RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW NAME: XXXXXXXXXXXXXXXXXX BRANCH OF SERVICE: ARMY CASE NUMBER: PD1200796 DATE OF PLACEMENT ON TDRL: 19980610 BOARD DATE: 20130207 DATE OF PERMANENT SEPARATION: 20021024 SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SGT/E-5 (92A20/Automated Logistics Specialist), medically separated for post-traumatic arthritis right wrist status post (s/p) radial peri-lunate dislocation which was treated with open reduction and fixation (ORIF) as well as ligament repair and low back pain (LBP) with L5/S1 degenerative disc disease (DDD). He sustained a dislocation of his right wrist in 1996 and underwent closed reduction, but subsequently required an ORIF of the scapho-lunate ligament and fixation with pins. After recovery from surgery, he had pain to the radial side of the joint and a reduced range-of-motion (ROM). He also had a history of DDD at L5-S1 with chronic LBP. The CI could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS) or satisfy physical fitness standards. He was issued a permanent U3/L3 profile and referred for a Medical Evaluation Board (MEB). Gout, asthma, post traumatic headaches, right shoulder pain, and bilateral pes planus conditions, identified in the rating chart below, were also forwarded by the MEB to the Physical Evaluation Board (PEB) as medically unacceptable. Hypertension was forwarded as medically acceptable. The PEB adjudicated the right wrist, low back and asthma conditions as unfitting, rated 10% each, with probable application of the Veteran’s Affairs Schedule for Rating Disabilities (VASRD). The remaining conditions were determined to be not unfitting and therefore not ratable. CI was placed on the Temporary Disability Retired List (TDRL). In September of 2002, at his third TDRL re-evaluation, the PEB recommended permanent separation. It also determined that the asthma condition was no longer unfitting. The CI appealed to the Army Board for the Correction of Military Records (BCMR) requesting the addition of gout as unfitting and ratable. It determined that the applicant provided insufficient evidence that would warrant granting a relief request and denied his application. The CI made no further appeals and was separated with a 20% combined disability rating. CI CONTENTION: “gout and sleep apnea and DJD in lower back” SCOPE OF REVIEW: The Board wishes to clarify that the scope of its review as defined in DoDI 6040.44, Enclosure 3, paragraph 5.e.(2) is limited to those conditions which were determined by the PEB to be specifically unfitting for continued military service; or, when requested by the CI, those condition(s) “identified but not determined to be unfitting by the PEB.” The ratings for unfitting conditions will be reviewed in all cases. The gout condition requested for consideration and the unfitting low back and right wrist conditions meet the criteria prescribed in DoDI 6040.44 for Board purview, and are accordingly addressed below. The other requested condition, sleep apnea, is not within the Board’s purview. Any conditions or contention not requested in this application, or otherwise outside the Board’s defined scope of review, remain eligible for future consideration by the Army Board of Correction of Military Records. The TDRL RATING COMPARISON: Service IPEB – Dated 20020903 VA* – All Effective Date 19980611 Condition Code Rating Condition Code Rating Exam On TDRL – 19980610 TDRL Sep. Rt Wrist Arthritis 5010-5003 10% 10% Rt Wrist Injury S/P ORIF 5211-5212 20% 19990416 Back Pain DDD 5299-5295 10% 10% DDD L-Spine 5003-5292 20% 20000328 Asthma 6602 10% Not Unfitting Asthma 6602 30% 19990416 Gout Not Unfitting NO VA ENTRY Post Traumatic HAs Not Unfitting Post Traumatic HAs 9304-8045 10% 19990416 Rt Shoulder Pain Not Unfitting Rt Shoulder Injury Post op 5203-5024 10% 19990416 Bil Pes Planus Not Unfitting Bilateral Pes Planus 5003-5276 30% 19990416 Hypertension Not Unfitting Hypertension 7101 10% 19990416 .No Additional MEB/PEB Entries. Rt Elbow Injury w/ DJD 5010-5206 10% 19990416 Sleep Disorder 6899-6847 50% 20000309 0% x 3/Not Service Connected x 4 19990416 Combined: 20% Combined: 90% * VA rating based on exam most proximate to date of permanent separation. ANALYSIS SUMMARY: Right Wrist Condition. In May 1996, the CI fell from a military vehicle when it moved forward while he was climbing aboard. He sustained a wrist fracture and dislocation and was treated with ORIF and casting. Despite occupational therapy (OT), he continued to have pain, limitations in ROM and grip weakness which prevented him from meeting duty requirements. He was issued a U3L3 profile and referred to a MEB. There were four ROM evaluations in evidence, proximate to TDRL entry, with documentation of additional ratable criteria, which the Board weighed in arriving at its rating recommendation; as summarized in the chart below. Right Wrist ROM Degrees MEB ~18 Mo. Pre-TDRL entry VA C&P ~2 Mo. Post- TDRL entry First TDRL re-evaluation 10 months after entry VA C&P ~10 Mo. Post- TDRL entry Dorsiflexion (0-70) 20 - 20 10 Palmar Flexion (0-80) 35 - 10 10 Ulnar Deviation (0-45) 15 - 10 10 Radial Deviation (0-20) 5 - 10 10 Comment Grip strength decreased No motion. Wrist not fused on x-ray Grip 4/5. NVI. Motion observed when the CI was distracted §4.71a Rating 10% 30% 10% The narrative summary (NARSUM) dictated on 11 December 1996, 18 months prior to TDRL entry. The scar was noted to be well