RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXX	CASE:  PD-2017-04355
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20061018

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was a Reserve E6, Watercraft Operator, medically separated for “chronic neck pain” and “pain right wrist,” rated 10% each, with a combined disability rating of 20%.  

CI CONTENTION:  He should be medically retired at 30% due to years of service and commitment.  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 - 20060814	VARD - 20070410	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Neck Pain…	5241	10%	Chronic Neck Strain…	5237-5242	10%	20070320	
Pain Right Wrist…	5099-5003	10%	CTS RUE with radicular pain*	8515	30%	20070315/20	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  60%	
*CTS=carpal tunnel syndrome.  RUE=right upper extremity

ANALYSIS SUMMARY:  

Neck Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s neck condition began in August 2003 after a fall aboard a ship and was aggravated in a snowmobiling accident on 23 February 2004.  His symptoms were not resolved with non-surgical treatment which led to a cervical fusion of C6-7 on 13 and 30 September 2004.  An MRI on 5 March 2005 showed a small amount of cord pathology at C6-7 along with central canal stenosis and degenerative changes.  Following surgery, he underwent rehabilitation and injections without significant improvement in his symptoms.  The 20 June 2005 MEB neurology NARSUM examination, 16 months prior to separation, recorded that the level of symptoms varied with activity.  Sensation was diminished for the left upper extremity (LUE), but the motor examination was essentially normal.  

The 7 September 2005 MEB orthopedic NARSUM examination, 13 months prior to separation, noted complaints of persistent pain and a burning sensation in the left forearm and little finger.  Physical examination showed full neck range of motion (ROM).  The CI could touch his chin to his chest.  He had a normal motor examination of the upper extremities including the hands.  A tingling and vibratory sensation was produced by left rotation of the neck.  The left triceps reflex was reduced at 1+; the remaining upper extremity reflexes were normal.  Two-point discrimination was decreased for the left little finger.  In a 17 January 2006 addendum to the NARSUM, the neurological examination was unchanged.  Sensation was diminished for the LUE, but the motor examination was essentially normal as ROM was normal.  

In orthopedics on 13 March 2006, the CI could bring his chin within 1 cm of his chest and he had a normal motor examination of the upper extremities including the hands.  A tingling, vibration sensation was produced by left rotation of the neck.  The left triceps reflex was reduced at 1+; the remaining upper extremity reflexes were normal.  In pain management on 17 April 2006, the CI had normal strength of the upper extremities.  In a follow-up pain management evaluation on 21 June 2006, the CI reported painful motion with flexion and left rotation as well as tingling down the spine and arms with flexion.  The sensory and motor examinations were normal.  

The CI was seen in orthopedics on 22 June 2006.  It was noted that there was neither tenderness nor spasm of the neck.  No comment was made on the neurological examination.  The CI endorsed “popping and grinding” of the neck with motion.  Flexion and rotation to the left were uncomfortable.  He was unable to bring his chin closer than 3 cm to his chest.  Formal ROM accomplished the same day in physical therapy (PT) showed, after rounding, flexion of 30 degrees (normal 45) and a combined ROM of 200 degrees (normal 340).  Of note, the panel observed that there was an undated set of measurements in the record showing flexion of 10 degrees and a combined ROM of 170.  This was an outlier from all other values proximate to separation.  Due to this and the lack of a date, it was determined to not be probative for rating purposes.  The neurological addendum to the NARSUM was again updated on 10 August 2006, 2 months prior to separation.  The CI reported a band of numbness from the left armpit into the left leg down to the mid-shin.  The neurologist reported that the examination was unchanged from the January 2006 examination which implied full ROM.  

At the 15 March 2007 VA Compensation and Pension (C&P) neurology examination, 5 months after separation, the CI reported ongoing pain and numbness complicated by an overlying median nerve neuropathy (CTS).  Physical examination reduced strength and sensation of the right hand (consistent with CTS), but it was a normal motor examination otherwise to include reflexes.  The general C&P examination 5 days later noted that examination of the neck was unremarkable, strength of upper extremities was normal, and flexion was 40 degrees with a combined ROM of 240 degrees.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the neck condition 10%, coded 5241 (spinal fusion), citing no tenderness or spasm, passive flexion of 32 degrees, and an antalgic gait.   The VA also rated the neck condition 10%, coded 5237-5242 (cervical spine strain - degenerative arthritis of the spine) based on the C&P examination, citing forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees; or, combined ROM of the cervical spine greater than 170 degrees but not greater than 335 degrees.  The panel noted that the preponderance of evidence supported the 10% rating adjudicated by the PEB and VA.  

