RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXX	CASE:  PD-2013-02218
BRANCH OF SERVICE:  Army	BOARD DATE:  20150106
SEPARATION DATE:  20070515

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SFC/E-7 (21B/Combat Engineer) medically separated for left forearm and hand injury and chronic left upper extremity (LUE) pain.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty.  He was issued a permanent U3 profile and referred for a Medical Evaluation Board (MEB).  The upper extremity condition, characterized as “right shoulder stiffness, bilateral upper extremity pain and residual disability” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other conditions were submitted by the MEB.  The Informal PEB adjudicated “left non-dominant forearm and hand injury, with reduced grip strength and chronic left upper extremity pain,” as unfitting rated 10% and 10%, with likely application of the VA Schedule for Rating Disabilities (VASRD) and the US Army Physical Disability Agency (USAPDA) pain policy, respectively.  The CI made no appeals and was medically separated.

CI CONTENTION:  The CI elaborated no specific contention in his application.

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 forearm and hand injury and LUE pain conditions are addressed below; no additional conditions are within the DoDI 6040.44 defined purview of the Board.  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 Board for Correction of Military Records.

RATING COMPARISON:

Service IPEB – Dated 20070320	VA - (3 Days. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Non-Dominant Forearm and Hand Injury…	5309	10%	Residual Fracture Left Index Finger with Scar	5309	10%	20070518	
			Scar, Residual Left Radius Fracture Status Post ORIF	5207	0%	20070518	
Chronic Left Upper Extremity Pain…	5099-5003	10%	Left Shoulder Pain	5201	0%	20070518	
Other x 0 (Not In Scope)	Other x 14	
Combined:  20%	Combined:  50%	
Derived from VA Rating Decision (VARD) dated 20070618 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:  IAW DoDI 6040.44, the Board’s authority is limited to making recommendations on correcting disability determinations.  The Board’s role is thus 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 ratable severity at the time of separation.

Introduction: Left Non-Dominant Forearm and Hand Injury and Chronic LUE Pain.  The narrative summary (NARSUM) notes the CI sustained multiple injuries due to an improvised explosive device blast on 4 December 2004 including open fractures of the right upper arm (humerus), left forearm and left second metacarpal.  Radiographs of the LUE on the same day showed a comminuted fracture of the mid-radius.  He was stabilized in the field and then was medically evacuated for additional care and had open reduction and internal fixation (ORIF) of the left forearm.  Left arm X-rays performed on 10 December 2004 noted the left forearm was casted with surgical hardware in place, but showed no fracture of the hand.  Repeat X-rays on 5 January 2005 showed a healing comminuted fracture of the radius, stabilized in normal alignment with a plate and screw.  Left finger X-rays on 15 April 2005 noted a fragmented fracture of the index finger at the base of the proximal phalanx that extended into the second metacarpophalangeal (MCP) joint (base of the finger into the hand.)  The CI participated in physical therapy and occupational therapy but when maximum medical improvement was attained he was referred for a medical evaluation board due to persistent pain and stiffness of the right shoulder, and left arm and hand.

Left Non-Dominant Forearm and Hand Injury.  At the MEB examination on 27 December 2006, 5 months prior to separation, the CI reported pain.  Range-of-motion (ROM) was elbow flexion of 130 degrees (normal 145 degrees) and extension limited by 15 degrees (normal 0 degrees), normal forearm pronation (normal 90 degrees) and supination (normal 80 degrees), and wrist full flexion (normal 80 degrees) and extension of 35 degrees (normal 70 degrees).  Mild to moderately limited ROM was noted of all fingers at the MCP joints (knuckles).  Occupational therapy (OT) measured ROM of the LUE on 12 March 2007, 2 months prior to separation, noted elbow ROM of flexion 132 degrees, 132 degrees, 130 degrees and extension limited by 16 degrees, 16 degrees, and 20 degrees.  Forearm pronation was 75 degrees, 75 degrees, 75 degrees and supination of 75 degrees, 80 degrees, 80 degrees, wrist flexion of 65 degrees, 65 degrees, 60 degrees extension of 45 degrees, 50 degrees, 45 degrees.  At the OT evaluation the CI was noted to be able to make a full fist with the left hand, touch the proximal transverse crease of the palm with all fingers, and have normal opposition of the thumb to all fingers.  Grip strength was moderately decreased on the left.  The MEB examiner indicated no imaging studies were needed because “fractures healed and in good position.”