healed, but there was tenderness over the wrist near the base of the thumb, the site of the prior injury and surgery. X-ray showed mild bone loss and early arthritis. The ROM was reduced as above. Two addenda to the NARSUM were dictated in the July 1997 timeframe. The CI complained of a painful hand and wrist with decreased ROM. Objectively, he was observed to be anxious. There was marked guarding of movement of the right wrist, but he had full passive ROM. Active motion was not measured as the CI refused to move his wrist. There was no wasting of the muscles of the hand. Under fluoroscopic examination, no instability was noted and there was no evidence of DDD although nonunion of the ulnar styloid was noted as well as a healed scaphoid (radial) styloid. A nerve conduction velocity electromyogram test (NCV/EMG), testing nerve and muscle function, was normal. The examiner noted “pain complaints far in excess of radiographic and physical findings.” A second note documented that the CI had progressive wrist pain, used a brace for functional activity and showed increased evidence of arthritis on x-ray. At the VA Compensation and Pension (C&P) examination on 13 August 1998, 2 months after TDRL entry, the CI reported continued pain. On examination, the right wrist was extremely painful to palpation without motion active or passive. He was noted to hold the wrist rigidly. No hand weakness was noted. On x-ray, he had nonunion of the ulnar styloid and an old fracture of the radial styloid. The Board noted that at a 9 November 1998 VA physical medicine functional evaluation for a job at the post office, the CI was cleared for employment. His review of symptoms was negative and the neurological examination normal with intact sensation, strength and reflexes. There was no muscle tenderness or atrophy noted. The gait was normal. The examiner specifically noted the history of LBP, the wrist surgery, gout and the diagnosis of asthma. The first TDRL re-evaluation was 9 April 1999, 10 months after TDRL entry. The CI noted continuous pain and reduced ROM with a weakened grip and decreased lifting ability. The ROM is above. His scar was well healed and the grip strength reduced at 4/5. The VA accomplished a second C&P on 16 April 1999, 10 months after TDRL entry. It noted that he was an office manager. The CI reported that he had pain even at rest. There was no active motion of the wrist when directly examined, but during the rest of the examination it was noted that he had about 10 degrees (later 15 degrees was written) of motion. He was noted to hold the wrist rigidly during the “conscious part of the examination.” No atrophy of the forearm muscles was noted. X-ray showed degenerative changes of the wrist and non-union of fractures of the radial and ulnar styloid processes. The examiner noted that there was an immobile wrist (to active movement), although there was movement when the CI was distracted. The PEB rated the right wrist at 10% and utilized the codes 5010 and 5003 for traumatic and degenerative arthritis, respectively. The VA rated the wrist at 20% using the codes 5211 and 5212, for impairment of the ulna and radius, respectively. The ulnar styloid process was noted to have non-union of a fracture on both VA examinations and one NARSUM. However, this finding typically has no bearing on prognosis unless there is also instability present between the ulna and radius. The addendum in 1997 specifically noted that there was no instability present. The finding on a non-union of a radial styloid process fracture was also not consistently present and noted only on one VA examination whereas the prior VA examination had documented that it was healed. The preponderance of evidence does not support the presence of separately unfitting conditions from either a non-union of the radial or ulnar styloid process. The Board determined that the code 5215, limitation of motion, would be most appropriate. This, however, provides no advantage to the CI. After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the right wrist condition at TDRL entry. The Board then turned its attention to the TDRL exit (permanent) rating. There was one set of ROM measurements proximate to TDRL exit which is in the table below. The CI had his third TDRL evaluation on 17 May 2002, 4 years after TDRL entry and 5 months prior to permanent separation. He noted mild pain on the radial (thumb) side of the wrist and stated that he had residual amount of motion and diminished grip strength. On examination, grip strength was 4/5 and there was tenderness over the radial aspect of the right wrist. No swelling or deformity was noted. The examiner noted that X-rays from May 2000 showed post-traumatic changes. No comment was made on residual non-union of the styloid processes. There were no other examinations proximate to TDRL exit in evidence. Right Wrist ROM Degrees MEB ~5 Mo. Pre-TDRL Exit Dorsiflexion (0-70) 30 Palmar Flexion (0-80) 30 Ulnar Deviation (0-45) 10 Radial Deviation (0-20) 10 Comment §4.71a Rating 10% The PEB rated the right wrist at 10% and utilized the codes 5010. The VA did not re-evaluate the wrist condition after the initial rating. The Board noted that the CI endorsed less pain than at entry to TDRL status and that the ROM showed modest improvement. After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the right wrist condition at TDRL exit. Low Back Condition. The CI first met a MEB