RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2013-02437
BRANCH OF SERVICE:  Army	BOARD DATE:  20150108
Separation Date:  20091108

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty PFC/E-3 (92F/Petroleum Supply Specialist) medically separated for a chronic low back pain (LBP) and arthropathy of right wrist conditions.  The conditions could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS) but he could perform an alternate physical fitness test.  He was issued a permanent U3L3 profile and referred for a Medical Evaluation Board (MEB).  The LBP and right wrist conditions, characterized as “chronic low back strain and chronic right wrist arthropathy,” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  Three other conditions (nephropathy, hypertension and obstructive sleep apnea) were submitted by the MEB.  The Informal PEB adjudicated “chronic low back pain and arthropathy of right wrist” as unfitting, rated 10% and 10% respectively, citing criteria of the VA Schedule for Rating Disabilities (VASRD).  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 rating for the unfitting chronic LBP and arthropathy of right wrist 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 200908730 | VA - (44 Mos. Post-Separation)
Condition | Code | Rating | Condition | Code | Rating | Exam*
Chronic LBP | 5299-5237 | 10% | Lumbar Spine Sprain | 5237 | 10% | 20130716
Arthropathy of Right Wrist | 5099-5003 | 10% | Arthropathy Of Right Wrist | 5003-5215 | 10% | 20130716
Other x 0 (Not In Scope) | Other x14
Combined:  20% | Combined:  70%
Derived from VA Rating Decision (VARD) dated 20130916 (most proximate to date of separation [DOS]).  * Original C&P missing.

ANALYSIS SUMMARY:  IAW DoDI 6040.44, the Board’s authority is limited to making recommendations on correcting disability determinations.  The Board reviews medical records and other available evidence to assess the fairness of PEB rating determinations, using the VASRD standards, based on ratable severity at the time of separation.  Additionally, the Board notes the earliest VA evaluation was 44 months after the date of separation and was not available for review.  DoDI 6040.44 provides for consideration of post-separation VA findings, particularly within 12 months of separation, although the Board’s recommendation is premised on the degree of disability at separation.  Therefore the service record evidence was assigned exclusive probative value with respect to the Board’s recommendations.

Chronic LBP Condition.  The CI had an insidious onset of LBP during his second Operation Iraqi Freedom (OIF) deployment in early to mid-2007.  The Family Practitioner noted that the CI reported LBP and stiffness in the lower region.  There were physical exam findings of costovertebral angle tenderness and pain with range-of-motion (ROM).  A physical therapist (PT) noted that the CI reported LBP and tightness with running and worsening of symptoms.  There were physical exam findings of mild flexion and extension restriction, mild tenderness to palpation (TTP) in the paraspinal muscles, and abdominal weakness with pelvic tilt and difficulty performing lateral lean.  The CI continued to complain of LBP and was followed by PT and Family Practice throughout 2008.  A lumbar spine X-ray noted a mild levoconvex curve centered at L3; otherwise the spine alignment was normal.  The lumbar spine magnetic resonance imaging was normal.  The orthopedist noted chronic LBP that radiated to the thighs with a normal physical exam.  The CI was given a U3/L3 profile for LBP and right wrist pain.  The commander’s statement documented that the CI had many complications which prevented him from performing his soldiering duties.  The CI’s LBP worsened and he was evaluated by PT with the physical exam findings summarized in the chart below.  The MEB narrative summary (NARSUM) exam approximately 4 months prior to separation documented that the CI reported pain exacerbation after carrying a ruck sack, constructing a fighting position or doing 5-second rushes.  He felt that he would be unable to perform the two mile run, sit-up or push up events.  The MEB NARSUM physical exam findings are summarized in the chart below.  There is no VA Compensation and Pension (C&P) exam present in evidence for review.

There was one goniometric ROM evaluation in evidence, with documentation of additional ratable criteria, which the Board weighed in arriving at its rating recommendation; as summarized in the chart below.

