Author: JOHN J. D'ORAZIO
Last saved by: BARKSDALE, JAMEILL M GS7 USAF SAF SAF/MRBE
Company: Pre-installed Company

RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  	CASE:  PD1200941
BRANCH OF SERVICE:  Army	BOARD DATE:  20130717
Separation Date:  20020910

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a mobilized Reserve SPC/E-4 (88M/Truck Driver) medically separated for left ankle pain, right wrist pain and left ring finger distal interphalangeal (DIP) ankylosis.  The CI served on active duty from February 1988 through November 1995.  The CI injured his left ring finger (non-dominant), right ankle, and right wrist during his initial period of active duty.  The CI reportedly injured his right ankle in 1988.  He underwent a modified Brostrom lateral ankle and subtalar reconstruction in April 1995.  In 1992, the CI complained of a mass on his right wrist and underwent a surgical excision of his carpal metacarpal boss, second metacarpal trapezoid joint.  He injured his left ring finger, diagnosed as a ruptured flexor digitorum profundus (FDP) tendon rupture/avulsion that was repaired in November 1992.  He did well until he later sustained an intra-articular fracture of the DIP joint and in April 1993, he had his left ring finger DIP surgically fused.  He apparently improved sufficiently and did not require a Medical Evaluation Board (MEB) prior to his expiration of term of service in 1995.  His original VA rating in 1995 was 0% for his right ankle (later increased to 10% with the same effective date) and 0% for both his right wrist and left ring finger.  He joined the Army Reserves and reported his right ankle and left ring finger continued to bother him on his enlistment physical exam in 1999.  He was a member of the Reserves from approximately November 1999 until he was mobilized in October 2001 in support of Operation Noble Eagle.  During his mobilization period he complained of right ankle, right wrist, and left ring finger pain.  The ankle, wrist, and finger conditions 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 U2L3 profile and referred for a MEB.  The right ankle, right wrist and left ring finger, characterized as “degenerative joint disease of the left ankle”(apparent error), “s/p [status post] DIP rupture w/secondary loss of motion to the DIP joint of left ring finger” and “right wrist pain” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other conditions were submitted by the MEB.  The PEB adjudicated “pain left ankle and right wrist” as a single unfitting condition, rated 0% and “fusion of distal interphalangeal joint of the left non-dominant ring finger” as unfitting, rated 0%, with application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The CI made no appeals and was medically separated.

CI CONTENTION:  “I was close to retirement and I could of done the rest of my time and have better results from the Army.”

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 the unfitting left ankle, right wrist, and left ring finger are addressed below; and, no additional conditions are within the DoDI 6040.44 defined purview of the Board.  Any conditions or contention either not requested in this application or otherwise outside the Board’s defined scope of review, remain eligible for future consideration by the Board for Correction of Military Records.

RATING COMPARISON:

Service IPEB – Dated 20020815 | VA - (39 Mos. Pre-Separation)
Condition | Code | Rating | Condition | Code | Rating | Exam
Pain Left (this should be right) Ankle and Right Wrist | 5099-5003 | 0% | Right Ankle Fracture | 5010-5271 | 10%* | 19990626
| | | Right Wrist, Residuals, status post (s/p) Ganglion Cyst Removal | 7805 | 0% | 19990626
Fusion of Distal Interphalangeal Joint of Left Ring Finger (non-dominant) | 5227 | 0% | Crush Injury, Left 4^th Finger, s/p Tendon Repair | 5227 | 0% | 19990626
No Additional MEB/PEB Entries | Other x 6 |
Combined Rating:  0% | Combined Rating:  10%
Derived from VA Rating Decision (VARD) dated 19990723 (most proximate to date of separation [DOS]).   
All ratings were discontinued during active duty period 20011016 to 20020910 and the above ratings resumed on 20020911.
*Initial Right Ankle rating from VARD 19980928 was 0% effective 19951127; an 19990723 VARD increasing the rating to 10% effective the same date was based on exams 19961207, 19971031, and 19990626 and a personal hearing all prior to separation on 20020910).