for LBP in 1994. He reported a year history of LBP with the increased physical training at his duty location and denied any history of trauma. Other than pain, he was relatively asymptomatic. His gait, strength and reflexes were all normal. There was diffuse tenderness to the lumbar region and flexion was limited to 60 degrees. The MEB found him medically unacceptable, but the PEB found him fit for duty. He again was referred to MEB in 1996 in conjunction with his right wrist condition discussed above. The narrative summary (NARSUM) was dictated on 11 December 1996, 18 months prior to TDRL entry. The CI reported moderate LBP which precluded him from lifting, doing sit ups and running. He was noted to be free of spasm, but with tenderness in the lumbar region. X-rays were normal. The ROM was reduced slightly reduced in extension and flexion limited to fingers six inches from the floor. A provocative test for nerve root irritation was positive at the limit of the test. At the C&P examination on 13 August 1998, 2 months after TDRL entry, the CI reported continued pain aggravated by forward flexion, carrying over 20 pounds or standing over an hour. The ROM showed a restriction to flexion of 40 degrees vice the normal 90 with painful motion. No other comments on the examination were made, but the Xray was noted as showing DDD. The Board noted that at a 9 November 1998 VA physical medicine functional evaluation for a job at the post office, the CI was cleared for employment. His review of symptoms was negative and the neurological examination normal with intact sensation, strength and reflexes. There was no muscle tenderness or atrophy noted. The gait was normal. The examiner specifically noted the history of LBP, the wrist surgery, gout and the diagnosis of asthma. The first TDRL re-evaluation was 9 April 1999, 10 months after TDRL entry. The CI noted the inability to stand for long periods of time. On examination, the gait was normal and ROM full. He did note pain with flexion and extension. Strength and reflexes were normal. On X-ray, a narrowed disc space was noted at L5-S1. The VA accomplished a second C&P on 3 March 2000, 10 months after TDRL entry. It noted that he was an office manager. The CI reported that he had spasms that involved the lower back to the gluteal region, but denied radicular symptoms. On examination, he had some straightening of the lumbar lordosis, but was without atrophy or spasm. The ROM was reduced in extension to 15 degrees and flexion to fingers ten inches from the floor. The neurovascular exam was intact without evidence of a radiculopathy. On X-ray, minimal narrowing of the T12-L1 and L4-5 disc spaces was noted, but without DJD. Magnetic resonance imaging (MRI) on 19 June 2000 showed L4-5 DDD without herniation or nerve impingement. The Board directs attention to its rating recommendation based on the above evidence. The PEB rated the back condition at 10% and coded it 5299-5295, analogous to lumbosacral strain. The VA rated the back at 20% and coded it 5003-5292, degenerative arthritis and lumbar limitation in motion, citing the 40 degree limitation in flexion as consistent with moderate limitation in motion. The Board noted that this examination was an outlier from the other examinations and inconsistent with the minimal radiographic evidence and the remainder of the physical examinations. After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the back condition at TDRL entry. The Board then turned its attention to the TDRL exit (permanent) rating. The CI had his third TDRL evaluation on 17 May 2002, 4 years after TDRL entry and 5 months prior to permanent separation. The CI noted continued LBP which was unchanged from his prior evaluation. There was tenderness to palpation over the lumbosacral spine. The CI was able to flex to his mid-shins, bend laterally to mid-thigh and extend 10 degrees. There was slightly increased tone of the paravertebral muscles. Strength, sensation and gait were all normal. There was narrowing of the L5-S1 disc space. The PEB continued the 10% rating and 5299-5295 code at permanent separation. The VA did not re-evaluate for several years, but did note ROM improvement in the 9 February 2007 rating decision which would support a lower rating. However, it also noted that the rating criteria had changed and that this precluded a change in rating barring an overall change in the condition. The Board noted that the loss of flexion was slight and the neurological examination normal. The findings on X-ray were minimal and would not be uncommon in someone the age of the CI. After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the back condition at TDRL exit. Asthma. The CI was determined to have an unfitting asthma condition at TDRL entry and rated at 10% disability. At the initial MEB examination on 11 December 1996, 18 months prior to TDRL entry, he reported the used of an inhaler on a daily basis and limitations in activity. At a TDRL reevaluation on 28 September 1999, 15 months after TDRL entry, the CI reported that he used a rescue inhaler (Proventil) two times every 2 weeks. He noted shortness of breath even at rest. On examination, his lungs were clear and he was noted to have a thick neck and be moderately overweight. Pulmonary function tests (PFTs) showed no obstructive lung disease (which asthma is), but did show a restrictive defect which could be explained, at least partially, by