS SUMMARY:

Chronic Bilateral Hand Pain. The PEB combined the left and right hand conditions under a single disability rating, coded analogously to 5003 (degenerative arthritis) and rated 10% with application of the US Army Physical Disability Agency (USAPDA) pain policy and AR 635-40 B24.f. 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. The evidence for the bilateral hand conditions are presented below, with attendant recommendations regarding separate unfitness, and separate rating if indicated.

According to the service treatment record (STR) and MEB narrative summary (NARSUM), the right-handed CI underwent surgery (A1 pulley release) for trigger finger release of the right ring finger and left middle finger in February 2003. Following surgery, the CI developed persistent bilateral hand pain. During the 6 July 2004 MEB examination (recorded on DD Forms 2807-1 and 2808), 5 months prior to separation, the CI reported worse pain with grasping following trigger finger surgeries. The CI was unable to do push-ups, pull-ups, or lift more than 5 pounds. Physical examination revealed the CI was able to make a fist and fingers had full flexion/extension. Scars were well-healed.

The 26 August 2004 MEB NARSUM examination, 3 months prior to separation, noted complaints of persistent bilateral hand pain without trigger finger symptoms or numbness. Physical examination showed the right ring finger and left middle fingers with well healed incisional scars with tenderness over the region of the scars. There was mild nodularity of the flexor tendon with motion of the fingers. No triggering or neurologic deficit was appreciated except for triggering of the left ring finger (non-operated).

At the 26 October 2004 VA Compensation and Pension (C&P) examination, one month before separation, the CI reported chronic bilateral hand pain with weakness, stiffness, fatigue, and lack of endurance. He also had trigger-like symptoms of the left ring finger. The examiner found the left middle finger and right ring finger with no swelling or deformity. There was full active range of motion (ROM) with ability of the fingertips to approximate the midline transverse crease of the palm and fingertips to approximate the thumb. Painful motion was noted throughout the ROM testing with weakness and fatigability of the fingers with repetitive use. There was tenderness over the palmar surface proximal interphalangeal (PIP) joint and metacarpophalangeal joints. Scars were noted on the palmar surface of the left hand overlaying the third metacarpal and over the right fourth metacarpal with no tissue loss or adherence to underlying structures. The left ring finger was without deformity. There was mild catching with flexion at the PIP joint with normal, but painful, ROM.

The panel directed attention to its rating recommendation based on the above evidence. As noted above, the PEB rated the bilateral hand pain (bundled) at 10%, coded 5099-5003, citing the USAPDA pain policy. The VA rated the left middle finger at 0%, coded 5299-5229 (analogous to limitation of motion of the index or long finger) based on the C&P examination citing “a non- compensable evaluation due to not meeting the minimal ROM limitation criteria assigned for limitation of motion of the index or long finger with a gap of less than one inch (2.5 cm) between the fingertip and the proximal transverse crease of the palm, with the finger flexed to the extent possible, and; extension is limited by no more than 30 degrees.” The VA additionally rated the left and right ring fingers at 0% each, using the 5299-5030 code (limitation of motion of the ring or little finger), based on the C&P examination, citing a non-compensable evaluation for any limitation of the ring or little finger.

The panel first considered if each hand was reasonably unfitting when unbundled. The commander’s statement and other STR evidence did not provide any information which would permit the panel to discriminate the performance limitations attributable to either hand over the

other. Since undue speculation would be required to conclude that left or right hand impairment would not have unacceptably interfered with the performance of military duties, members agreed that each hand was reasonably justified as separately unfitting.

The panel next deliberated on the rating of each hand separately, and considered analogous ratings under VASRD §4.71a (musculoskeletal system) for joint/tendon, §4.124a (neurological conditions and convulsive disorders) for neuritis/neuralgia, or §4.118 (skin) for scar. The panel majority determined that the PEB “hand pain” referred solely to the trigger fingers, and did not include residuals of surgery such as painful scar or possible neuritis/neuralgia, and that therefore only PDBR ratings under VASRD §4.71a were applicable. There was no limitation of motion for any finger sufficient to achieve a 10% rating for either hand. Although there was painful motion of the involved fingers, fingers are considered minor joints and do not meet the 10% criteria under VASRD §4.56 for painful motion for each finger. Rating each hand condition separately under §4.71a would be 0% for each hand and not be of benefit to the CI. Rating analogous to 5003 for a collection of two or more minor joint groups was considered, but there was no evidence of arthritis of multiple joints, and any 5003-rating would be no higher than the combined/bundled 10% adjudicated by the PEB. The panel majority adjudged that there was not sufficient evidence to rate either hand separately at 10% under any VASRD coding. After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel majority concluded there was insufficient cause to recommend a change in the PEB adjudication for the bilateral hand condition.

BOARD FINDINGS: In the matter of the chronic bilateral hand pain and IAW VASRD §4.71a, the panel majority recommends no change in the PEB adjudication. The single voter for dissent submitted the appended minority opinion. 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:MINORITY OPINION: The minority voter strongly disagrees with the majority’s stance that only ratings for the trigger finger and analogous coding under VASRD §4.71a were applicable or in scope. Each hand had clear and convincing evidence of a painful scar which warranted a 10% rating for each hand rated analogous to 7888-7804 (painful scar), for a combined 20% disability rating.

The CI had non-specified chronic hand pain as a residual of trigger finger surgery and no longer had trigger fingers at separation. The surgery for correction of trigger fingers left the CI with hand pain that interfered with duty performance. None of the DES documents (commander’s statement, NARSUM, MEB, or PEB) specified flexor tendinopathy, limited finger ROM, joint arthritis, or other finger-specific diagnoses for the hand pain which would limit the analogous rating for “hand pain.” The issue was therefore not a scope issue as each hand was unfitting without limitations to a specific joint or finger—the key issue is appropriately rating the CI’s unfitting left and right hand pain IAW VASRD guidelines.

VASRD §4.20 (analogous ratings) states: “When an unlisted condition is encountered it will be permissible to rate under a closely related disease or injury in which not only the function is affected, but the anatomical localization and symptomatology are closely analogous.” “Hand pain” is clearly more closely analogous to a neuralgia or to palm tenderness due to the surgical residuals of the CI’s painful scars. Although alternative analogous rating for a neuralgia of the hand (8715-radial or 8715-median nerve) as mild (10%) would clearly be supported, there was no diagnosis of neuralgia, and analogous rating to a painful scar (7804-scars, superficial, painful on examination), which was documented on all examinations for each hand, was predominate.

The minority voter strongly recommends that given the CI’s chronic bilateral hand pain, tenderness at the location of the surgical scars and the functional limitations for the use of each hand, that each hand be separately adjudicated as follows: an unfitting right hand condition coded 7899-7804 and rated 10%, and an unfitting left hand condition, coded 7899-7804 and rated 10%, both IAW VASRD §4.118.

The minority voter recommends the CI’s prior determination be modified as follows, effective the date of medical separation:

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic Right Hand Pain S/P Finger Pulley Release	7899-7804	10%	
Chronic Left Hand Pain S/P Finger Pulley Release	7899-7804	10%	
	COMBINED	20%	

	PD-2017-04231

AR20190012194, XXXXXXXXXXXXXXXXX 

Dear XXXXXXXXXXXXX

	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.