ANALYSIS SUMMARY:  The Disability Evaluation System (DES) is responsible for maintaining a fit and vital fighting force.  While the DES considers all of the member's medical conditions, compensation can only be offered for those medical conditions that cut short a member’s career, and then only to the degree of severity present at the time of final disposition.  However the Department of Veterans Affairs (DVA), operating under a different set of laws (Title 38, United States Code), is empowered to compensate service-connected conditions and to periodically re-evaluate said conditions for the purpose of adjusting the Veterans disability rating should his degree of impairment vary over time.

The PEB and MEB erroneously documented pain in the left ankle on the DA Forms 199 and 3947.  The MEB narrative summary (NARSUM) described a right ankle condition but listed degenerative joint disease (DJD) of the left ankle as a diagnosis.  However, all service treatment notes and VA examinations indicate that the right ankle was affected.  Additionally, the DA Form 3947 identified the right ring finger but the left ring finger underwent surgery.

Pain, Right Ankle and Right Wrist Condition.  The PEB combined the right ankle and right wrist conditions under a single analogous 5003 degenerative arthritis code.  Although VASRD §4.71a permits combined ratings of two or more joints under 5003, it allows separate ratings for separately compensable joints.  The Board must follow suit (IAW DoDI 6040.44) if the PEB combined adjudication is not compliant with the latter stipulation, provided that each ‘unbundled’ condition can be reasonably justified as separately unfitting in order to remain eligible for Service rating.  If the members judge that separately ratable conditions are justified by performance based fitness criteria and indicated IAW VASRD §4.7 (higher of two evaluations), separate ratings are recommended; with the stipulation that the result may not be lower than the overall combined rating from the PEB.  The Board’s initial charge in this case was therefore directed at determining if the PEB’s combined adjudication was justified in lieu of separate ratings.  To that end, the evidence for the right ankle and right wrist are presented separately; with attendant recommendations regarding separate unfitness, and separate rating if indicated.

Pain, Right Ankle Condition:  The Board first considered if the pain, right ankle condition, having been de-coupled from the combined PEB adjudication, was reasonably justified as independently unfitting.  The service treatment record (STR) includes a long history of right ankle pain with frequent visits.  In June 1994, the CI was issued a permanent L3 profile with no running or jumping and an alternate aerobic event on the Army Physical fitness test (APFT) for DJD of the right ankle.  A MOS/Medical Retention Board was completed in August 1994 and the case was referred to a PEB however, there is no record of any PEB proceedings in 1994 or 1995.  The CI was diagnosed with right ankle chronic lateral ankle and subtalar instability and he underwent a modified Brostrom lateral ankle and subtalar surgical reconstruction in April 1995.  After this procedure, an orthopedic evaluation noted an MEB was not indicated.  In September 1995, a permanent L2 profile was issued for right ankle reconstructive surgery with running at own pace and distance, no road marching, marching up to two miles at his own pace, and continued alternate aerobic event on the APFT.  In May 2002, a permanent L3 Profile for s/p right ankle reconstruction was issued and the CI was referred for an MEB.  This profile included no running marching, or jumping; walking at own pace and distance; and no aerobic event on the APFT.  The commander’s statement does not specifically address any of the conditions but generalizes that the CI could not reasonably perform duties specific to his MOS such as performing routine maintenance, unscheduled maintenance, or the basic operation of equipment.  All Board members agreed that the functional limitations in evidence reasonably justified the conclusion that the condition was integral to the CI’s inability to perform his MOS and accordingly a separate rating is recommended.

There were range-of-motion (ROM) evaluations in evidence, with documentation of additional ratable criteria, which the Board weighed in arriving at its rating recommendation; as summarized in the chart below.

Right Ankle ROM
(Degrees)

VA C&P ~ 39 Mo. Pre-Separation

MEB ~ 2 Mo. Pre-Separation

Dorsiflexion (20 Normal) | 10 | 5-10
Plantar Flexion (45) | 25 | 45 (50)
Comment | Sensation intact; nontender; no swelling; steady gait; pain with “any fast walking or pounding” and “vigorous activities” | Sensation pulses strong, symmetrical non-tender throughout; “chronic pain”
§4.71a Rating | 10% | 10%

