RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-04377
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20081222

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Air Traffic Control Operator, medically separated for “asthma” and “right carpal tunnel syndrome,” rated 10% each, with a combined disability rating of 20%.  

CI CONTENTION:  Review requested review of additional conditions not identified by the Medical Evaluation Board (MEB) and/or 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 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 - 20080916	VARD - 20090127	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Asthma	6602	10%	Asthma	6602	30%	20091111	
Right Carpal Tunnel Syndrome	8799-8715	10%	Right Carpal Tunnel and Cubital Tunnel Syndrome and Ulnar Nerve Entrapment (Dominant)	8799-8715	0%	20091111	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Asthma.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI was treated with albuterol (inhalational bronchodilator) for difficulty breathing after returning from a deployment in 2007.  The medication provided no relief and he was seen by pulmonary specialists in January 2008.  Pulmonary function tests (PFTs) revealed post-bronchodilator FEV-1 of 93% of predicted and an FEV-1/FVC ratio of 73%, with a full volume loop consistent with borderline to mild obstruction.  A methacholine challenge was positive and the CI was diagnosed with asthma and treated with Advair (inhalational anti-inflammatory/bronchodilator combination) and albuterol with addition of daily Singulair (montelukast-oral indirect-acting bronchodilator) in March 2008; however he continued to have symptoms.  

During the 6 May 2008 MEB examination (recorded on DD Forms 2807-1 and 2808), 8 months prior to separation, the CI reported asthma symptoms with exercise or humidity, and use of daily Advair, daily Singulair and as-needed albuterol.  Physical examination revealed clear lungs, and the medication profile showed issuance of a 90-day supply of twice daily Advair on 5 February 2008, with an additional 90-day supply on 19 March 2008, as well issuance of montelukast in March and albuterol on 1 May 2008 (with prior levalbuterol).  The 23 July 2008 MEB NARSUM examination, 5 months before separation, noted complaints of continued asthma symptoms despite medication use as prescribed.  The examiner found diffuse bilateral expiratory wheezing.  

As summarized in the VARD, at the 11 November 2008 VA Compensation and Pension (C&P) examination, 1 month prior to separation, the CI reported current treatment with twice daily Advair, daily Singulair, and as-needed albuterol.  Previous PFTs from August 2008 showed an FEV-1 of 89%, and an FEV-1/FVC of74%, with a confirmed diagnosis of moderate, persistent asthma.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the asthma 10%, coded 6602 (asthma), citing a 40% decrement during a methacholine challenge, FEV-1 83% of predicted, and medication profile indicating intermittent use of controller medications.  The VA rated the asthma 30%, coded 6602, based on the C&P examination, citing required daily inhalational medication as treatment for asthma.  Panel members noted that a 30% rating stipulates “FEV-1 of 56- to 70-percent predicted, or; FEV-1/FVC of 56 to 70 percent, or; daily inhalational or oral bronchodilator therapy, or; inhalational anti-inflammatory medication.”  Both the NARSUM and VA examinations, as well as the preponderance of the STR entries documented use of inhalational anti-inflammatory medication, and thus panel members agreed that the threshold for a 30% rating was reasonably satisfied in this case.  A 60% rating was not warranted in the absence of at least monthly visits to a physician for required care of exacerbations, intermittent (at least three per year) courses of systemic corticosteroids, or PFT evidence.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 30% for the asthma, coded 6602.  

Right Carpal Tunnel Syndrome.  According to the STR and MEB NARSUM, the CI’s right (dominant) hand symptoms started with paresthesias in November 2007 after firing a pistol but without specific trauma.  He used a brace until June 2008 but had no symptom relief.  The 4 August 2008 MEB NARSUM neurology addendum examination, 4 months prior to separation, noted complaints of right hand numbness and tingling with episodic loss of motor skills and awakening with numbness and decreased grip strength.  The hand did not fall asleep while driving a car or using a phone, and there were no color changes or Raynaud's phenomenon.  Symptoms were worse when wearing gear or body armor.  The neurologist interpreted June 2008 electrodiagnostic studies as demonstrating bilateral carpal tunnel syndrome (median nerve) as well as ulnar nerve delay at the wrists (entrapment at Guyun’s canal).  Physical examination showed weakness of the right pincer grip and ulnar lumbricles (intrinsic muscles of the hand; finger flexion and extension).  Wrist X-rays were normal and the CI was diagnosed with moderate ulnar nerve entrapment and right carpal tunnel with motor involvement.  

The pre-discharge C&P examination, as summarized in the VARD, noted the CI began having recurrent numbness in both hands in June 2007 (the source examination was not in evidence).  He had declined surgery, and current treatment consisted of wrist splints and occasional use of an anti-inflammatory medication.  Physical examination showed symmetrical deep tendon reflexes at 2+/4 and no evidence of sensory or motor impairment.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right carpal tunnel syndrome 10%, analogously coded 8799-8715 (median nerve, neuralgia), citing the condition as analogous to mild paralysis of the right median nerve.  The VA rated the right carpal tunnel syndrome 0%, analogously coded 8599-8516 (paralysis of the ulnar nerve), based on the C&P examination, citing no evidence of sensory or motor impairment.  Panel members deliberated over the probative value of the disparate findings on the MEB neurology addendum and the summary of the C&P examination.  Although the NARSUM addendum examination results may have more nearly approximated moderate (20%) impairment criteria, there were no ratable findings by the time of the C&P examination, which was most proximate to separation.  Given the CI’s episodic slight weakness and paresthesias of the dominant hand, the panel agreed that there was insufficient evidence to decrease the PEB’s 10% rating, or to increase the rating to the next higher 30%.  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 carpal tunnel syndrome.  

BOARD FINDINGS:  In the matter of the asthma, the panel recommends a disability rating of 30%, coded 6602 IAW VASRD §4.97.  In the matter of the right carpal tunnel syndrome and IAW VASRD §4.124a, the panel recommends no change in the PEB adjudication.  There are no other conditions within the panel’s scope of review for consideration.  

The panel recommends the CI’s prior determination be modified as follows; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective the date of medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Asthma	6602	30%	
Right Carpal Tunnel Syndrome	8799-8715	10%	
COMBINED	40%	

The following documentary evidence was considered:

AR20200000685 

Dear XXXXXXXXXXXXXXX

I accept the recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) to re-characterize your separation as a permanent disability retirement with the combined disability rating of 40% effective the date of your medical separation for disability with severance pay.  Enclosed is a copy of the Board’s recommendation and record of proceedings for your information.

	The re-characterization of your separation as a permanent disability retirement will result in an adjustment to your pay providing retirement pay from the date of your original medical separation minus the amount of severance pay you were previously paid at separation.
 
	The accepted DoD PDBR recommendation has been forwarded to the Army Physical Disability Agency for required correction of records and then to the U.S. Defense Finance and Accounting Service to make the necessary adjustment to your pay and allowances.  These agencies will provide you with official notification by mail as soon as the directed corrections have been made and will provide information on your retirement benefits.  Due to the large number of cases in process, please be advised that it may be several months before you receive notification that the corrections are completed and pay adjusted.  Inquiry concerning your correction of records should be addressed to the U.S. Army Physical Disability Agency, (AHRC-DO).

	A copy of this decision has also been provided to the Department of Veterans Affair.