RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXX	CASE:  PD-2017-04270
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20080225

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Information Management Craftsman, medically separated for “right wrist pain status post [s/p] triangular fibrocartilage debridement and synovectomy and hemiresection of distal ulna” and “left shoulder s/p arthroscopic subacromial decompression and synovectomy,” 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 - 20170809	VARD - 20080930	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Wrist Pain… 	5003	10%	Resection, Distal Ulna with Prosthesis, Distal and Radial And Internal Fixation, Right	5215	0%	20080716	
Left Shoulder S/P Arthroscopic… Decompression and Synovectomy	5003	10%	Old Resection Distal Clavicle, Left	5203	0%		
Obstructive Sleep Apnea	Cat II	Obstructive Sleep Apnea	6847	50%	20080613	
Obesity	Cat III	No VA Placement	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  70%	

ANALYSIS SUMMARY:  

Right Wrist Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI underwent two right (dominant) wrist surgeries, with the last involving a triangular fibrocartilage debridement (ulnar aspect of the wrist) and synovectomy in March 2007.  Wrist X-rays in July 2006 showed mild degenerative changes with distal ulnar deformity and widening of the distal radioulnar joint (DRUJ).  Initially, the CI had an excellent result from the second surgery, but at an orthopedic examination on 13 December 2007, she reported right ulnar-sided wrist pain since September 2007 after working out.  A repeat MRI showed no changes, and she was given a steroid injection.  Another surgical procedure for excision of the remaining portion of the ulnar head was discussed if there was no improvement.  

The 5 November 2007 MEB NARSUM examination, 3 months prior to separation, noted CI complaints of wrist pain.  Physical examination showed right wrist full range of motion (ROM) with pain at the extreme of motion and wrist strength reduced due to pain.  At an orthopedic examination on 8 April 2008, 2 months after separation, the CI reported right wrist pain with ulnar deviation.  The provider noted wrist and the ulnar styloid process tenderness, with full but painful motion, particularly with ulnar deviation.  A week later, an orthopedic surgeon documented DRUJ instability and pain with ulnar grind testing and DRUJ compression.  Wrist ROM measurements, in degrees, showed dorsiflexion (DF) of 70 (normal), palmar flexion (PF) of 60 (normal 80), ulnar deviation of 35 (normal 45) and radial deviation of 20 (normal).  Wrist X-rays revealed narrowing of the DRUJ space with gripping.  On 23 May 2008, the CI underwent a surgical resection of the right ulnar head with a prosthetic joint replacement.  

At the 16 July 2008 VA Compensation and Pension (C&P) examination, 5 months after separation, the CI reported continued physical therapy since the May 2008 surgery, and constant right wrist pain with flare-ups about once a week with no apparent cause.  Physical examination showed a healing surgical scar and well-healed old scars.  There was no tenderness, but some swelling near the incision.  Strength was normal, and wrist ROM, in degrees, revealed DF to 70, PF to 72, ulnar deviation to 25, and radial deviation to 10, after repetition, and with no complaint of pain.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right wrist condition 10%, coded 5003 (arthritis, degenerative), citing wrist pain.  The VA rated the right wrist condition 0%, coded 5215 (wrist, limitation of motion of), based on the C&P examination, citing noncompensable ROM without objective evidence of painful ROM. Panel members agreed there was no ankylosis (5214) or limitation of DF or PF (5215) to support compensable ratings, however there was painful motion causing functional loss to support a 10% rating (based on §4.59, §4.40 and §4.45) as adjudicated by the PEB.  There was no rating higher than a 10% rating under any other applicable VASRD code.  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.  

Left Shoulder Pain.  According to the STR and MEB NARSUM, the CI underwent two left shoulder surgeries for acromioclavicular (AC) joint separations with the second procedure on 17 May 2007 for subacromial decompression (Mumford procedure).  Orthopedic follow-up visits noted a good response following surgery with “almost total” painless flexion documented on 20 July 2007.  At the MEB NARSUM examination, the CI reported post-operative improvement in her quality of life, however, the left shoulder restricted her from impact activities, push-ups, or carrying more than 20 pounds.  Physical examination showed full ROM with pain at the extremes of motion and strength limited due to pain.  

At the C&P examination, the CI complained of left shoulder pain a few days a week, with flare-ups once per month.  Physical examination showed healed surgical scars, AC joint tenderness, and normal strength.  Shoulder ROM, after three repetitions, revealed flexion of 145 degrees and abduction of 125 degrees (both normally 180), with no complaint of pain.  Left shoulder X-rays showed the distal clavicle resection but no other abnormalities.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left shoulder condition 10%, coded 5003, citing shoulder pain.  The VA rated the left shoulder condition 0%, coded 5203 (clavicle or scapula, impairment of), based on the C&P examination, citing noncompensable ROM without objective evidence of painful motion.  Panel members noted that the VASRD §4.71a threshold for rating for ROM impairment under code 5201 is “at shoulder level” (approximately 90 degrees from the side), and the examinations in evidence demonstrated motion above this level.  However, a 10% rating was justified with application of VASRD §4.59 (painful motion).  There was no malunion or recurrent dislocation of the humerus (5202), and no nonunion with loose movement of the clavicle (5203) to warrant the next higher 20% rating.  There was therefore no higher than a 10% rating supported with any applicable VASRD code.  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 left shoulder condition.  

Contended PEB Condition:  Obstructive Sleep Apnea (OSA) and Obesity.  The panel’s main charge is to assess the fairness of the PEB determination that the contended conditions were not unfitting.  The OSA was not profiled or implicated in the commander’s statement.  There was no performance-based evidence from the record that the condition 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 the contended OSA, so no additional disability rating is recommended.  Obesity is a condition not constituting a physical disability IAW DoDI 1332.38 and the panel therefore has no basis for recommending it as unfitting.  

BOARD FINDINGS:  In the matter of the right wrist condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the left shoulder condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the contended OSA, the panel recommends no change from the PEB determination as not unfitting.  In the matter of the contended obesity, the panel agrees it cannot recommend it for additional disability rating.  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:

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

Dear XXXXXXXXXX:

		Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2017-04270.

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 appropriate.  Accordingly, the Board recommended no re-characterization or modification of your separation.

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding and their conclusion that re-characterization of your separation is not warranted.  Accordingly, I accept their recommendation that your application be denied.