The CI had a long well documented history of right ankle pain that started with a right ankle fracture during basic training in 1988.  The CI was seen in acute medicine for right ankle pain.  A right ankle X-ray showed a small boney osteophyte off the navicular talus that the radiologist opined “may indeed cause some pain.”  The CI was followed by orthopedics and podiatry for chronic right ankle pain and treated with non-steroidal anti-inflammatory drugs (NSAIDs), aggressive physical therapy (PT), and several temporary L3 Profiles.  In 1989, the podiatrist ordered an ankle brace due to complaints of ankle pain when running.  The CT scan of feet and ankles in October 1989 showed minimal post-traumatic residuals in the area of the medial malleolus.  However, a repeat CT scan in 1999 demonstrated normal talar and subtalar joints.  The CI was diagnosed with right ankle chronic lateral ankle and subtalar instability and he underwent a modified Brostrom lateral ankle and subtalar reconstruction in April 1995.  The VA Compensation and Pension (C&P) exam approximately 39 months prior to separation noted that the CI still had right ankle pain when he did any fast walking or pounding or vigorous activities.  The C&P physical exam findings are summarized in the chart above.  The CI was seen by orthopedics in May 2002 for chronic ankle pain unrelieved with rest, NSAIDs, and PT.  The MEB NARSUM exam approximately 2 months prior to separation documented chronic right ankle pain and the examiner diagnosed right ankle DJD.  The examiner cited a right ankle X-ray that revealed mild spurring at the tibiotalar joint consistent with early degenerative process.  The MEB NARSUM physical exam findings are summarized in the chart above.  The examiner stated “dorsiflex 10 degrees and 5 degrees” and the exact meaning of this is not clear.  The CI was granted a permanent L3 profile for s/p right ankle reconstruction.  The commander’s statement does not specifically address any of the conditions but generalizes that the CI could not reasonably perform duties specific to his MOS such as performing routine maintenance, unscheduled maintenance or the basic operation of equipment.  The CI did later require another surgery but this did not occur until January 2010, more than 7 years after separation.  After a temporary 100% rating at the time of the surgery, the VA resumed the 10% rating.
The Board directs attention to its rating recommendation based on the above evidence.  The PEB coded the right ankle condition bundled with the right wrist pain as analogous to 5003 arthritis, degenerative (hypertrophic or osteoarthritis) and rated at 0% as described above.  The VA coded the right ankle fracture condition as 5010 arthritis, due to trauma, substantiated by X-ray findings coupled with 5271 ankle, limited motion of and rated at 10% effective the day after initial separation from active duty.  This rating was based on the June 1999 C&P examination as well as a personal hearing in May 1999 and earlier C&P examinations from October 1997 and December 1996.  Both VA and Army examinations proximate to separation documented pain-limited motion.  While VASRD code 5271 assigns 10% for moderate limitation of motion and 20% for marked limitation of motion, it does not provide actual ROM measurements for a determination of moderate versus marked limitation of motion.  Dorsiflexion was limited to half of normal on both the VA and the MEB NARSUM examinations.  While plantar flexion was limited to 25 degrees on the VA examination, it was normal on the MEB NARSUM examination.  The Board considered this to be a moderate limitation of motion of the ankle.  The Board also discussed rating as 5003 but determined this would also result in a 10% rating and offered no advantage.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the pain, right ankle condition.

Pain, Right Wrist Condition.  The Board first considered if the pain right wrist condition, having been de-coupled from the combined PEB adjudication, was reasonably justified as independently unfitting.  The STR includes a long history of right wrist pain with frequent visits and a permanent U2 profile for s/p surgery right wrist and left ring finger.  The commander’s statement does not specifically address any of the conditions but generalizes that the CI could not reasonably perform duties specific to his MOS such as performing routine maintenance, unscheduled maintenance or the basic operation of equipment.  The CI had multiple outpatient visits in 1992 and 1993 and multiple temporary U3 profiles for his right wrist in 1992.  While the MEB NARSUM states the CI underwent surgery for removal of a ganglion cyst of his right wrist in 1991 and had continuous wrist pain ever since, the CI underwent surgery to remove a symptomatic carpal boss on the second metacarpal trapezoid joint in May 1992.  The CI was evaluated for bilateral carpal tunnel syndrome symptoms in 2000 and 2002 and had normal bilateral nerve conduction and electromyogram studies completed in May 2002.  Symptomatic treatment was recommended.  A permanent U2 profile was issued in May 2002 with limitations of no push-ups and lifting up to 20 pounds.  Additionally, a 222222 profile is allowed for the 88M MOS.  All Board members agreed that the functional limitations in evidence do not reasonably justify the conclusion that the condition was integral to the CI’s inability to perform his MOS and accordingly a separate rating is not recommended.