Thoracolumbar ROM (Degrees) | PT 8 Mos. Pre-Sep | MEB 5 Mo. Pre-Sep
Flexion (90 Normal) | 85 | ROM’s used from PT exam
Combined (240) | 200 |
Comment | Normal gait; Pos. painful motion & TTP; No Spasm, guarding or abnormal spinal contour; Neg. Waddell’s | Pos. TTP right sacroiliac area; Neg. straight leg raise bilat.
§4.71a Rating | 10% | 10%

The Board directed attention to its rating recommendation based on the above evidence.  The PEB coded the chronic LBP condition as 5299 analogous to 5237 (lumbosacral or cervical strain) and rated at 10%.  The VA coded the lumbar spine sprain condition as 5237 and also rated it 10%.  There was well documented evidence in the service treatment record of localized lumbar spine tenderness.  The CI met the 10% rating criteria for “localized tenderness not resulting in abnormal gait” and for a ROM measurement of not greater than 85 degrees.  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 chronic LBP condition.

Arthropathy of Right Wrist.  The CI injured his right wrist after he fell off a high mobility multipurpose wheeled vehicle (Humvee) during his OIF deployment in May 2004.  An orthopedic evaluation revealed a torn triangular fibrocartilage complex and the CI underwent a repair in 2004.  Despite the surgery, the CI continued to report right wrist pain with repetitive flexion-extension ulnar or radial deviation as well as pain with prolonged gripping objects or carrying objects greater than 15 to 20 pounds with the right arm.  Right wrist X-rays on 25 May 2005 showed surgical pins in proper places; however, the X-ray on 28 February 2006 showed some fragmentation in some of the proximal carpal bones.  The CI underwent occupational therapy in 2005 for right wrist strengthening and increased ROM.  The PT noted that although his right wrist was showing improvement, the CI had wrist pain with pushups.  The MEB NARSUM exam documented that the CI was unable to perform basic soldering duties or carry/lift more than 25 pounds or engage in repetitive gripping, bending or twisting of the right wrist.  The MEB NARSUM physical exam findings are summarized in the chart below.  There was no VA C&P exam present for review.

There was one goniometric ROM evaluation 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 Wrist ROM (Degrees) | PT 8 Mos. Pre-Sep | MEB 5 Mo. Pre-Sep
Dorsiflexion (70 Normal) | 57 | PT ROM’s used
Extension (80) | 60 |
Ulnar Deviation (45) | 30 |
Radial Deviation (20) | 16 |
Comments | | Pos. TTP & painful motion
§4.71a Rating | 10% | 10%

The Board directed attention to its rating recommendation based on the above evidence.  The PEB coded the arthropathy of right wrist condition as 5099 analogous to 5003 (arthritis, degenerative [hypertrophic or osteoarthritis]) and rated at 10%.  The VA coded the arthropathy of right wrist condition as 5003 with 5215 (wrist, limitation of motion of) and rated at 10%.  The MEB examiner noted that the CI had a functional impairment of an inability to perform strenuous activity to include pushups and pull-ups.  The CI had continued right wrist pain with daily activities, limited ROM and an inability to lift greater than 25 pounds.  Alternate analogous coding and rating under the criteria of 5212 (radius, impairment of) can be supported, but is not advantageous.  The only higher rating available for the wrist requires ankylosis (code 5214), and the evidence makes clear that significant joint excursion was retained in this case.  The painful motion on ROM was met by the MEB evidence.  The minimum 10% rating can be justified in this case by either VASRD §4.59 (painful motion) or §4.40 (functional loss).  There is no VASRD compliant pathway to a rating higher than 10%.  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 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.  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 chronic LBP condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the arthropathy of right wrist condition and IAW VASRD §4.71a, 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, 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 20131113, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

XXXXXXXXXXXXXXX
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 XXXXXXXXXXXXXXX, AR20150007622 (PD201302437)

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

PD-2013-02437