RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2013-01505
BRANCH OF SERVICE:  Army	BOARD DATE:  20150123
SEPARATION DATE:  20040311

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (Information Manager) medically separated for chronic pain right wrist.  The condition could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty (MOS) or satisfy physical fitness standards.  She was issued a permanent U3 profile and referred for a Medical Evaluation Board (MEB).  The chronic pain right wrist condition, characterized as “triangular fibrocartilage complex tear, right wrist” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other conditions were submitted by the MEB.  The Informal PEB adjudicated “chronic pain right wrist” as unfitting, rated 0%, citing criteria of the US Army Physical Disability Agency (USAPDA) pain policy. The CI made no appeals and was medically separated.

CI CONTENTION:  “An additional three surgeries have been performed to correct the injury one of which bone from the hip was removed and placed into the arm more than three years in different types of braces and over six months casted.”  [sic]

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 when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting.  Any conditions outside the Board’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/Naval Records.  Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards to the unfitting medical condition at the time of separation.  The Board 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, operating under a different set of laws.  The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation. 

RATING COMPARISON:

Service IPEB – Dated 20040129 | VA – (At Separation)
Condition | Code | Rating | Condition | Code | Rating | Exam
Chronic Pain Right Wrist | 5099-5003 | 0% | Status Post Residuals Right Wrist Injury with Triangular Fibrocartilage Tear and Scar (Non Dominant) | 8699-8614 | 20% | 20040301
Other x 0 (Not in Scope) | Other x 4 (Not in Scope) |
Combined:  0% | Combined:  30%
Derived from VA Rating Decision (VARD) dated 20040519 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:  

Chronic Pain Right Wrist Condition.  The CI had a 3-to-4 month history of right wrist pain with numbness of the right palm in the absence of trauma according to a occupational therapy consultation dated 14 December 2001.  Treatment consisting of splinting and occupational therapy afforded little pain relief.  She was noted to have carpal tunnel syndrome (compression of the median nerve of the central inner wrist) based on the aforementioned symptoms, but there was no electro-diagnostic evidence for a median nerve neuropathy at the right wrist or elbow.  X-rays demonstrated normal bone structures of the hand and wrist, while a magnetic resonance imaging showed extravasation (spillage) of contrast material into the right wrist (radioulnar joint space) suggestive of a triangular fibrocartilage complex (TFCC) tear.  Arthroscopy on 27 November 2002 confirmed the torn cartilage of the radial margin (thumb side of the wrist), which was repaired.  Post-operative pain of the right wrist, thought to be from scarring and adhesions and marked by tightness of over the ulnar side (little finger side of the wrist) and tenderness over the dorsal radial portal (on the top of the thumb side of the wrist), persisted and limited her from keyboarding (typing) for a prolonged timeframe and other MOS requirements.  A U3 physical profile was issued on 29 September 2003 for the TFCC tear of the right wrist with limitations of no push-ups, heavy lifting, pull ups, and climbing onto vehicles and she was to use of a wrist brace for support.  At the MEB examination dated 20 October 2003, the CI reported having had a TFCC tear.  The MEB physical examination noted flexion of the left wrist greater than 10 degrees and extension 22 degrees with nerve irritation (positive Tinel’s sign) and normal blood supply of the hand (positive Allen’s sign).  The commander’s statement dated 22 October 2003 indicated the CI was unable to perform all her duties as needed and could not fully participate in physical fitness, field or combat training nor participate in many critical training events prior to deployment.

The MEB narrative summary dated 6 November 2003 noted wrist extension (dorsiflexion) of 60 degrees (Normal 70 degrees) and flexion (palmar flexion) of 50 degrees (Normal 80 degrees) with tenderness over the TFCC and a positive ulnar grind test (for instability).  Neurologically, she had a negative Tinel’s sign (nerve irritation) with a positive flexion/compression test of the median nerve and normal two point sensation.  She had continued to have limited ability to use the right wrist and perform certain physical training exercises and tasks related to her MOS.  Her pain was determined to be minimal and intermittent; and, she denied pain at night or at rest.  Because of some symptoms and physical examination findings of carpal tunnel syndrome, she received an injection of a local anesthetic and steroid to evaluate her response for potential future carpal tunnel release surgery.  Improvement was noted for 3 weeks post injection with recurrence thereafter.  She was advised to follow-up at the VA after completion of pregnancy and post-separation for treatment/surgery.