The panel also noted that the PEB commented on the decreased sensation and normal motor examination, which were not independently ratable.  In orthopedics on 13 March 2006, the sensory and motor examinations were normal.  Multiple neurology evaluations prior to separation noted a normal motor examination, but numbness of the LUE on some and a band of numbness from the left armpit to the shin on another which indicated a non-radicular pattern inconsistent with pathology at a particular cord level.  The neurology C&P examination documented normal strength but diminished sensation of the left arm and forearm.  The general examination 5 days later also noted normal strength but made no comment on sensation.  The panel determined that the evidence was not sufficient to overcome the PEB adjudication that the neurological condition was not independently ratable (not unfitting).  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 neck pain condition.  

Right Wrist Pain.  According to the STR and MEB NARSUM, the right-dominant CI injured his right wrist in the same snow mobile accident discussed above.  The fracture was surgically reduced and pinned on 5 March 2004.  The CI subsequently had a carpal tunnel release on 13 May 2004.  Following surgery, he underwent rehabilitation without significant improvement in his symptoms.  

The MEB neurology NARSUM examination recorded painful motion of the right wrist for extension.  Sensation was diminished for the LUE, but sensation of the right wrist and the motor examination were essentially normal.  The MEB orthopedic NARSUM examination noted complaints of persistent numbness and tingling.  Physical examination showed a normal motor examination of the upper extremities including the hands and normal sensation on the right.  Percussion of the median nerves elicited paresthesia.  X-rays showed expected post-operative changes with good alignment and hardware placement.  Some loss of the normal inclination was present.  

In pain management on 13 January 2006, the CI had normal strength of the upper extremities.  
ROM was reduced, but not quantified.  Sensation was reduced over the distribution of the radial aspect of the right hand.  In orthopedics 3 months later the CI had mild limitation in ROM and vague tenderness of the right wrist but without deformity.  The right wrist sensory and motor examinations were normal, although percussion of the median nerves caused paresthesia.  On 9 May 2006, PT measured ROM in degrees and after three repetitions dorsiflexion was 50 (normal 70), palmar flexion was 34 (normal 80), ulnar deviation was 15 (normal 45), and radial deviation was 10 (normal 20).  

The CI was seen in orthopedics on 22 June 2006 where mild soreness and prominence over the surgical plate were noted.  Outpatient removal was recommended to prevent future problems.  The fracture was well healed on X-ray.  Neither ROM nor a neurological examination were recorded.  In follow-up on 6 July 2006, the CI noted pain with extremes of motion and twisting, but he was able to tolerate day-to-day activities.  Motion was painful but limitation was not documented.  Compression of the wrist bones was tender, but percussion of the median nerve was negative (previously positive as noted above).  The 10 August 2006 updated neurological addendum to the NARSUM noted that the CTS condition was thought to be medically acceptable.  No comment was otherwise made regarding the wrist.  

At the C&P neurology evaluation the CI reported ongoing pain and numbness complicated by an overlying median nerve neuropathy (CTS).  Physical examination showed reduced strength and sensation of the right hand (consistent with CTS), but reflexes and motor examination were otherwise normal.  The general C&P examination 5 days later noted mild swelling in the wrist.  ROM measured in degrees, was dorsiflexion 10, palmar flexion 10, ulnar deviation 10, and radial deviation 5.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right wrist condition 10%, analogously coded as 5003 (degenerative arthritis), citing pain as slight and frequent.  The VA rated the right wrist CTS/radiculopathy condition 30%, coded 8515 (paralysis of the median nerve), based on the C&P examination, citing incomplete paralysis of hand movements which is moderate.  The VA did not separately rate the wrist fracture and repair nor was it subsumed in the discussion of the nerve conditions.  

A 10% rating is supported by the code 5003 for painful motion and by the use of the code 5215 (limitation of motion of the wrist) for dorsiflexion of less than 15 degrees as recorded on the VA examination.  Absent ankylosis or nonunion, no higher rating was available.  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.  

BOARD FINDINGS:  In the matter of the neck pain condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the right wrist condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  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:

AR20190005472, XXXXXXXXXX

Dear XXXXXXXXXX:

	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.