At the VA Compensation and Pension (C&P) General examination on 18 May 2007, 3 days after separation, the CI reported limited ROM of the wrist and index finger with pain in the left hand.  On examination the CI was noted to be right handed.  There were painful scars on the left forearm and finger that did not limit ROM.  Elbow ROM was reported as full; left wrist ROM full, except for extension of 50 degrees, and mildly limited index finger ROM at the MCP and proximal interphalangeal joints.  Sensation, reflexes, and strength of the LUE were normal, except for mild decreased left grip strength graded 4.5/5 (5/5 full strength).  At the VA C&P Joints examination on 7 December 2007, 7 months after separation, the CI reported left forearm pain rated 7-8/10 with stiffness, and left hand pain with use.  Wrist ROM was extension of 40 degrees and flexion of 55 degrees with painful motion, with no change in ROM with three repetitions.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the left forearm/hand injury 10%, coded 5309 (Group IX – forearm and intrinsic hand muscles).  The VA rated residual left index finger fracture with scar 10%, coded 5309 and residuals of left radius fracture post ORIF 0%, coded 5207 (limited forearm extension).  The VARD dated 24 July 2007, approximately 2 months after separation, increased the rating of the residuals of left radius fracture to 10%, coded 5299-5014 (analogous to osteomalacia) and noted that it had been previously evaluated as left shoulder pain claimed as LUE pain.  According to VASRD §4.73 muscle injuries of the hand are rated on ROM with a minimum of 10%.  The Board reviewed to see if a higher evaluation than 10% was achieved with any applicable alternative coding.  The evidence in record did not support rating greater than 10% for limited thumb or finger motions IAW §4.71a (musculoskeletal system)-5228 specifies a threshold for a compensable rating for thumb limited motion of “a gap of one to two inches (2.5 to 5.1 cm.) between the thumb pad and the fingers, with the thumb attempting to oppose the fingers” and 5229 specifies a threshold for a compensable rating for limitation of index or long finger motion of “a gap of one inch (2.5 cm.) or more between the fingertip and the proximal transverse crease of the palm, with the finger flexed to the extent possible, or; with extension limited by more than 30 degrees.”  The Board next considered if there was evidence of additional ratable impairment of the forearm or hand.  There was no evidence of limited ROM meeting the threshold for a compensable rating of the elbow, forearm, or wrist according to the rating criteria of 5206, 5207, 5208 or 5213 for the forearm and elbow, or 5215 for the wrist and there was no evidence of nonunion or malunion of the radius for coding as 5212 (radius impairment) and there was no evidence of nerve related impairment.  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 left forearm/hand condition.

Chronic Left Upper Extremity Pain.  The NARSUM notes the CI reported LUE pain.  The LUE pain as related to the forearm and hand is discussed in the forearm/hand section above.  Additionally, the MEB examination on 27 December 2006 noted left shoulder ROM of flexion of 180 degrees (normal 180 degrees), abduction of 180 degrees (normal 180 degrees).  Physical therapy ROM of the left shoulder on 15 February 2007 was flexion of 165 degrees, 165 degrees, 165 degrees and abduction of 150 degrees, 150 degrees, 155 degrees.  The CI reported right shoulder pain with pain and stiffness noted.

At the VA C&P General examination on 18 May 2007 3 days after separation, the CI reported chronic LUE pain and noted a hypersensitive scar in the palm of his left hand and at the VA C&P examination on 7 December 2007 the CI reported chronic pain of the forearm and hand and forearm stiffness.  There was no additional examination of the LUE than that noted in the forearm/hand section above at either C&P examination.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated chronic LUE pain at 10%, coded 5099-5003 and cited application of the USAPDA pain policy.  The VA rated left shoulder pain 0%, coded 5201 (limited arm motion).  The original VARD noted that the PEB proceedings showed LUE pain without compensable limitation of motion [of the shoulder] and the C&P exam noted reported LUE pain.  As noted in the discussion of the forearm/hand condition above the VARD on 24 July 2007, approximately 2 months after separation provided a 10% rating for residual of left radius fracture, coded 5299-5014 (analogous to osteomalacia) and noted it was in lieu of providing rating for left shoulder pain based on the claim for LUE pain.

The Board notes that there was no reported pain specific to the left shoulder in the record; LUE was consistently reported as related to the forearm and hand.  The Board opined that based upon the evidence it appeared that the PEB provided a 10% rating for LUE according to the pain policy to capture disability related to residual pain and stiffness of the forearm status post fracture, that may be unrelated to the pain and weakness of the hand due to the residuals of the finger fracture separately rated as muscle injury.  Other than pain of the LUE, there was no additional ratable impairment of the left shoulder based on ROM according to criteria of 5201 (limited arm motion) or impairment of the humerus clavicle, or scapula according to 5202 or 5203 criteria.  As mentioned in the discussion of the forearm/hand condition, there was no compensable loss of ROM of the forearm or wrist, but based upon the evidence at the post-separation C&P Joints examination, a 10% rating could be recommended for painful wrist ROM IAW §4.59 (painful motion).  However, this change in coding which would be in compliance with the VASRD (rather than based on the pain policy), would confer no ratings benefit to the CI.  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 LUE pain 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 the LUE pain condition was operant in this case and the condition was adjudicated independently of that policy by the Board.  In the matters of the left forearm and hand condition IAW VASRD §4.73 and in the matter of the LUE pain condition IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudications.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  The Board, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination.

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20131105, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

				
XXXXXXXXXXXXXXXXX
President
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 XXXXXXXXXXXXXXXXX, AR20150007052 (PD201302218)

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						     XXXXXXXXXXXXXXXXX
						     Deputy Assistant Secretary of the Army
						          (Review Boards)
						         
CF: 
(  ) DoD PDBR
(  ) DVA