RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW NAME: XXXXXXXXXXXXXXX BRANCH OF SERVICE: ARMY CASE NUMBER: PD1201049 SEPARATION DATE: 20040401 BOARD DATE: 20130220 SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an activated National Guard SSG/E-6 (88M30/Motor Transport Supervisor), medically separated for chronic left forearm and knee pain, combined as a single unfitting condition. With a prior history of compound fractures of the forearm and patella, the CI reinjured his left knee and left forearm after loading trucks in February 2003. The CI stated that he was unable to drive trucks or do his job due to unrelieved pain and functional limitations. 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). The Physical Evaluation Board (PEB) adjudicated chronic left forearm and knee pain, combined as a single unfitting condition, rated 0%, with cited application of the US Army Physical Disability Agency (USAPDA) pain policy. The CI made no appeals and was released from active duty due to medical disability. The CI elected not to receive severance pay but, with greater than 20 years of satisfactory Federal service, on 22 December 2003, elected transfer to the Retired Reserve List. CI CONTENTION: The CI attached a one page statement to his application suggesting that the information provided to the MEB was incorrect. SCOPE OF REVIEW: The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e.(2). It is limited to those conditions determined by the PEB to be unfitting for continued military service and those conditions identified but not determined to be unfitting by the PEB when specifically requested by the CI. The ratings for unfitting conditions will be reviewed in all cases. 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 for the Correction of Military Records. RATING COMPARISON: Service IPEB – Dated 20031211 VA – All Effective Date 20040430 Condition Code Rating Condition Code Rating Exam Chronic Lt Forearm & Knee Pain 5099-5003 0% DJD Lt Knee w/ Scar 5260 10% STR Nerve Compression LUE S/P Surgery w/ Scar 8615 10% STR .No Additional MEB/PEB Entries. HTN w/ Chronic Renal Failure 7101-7507 30%* STR 0% X 0 / Not Service-Connected x 0 STR Combined: 0% Combined: 40% *Original VARD 20050209 rated HTN @ 10%, combined @ 30%. Upon appeal, HTN rating was increased to 30%, combined to 40%, retroactive to DOS, per VARD 20051007. ANALYSIS SUMMARY: The Board has neither jurisdiction nor authority to scrutinize or render opinions in reference to the CI’s statements in the application regarding suspected Disability Evaluation System (DES) improprieties in the processing of his case. The Board’s role is confined to the review of medical records and all evidence at hand to assess the fairness of PEB rating determinations, compared to VASRD standards, based on severity at the time of separation. It must also judge the fairness of PEB fitness adjudications based on the fitness consequences of conditions as they existed at the time of separation. The PEB combined the left forearm condition and the left knee condition as a single unfitting condition coded to 5099-5003 and rated 0%, with application of the USAPDA pain policy. This approach by the PEB reflected its judgment that the constellation of conditions was unfitting, and there was no need for separate fitness adjudications or implied adjudication that each condition was separately unfitting. The Board’s initial charge in this case was therefore directed at determining if the PEB’s approach of combining conditions under a single rating was justified in lieu of separate ratings. When considering a separate rating for each condition, the Board considers whether each unbundled condition is reasonably justified as separately unfitting or the totality of the evidence indicates the condition would not cause the member to be referred into the DES or be found unfit because of that condition. When the Board recommends separate fitness recommendations in this circumstance, its recommendations may not produce a lower combined rating than that of the PEB. Left Forearm Condition. The MEB narrative summary (NARSUM) notes that the CI suffered a compound radial and ulnar fracture in a motorcycle crash in 1992, while in civilian status, with open reduction and internal fixation (ORIF). Soon after, he developed a non-union in the forearm with loosening of the hardware, resulting in a second ORIF with bone graft from the left hip. Prior to coming on active duty for Operation Enduring Freedom on 13 February 2003, the CI’s profile was PULHES 1, noting only a history of controlled hypertension and “Fit for full duty.” In a pre-deployment questionnaire on 1 February 2003, the CI stated that he was not in a limited duty status and had no medical complaints. A medical note dated 14 March 2003 notes left forearm pain for one week, stating that the CI had been exempt from push-ups and sit-ups, but “does lifting at work.” Examination at this occasion noted mild forearm tenderness, no swelling and full range-of-motion (ROM). The CI was returned to CONUS in September 2003 primarily due to poorly controlled hypertension. Following return to his home base, the CI was evaluated in the orthopedic clinic on 20 October 2003 for the MEB. The examiner dictated the MEB NARSUM on 31 October 2003 based on this evaluation. At the exam, the CI reported that he re-injured his forearm while loading trucks while deployed in February 2003. The CI reported stiffness in the forearm and 4/10 pain over the ulnar styloid process (tip of the forearm at the wrist) and that the ulnar styloid was “turning upwards.” He reported pain and numbness with any use of the arm, and occasionally lost grip when holding items. He stated he had numbness in all his fingers, and added that he was unable to do his job “due to his inability to feel his left arm while driving.” On examination, the orthopedist noted