At the VA Compensation and Pension (C&P) examination dated 1 March 2004, performed 10 days prior to separation, the CI reported a history of cold weather injury in 2001 with her right  2nd, 3rd, and 4th fingertips having had some numbness that recurred when exposed to cold.  She reported carpal tunnel syndrome (pain, weakness, numbness and tingling) of the right hand and wrist and had relative numbness of the 2nd through 4th digits.  Pain in the right wrist was present and was worse during cold weather or repetitive movement.  Improvement of symptoms improved after the injection in November 2003.  Although she had electro-diagnostic tests that were negative, the diagnosis of carpal tunnel syndrome was made.  Examination noted the CI was left hand dominant.  The right wrist ROMs were flexion 0 degrees-70 degrees and extension 0 degrees-60 degrees, radial deviation 0 degrees-20 degrees (Normal 20 degrees), and ulnar deviation 0 degrees-40 degrees (Normal 45 degrees).  Right hand grip was normal.  Repetitive movement caused more symptoms; and, the right wrist was additionally limited due to pain and weakness when lifting more than 10 pounds or typing more than 70 words per minute.  
Temporally remote VA C&P examinations were reviewed; however, they offered very limited or no probative post-separation evidence of any significant value, but did document additional surgical procedures of the wrist in 2008 and 2009.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 0% rating using code 5099-5003 for chronic pain of the right wrist IAW USAPDA pain policy rated on minimal/intermittent pain.  The VA assigned a rating of 20% using code 8699-8614 (neuritis-musculospiral nerve [radial nerve]) for residuals of the right wrist injury.  The CI had documented pain on motion and an increase of symptoms with repetition at the VA C&P examination just prior to separation, a 10% rating using code 5099-5003 is reasonable.  However, the CI also had a mild limitation of motion of both dorsiflexion (extension) and palmar flexion of the wrist with some objective and subjective findings of carpal tunnel syndrome and tenderness on overlying the radial portal.  Therefore, IAW the Veterans Affairs Schedule for Rating Disabilities (VASRD) §4.124a the use of peripheral nerve codes was considered.  Either analogous code 8614 or 8514 for mild involvement of the radial nerve at 20% is reasonable in view of pain (neuritis) or partial paralysis marked by post-operative fibrosis and scarring (limitation of wrist extension), while either code 8615 or 8515 for mild involvement of the median nerve (carpal tunnel syndrome) at 10%.  Pyramiding IAW VASRD §4.14 of the wrist condition by the use 5099-5003 with a nerve code or combining the separate nerve codes for the radial and medial nerves can be avoided by the use a lower radicular nerve code 8612 at 20% for mild neuritis, which reasonably addresses the CI’s symptoms and objective findings.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 20% for the chronic pain of the right wrist 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.  As discussed above, PEB reliance on the USAPDA pain policy for rating chronic pain right wrist was operant in this case and the condition was adjudicated independently of that policy by the Board.  In the matter of the chronic pain right wrist condition, the Board unanimously recommends a disability rating of 20%, coded 8699-8612 IAW VASRD §4.124a.  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 her prior medical separation:

UNFITTING CONDITION | VASRD CODE | RATING
Chronic Pain Right Wrist | 8699-8612 | 20%
COMBINED | 20%

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20130923, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

			
XXXXXXXXXXXXXXXXXX
President
DoD Physical Disability Board of Review

SAMR-RB									

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation 
for XXXXXXXXXXXXXXXXXX, AR20150008366 (PD201301505)

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 20% 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						     XXXXXXXXXXXXXXXXXX
						     Deputy Assistant Secretary of the Army
						         (Review Boards)

CF: 
(  ) DoD PDBR
(  ) DVA

PD-2013-01505