his obesity. The examiner, a pulmonologist, opined that there was no evidence of asthma present. A re-evaluation on 3 May 2000 by a pulmonologist noted that the CI complained of shortness of breath after one flight of stairs and used an inhaler up to four times a day. It was noted that his weight had increased 11 pounds and the 65 inch CI now weighed 221 pounds. He was thought to have symptoms consistent with asthma. His PFTs showed no improvement with bronchodilators, though, and were consistent with a restrictive rather than obstructive defect. He nonetheless retained the diagnosis of asthma. The final TDRL evaluation on 13 June 2002, 4 months prior to TDRL exit. He had not used any inhalers for over a year and had not noted a change in his symptoms since he discontinued his medications. He had no response to bronchodilators during PFTs and a Methacholine challenge test was negative for the diagnosis of asthma. The diagnosis of asthma was again excluded. The Board noted that the PEB and VA both coded the asthma condition as 6602, but rated it at 10 and 30%, respectively. The action officer opined that the diagnosis of asthma has been excluded by several pulmonologists and that the CI was using medications once a week at the examination closest to TDRL entry. However, the Board is charged not to reduce adjudication by the PEB and therefore recommends no change to the TDRL entry adjudication. Further, it recommends that the PEB determination for the TDRL exit also remain unchanged. After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the asthma condition at TDRL entry or exit. Contended PEB Conditions. The contended condition adjudicated as not unfitting by the PEB was gout. It was judged to be medically unacceptable by the MEB, but not unfitting by the PEB. The Board’s first charge with respect to this condition is an assessment of the appropriateness of the PEB’s fitness adjudications. The Board’s threshold for countering fitness determinations is higher than the VASRD §4.3 (reasonable doubt) standard used for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard. The CI developed gout in 1995 and was treated with medications. There is no record of further attacks after the initial presentation other than a note, dated 8 August 1996, which documented that he had two gouty attacks in the past year. He had been placed on a temporary profile once, 3 years prior to TDRL entry. There was no specific mention by the commander of impairment from gout. The Board noted that at a 9 November 1998 physical medicine functional evaluation for a job at the post office, the CI was cleared for employment. His review of symptoms was negative and the neurological examination normal with intact sensation, strength and reflexes. There was no muscle tenderness or atrophy noted. The gait was normal. The examiner specifically noted the history of LBP, the wrist surgery, gout and the diagnosis of asthma. A 6 January 2000 rheumatology note documented that he had gone several months without a flare and was well controlled by medications. The gout condition was reviewed by the action officer and considered by the Board. There was no indication from the record that it significantly interfered with satisfactory duty performance. After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the gout condition and, therefore, no additional disability rating can be recommended. BOARD FINDINGS: IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication. The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised. In the matter of the right wrist, back and asthma conditions and IAW VASRD §4.71a and 4.100, the Board unanimously recommends no change in the PEB adjudication for either TDRL entry or exit. In the matter of the contended gout condition, the Board unanimously recommends no change from the PEB determination as not unfitting. There were no other conditions within the Board’s scope of review for consideration. RECOMMENDATION: The Board, therefore, recommends that there be no recharacterization of the CI’s disability and separation determination, as follows: UNFITTING CONDITION VASRD CODE RATING TDRL PERMANENT Post-Traumatic Arthritis Rt Wrist 5010-5003 10% 10% Low Back Pain with L5-S1 DDD 5299-5295 10% 10% Asthma 6602 10% Not Unfitting COMBINED 30% 20% The following documentary evidence was considered: Exhibit A. DD Form 294, dated 20120610, w/atchs Exhibit B. Service Treatment Record Exhibit C. Department of Veterans’ Affairs Treatment Record XXXXXXXXXXXXXXXXXXXXXX, DAF Acting Director Physical Disability Board of Review SFMR-RB MEMORANDUM FOR Commander, US Army Physical Disability Agency (TAPD-ZB / XXXXXXXXXX), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557 SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXXXXXX, AR20130005092 (PD201200796) I have reviewed the enclosed Department of Defense Physical Disability Board of Review (DoD PDBR) recommendation and record of proceedings pertaining to the subject individual. Under the authority of Title 10, United States Code, section 1554a, I accept the Board’s recommendation and hereby deny the individual’s application. This decision is final. The individual concerned, counsel (if any), and any Members of Congress who have shown interest in this application have been notified of this decision by mail. BY ORDER OF THE SECRETARY OF THE ARMY: Encl XXXXXXXXXXXXXXXXXX Deputy Assistant Secretary (Army Review Boards)