RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-05642
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20090203

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Heavy Construction Equipment Operator, medically separated from the Temporary Disability Retired List (TDRL) for “bilateral hand discomfort with unclear etiology” rated 10% each hand, with a combined disability rating of 20%.

CI CONTENTION:  “Chronic carpal tunnel syndrome.”  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 - 20081110	VARD - NA	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Hand Discomfort	8799-8715	20%	No VA Examination Proximate to Separation in Evidence	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  NA	

ANALYSIS SUMMARY:

Bilateral Hand Discomfort.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the right-hand-dominant CI underwent a left carpal tunnel release (CTR) in January 2005 and a right CTR in October 2005.  The CI’s condition did not improve.  He was placed on TDRL for bilateral recalcitrant carpal tunnel syndrome (CTS) on 21 April 2007.

At the 13 March 2008 TDRL examination, 11 months prior to TDRL removal, the CI reported continued bilateral hand pain and numbness with no change since the November 2006 MEB NARSUM.  Physical examination revealed full-bilateral wrist and finger ROM.  Grip strength was left 20 and right 25 pounds; the examiner opined the CI provided poor effort.  Pinch testing was right 9 and left 13 pounds.  Multiple carpel tunnel tests were negative.  Bilateral finger muscle testing showed 5/5 strength and finger-to-tip pinch was normal.  There was no clinical CTS evidence derived from sensory or strength testing.  A diagnosis of hand discomfort with unclear etiology was rendered.  The examiner also questioned the bilateral grip testing measurements, opining CTS does not cause grip weakness.  The September 2008 primary care evaluation noted no left side wrist tenderness or hand deformity, and good hand ROM with sensory intact.  The January 2009 right hand MRI showed an abnormal hand (trapezoid) bone signal.  The June 2009 primary care evaluation noted right forearm and hand pain with numbness and tingling in the right hand and fingers which caused swelling when he worked.  A wrist splint did not relieve the pain.  Physical examination showed right wrist and hand tenderness and decreased ROM.

There was no VA examination proximate to TDRL removal for the panel to review.  However, during the VA orthopedic evaluation performed on 14 August 2009, 6 months after TDRL removal, the CI complained of bilateral-thumb pain with flexion and making a fist, right greater than left.  Physical examination revealed right side thumb tenderness, positive DeQuervain’s tendonitis (swelling of the thumb tendon due to repetitive motion) testing and positive CTS testing.  The left side revealed positive DeQuervain’s tendonitis testing and negative CTS testing.  Bilateral DeQuervain’s tendonitis and bilateral ulnar nerve entrapment at the elbow diagnoses were rendered.  The 2 October 2009 electromyography and nerve conduction study demonstrated left ulnar motor entrapment neuropathy at the elbow, and “mild” right-sensory CTS.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral hand discomfort 20%, analogously coded 8799-8715 (neuralgia), citing bilateral mild incomplete paralysis.  The 2 October 2009 VA diagnostic testing proximate to TDRL removal revealed right CTS (median nerve) and left ulnar motor entrapment neuropathy.  Therefore, based on objective STR and VA evidence, the panel determined the CI’s bilateral hand discomfort was due to pain.  There was no documented arm, wrist, hand or finger atrophy nor reflex deficit in evidence.  IAW VARSRD §4.124a (neuralgia, cranial or peripheral) the highest possible neuralgia rating due to pain is “moderate” incomplete paralysis.

CTS is rated under VASRD code 8515 (paralysis of the medial nerve), code 8715 rates median nerve neuralgia, and the ulnar nerve can be rated under code 8716 (neuralgia).  The same rating criteria consists for each code:  10% for “mild” impairment or 30% for “moderate” impairment of the major (dominant side) or 20% for the minor (non-dominant side).  The panel reviewed the STR and VA evidence and agreed that the preponderance of evidence most approximated a “mild” 10% impairment at TDRL removal.  The only evidence supporting “moderate” impairment proximate to TDLR removal, was the CI’s weak grip and pinch tests reported by the TDRL evaluation; however, the examiner opined that the CI provided a poor effort.  Although the CI experienced increased wrist pain with repetitive motion while he worked, there was no documentation of the inability to perform activities of daily living.  The CI’s wrist and hand ROM was full, and wrist and finger strength and sensitive testing was normal; there was no hand deformity.  There was no applicable VASRD rating higher than the 20% adjudicated by the PEB.  After due deliberation, considering all of 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 bilateral hand discomfort.

BOARD FINDINGS:  In the matter of the bilateral hand discomfort 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.  Therefore, the panel recommends no modification or re-characterization of the CI’s disability and separation determination.

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170717, w/attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record

AR20180007490, 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.

Sincerely,					      
Enclosure