tenderness at the distal forearm and a bony prominence at the ulnar styloid, and a positive Tinel’s sign, indicating irritation of the median nerve at the carpal tunnel. No weakness was noted. Wrist extension (dorsiflexion) was 47 degrees, wrist flexion 43 degrees, wrist radial deviation 50 degrees, and wrist ulnar deviation 45 degrees. Forearm pronation was 90 degrees, and forearm supination 80 degrees. No VA Compensation and Pension (C&P) exam was performed within 12 months of the CI’s separation. The Board first considered whether the left forearm condition, when considered alone separate from the knee condition, was unfitting for continued military service. The Board concluded that the evidence in the service treatment record (STR) and the commander’s letter supported a conclusion that the left forearm condition standing alone would have caused the CI to be referred into the DES and to have been determined to be unfit. The Board then considered its rating recommendation for the unfitting left forearm condition at the time of separation. Forearm ROM was essentially normal and did not attain a minimum rating under diagnostic code 5213. Wrist motion was mildly limited but did not attain a minimum rating under diagnostic code 5215. Pain was intermittent, as noted in a 9 January 2004 clinic encounter, prior to separation. Motion was adequate, and neurological symptoms were intermittent and sensory only. According to the MEB, the patient “has a slight amount of pain occasionally.” The Board noted that the VA rated this condition analogously as a pain secondary to a mild neuritis of the median nerve (8615). However, neuropathy of the medial nerve would not affect all the fingers of the hand, and one would not experience diffuse distal forearm tenderness in the setting of median nerve neuropathy. The Board noted the approach by the VA for rating was reasonable for the symptoms and disability recorded. Alternatively a 10% rating was supportable for painful motion (§4.59) and functional loss (§4.40). However this approach would not result in a higher rating and, since it was based on the same impairment, two separate ratings are not appropriate (two ratings for the same disability cannot be granted in accordance with §4.14 (avoidance of pyramiding). Considering the totality of the evidence and mindful of VASRD §4.3 (reasonable doubt), members agreed that a disability rating of 10% for the left forearm condition, coded 5010-5213 for forearm pain, pain on motion and functional loss, is appropriate in this case. Left Knee Condition. The Board considered whether the left knee pain condition, when considered alone separate from the left forearm condition, was unfitting for continued military service. The MEB NARSUM notes that, in the same motorcycle accident in 1992, he suffered a fracture of the inferior pole of the patella, and required a tendon graft to repair. The CI later stated that he had re-injured his knee while pulling chain in January, 2003, prior to deployment, and on another occasion, he states it was April, 2003, while deployed. Review of treatment records while deployed show no care for or complaint of knee pain. The CI was returned from the deployed location due to poorly controlled high blood pressure. The orthopedic MEB evaluation on 20 October 2003 recorded a report of left knee pain with use; however, only the left forearm was mentioned as duty limiting. The left knee examination noted patellofemoral tenderness, and mild limitation of flexion but no swelling or instability. The examiner recorded at that time the CI reported slight pain occasionally. The examiner issued an L3 profile based on the CI report of pain with use and the condition was included in the MEB referral to the PEB. Board members concluded there was no evidence of significant knee impairment prior to referral into the DES, and that the knee was not a cause or contributor for the CI’s medical evacuation from the deployed location. The Board members concluded that the evidence did not show that the left knee condition standing alone would have caused the CI to be referred into the DES or be found unfit. 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. As discussed above, PEB reliance on the USAPDA pain policy for rating both the left forearm and the left patellar conditions was operant in this case and each condition was adjudicated independently of that policy by the Board. In the matter of the left forearm condition, the Board unanimously recommends a determination of separately unfit and a separation rating of 10%, coded 5010- 5213, IAW VASRD §4.59. In the matter of left knee pain condition, as combined in the PEB adjudication, the Board unanimously agrees that it could not be satisfactorily established as independently unfitting and is therefore not ratable for disability. There were no other conditions within the Board’s scope of review for consideration. RECOMMENDATION: The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of his prior medical separation: UNFITTING CONDITION VASRD CODE RATING Chronic Left Forearm Pain 5010-5213 10% Chronic Left Knee Pain Not Unfit COMBINED 10% The following documentary evidence was considered: Exhibit A. DD Form 294, dated 20120614, 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 / xxxxxxxxxxxx), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557 SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for xxxxxxxxxxxxxxxxxxxx, AR20130006028 (PD201201049) 1. 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 to modify the individual’s disability rating to 10% without recharacterization of the individual’s separation. This decision is final. 2. I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum. 3. I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures. BY ORDER OF THE SECRETARY OF THE ARMY: Encl xxxxxxxxxxxxxxxxxxxxx Deputy Assistant Secretary (Army Review Boards)