Fusion of Distal Interphalangeal Joint of Left Ring Finger (non-dominant):  There were ROM evaluations in evidence, with documentation of additional ratable criteria, which the Board weighed in arriving at its rating recommendation; as summarized in the chart below.

Left Hand 
(Non-Dominant) 
(Degrees)

VA C&P ~ 39 Mo. Pre-Separation

MEB ~ 2 Mo. Pre-Separation

| Left Ring Finger | Left Ring Finger
MCP 0-90 | - | -
PIP 0-100 | - | -
DIP 0-70 | Fused- no motion | Complete fusion—no motion
Comments | Good grip strength; nontender | “No function of the flexor profundus digitorum tendon, considerable pain”
§4.71a Rating | 0% | 0%

The CI had a long well documented history of left ring finger pain after his reinjury and fusion surgery in January 1993.  The CI was evaluated by orthopedics for pain around the DIP joint and decreased motion at the DIP joint.  The orthopedist recommended splinting of the finger for symptomatic treatment and follow-up.  The left hand X-ray showed some traumatic arthritis of the 4th digit DIP joint.  The CI underwent fusion of the DIP joint in April 1993.  The CI was reevaluated by occupational therapy for a splint to maintain position.  A DIP joint X-ray showed obliteration of the DIP joint space and partial bony fusion of the middle and distal phalanx.  The C&P exam approximately 39 months prior to separation indicated that the CI’s left DIP joint was not bothering him and there was normal sensation in the finger; however, there was no motion in the DIP joint.  The C&P physical exam findings are summarized in the chart above.  The CI was seen for follow up by orthopedics in May 2002 for left ring finger and noted to have no motion of the DIP joint.  The CI was granted a permanent U2 profile for s/p surgery right wrist and left ring finger.  The commander’s statement does not specifically address any of the conditions but generalizes that the CI could not reasonably perform duties specific to his MOS such as performing routine maintenance, unscheduled maintenance or the basic operation of equipment - activities that could require full use of the fourth digit of the left hand to perform.  The MEB NARSUM exam approximately 2 months prior to separation documented noted no FDP function and considerable pain.  Based on the MEB history and physical exam findings, the examiner diagnosed s/p DIP rupture with secondary loss of motion to the DIP joint of the left ring finger.  The MEB NARSUM physical exam findings are summarized in the chart above.

The Board directs attention to its rating recommendation based on the above evidence.  The PEB coded the fusion of DIP joint of left ring finger (non-dominant) condition as 5227 ring or little finger, ankylosis of rated at 0% (unfavorable or favorable).  The VA also coded the crush injury, left 4th finger, s/p tendon repair as 5227 and rated 0%.  There was ample documentation that there was no motion in the DIP joint of the 4th finger.  The only rating assigned to VASRD code 5227 is a 0% rating, regardless of whether the ankylosis is favorable or unfavorable or whether the dominant or non-dominant hand is involved.  A 10% rating with VASRD 5155 would require an amputation of the ring finger at, or proximal to, the proximal interphalangeal joint without metacarpal resection.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 reasonable doubt the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the fusion of DIP joint of left ring finger (non-dominant) condition.

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.  In the matter of the bundled pain, right ankle condition, the Board unanimously agrees that it was reasonably justified as separately unfitting and unanimously recommends a disability rating of 10% coded 5271 IAW VASRD §4.71a.  In the matter of the bundled pain, right wrist condition, the Board unanimously agrees that it is not reasonably justified as unfitting and therefore no separate disability rating can be recommended.  In the matter of the fusion of DIP joint of left ring finger (non-dominant) condition, the Board unanimously recommends no change in the PEB adjudication.  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
Pain, Right Ankle | 5271 | 10%
Pain, Right Wrist | Not Unfitting
Fusion of Distal Interphalangeal Joint of Left (Non-Dominant) Ring Finger | 5227 | 0%
COMBINED | 10%

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20120606, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

Physical Disability Board of Review

SFMR-RB									

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(TAPD-ZB),

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation 
for AR20130018091 (PD201200941)

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						
						         (Army Review Boards)

CF: 
(  ) DoD PDBR
(  ) DVA

PD1200941