RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXX	CASE:  PD-2013-02455
BRANCH OF SERVICE:  Army	BOARD DATE:  20140926
SEPARATION DATE:  20040517

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a National Guard SPC/E-4 (91G/Behavioral Health Specialist) medically separated for a right elbow condition.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty or satisfy physical fitness standards.  He was issued a permanent U3 profile and referred for a Medical Evaluation Board (MEB).  The right elbow condition, characterized as “right elbow instability post ulnar transposition and collateral ligament reconstruction” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded two other conditions for PEB adjudication.  The Informal PEB adjudicated “chronic pain and instability right elbow following ulnar transposition and collateral ligament reconstruction” as unfitting and rated it at 10%, citing the US Army Physical Disability Agency (USAPDA) pain policy.  The remaining conditions were determined to be not unfitting.  The CI did not submit an appeal and was medically separated.

CI CONTENTION:  “lnjury for which I was, rated was much worse than originally thought, which resulted in two additional surgeries after being separated from service.”

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 right elbow condition is addressed below and 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.

The Board acknowledges the CI’s information regarding the significant impairment with which his service-connected condition continues to burden him; but, must emphasize that the Disability Evaluation System has neither the role nor the authority to compensate members for anticipated future severity or potential complications of conditions resulting in medical separation.  That role and authority is granted by Congress to the Department of Veteran Affairs, operating under a different set of laws.

RATING COMPARISON:  

Service IPEB – Dated 20040409	VA 	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Pain and Instability Right Elbow…	5099-5003	10%	Ulnar Neuritis, Right Arm	Not Available	10%	C&P Not Available	
Other x 0  (Not in Scope)	Other x 2	C&P Not Available	
Combined:  10%	Combined:  20%	
Derived from VA Rating Letter dated 20050812 (best information available most proximate to date of separation)
ANALYSIS SUMMARY:  

Right Elbow Condition.  The CI had a long history of right elbow pain and tingling.  The initial entry in service treatment records is dated 7 November 1993, of an emergency room visit for right arm extension with swelling, pain and tingling.  By 18 November 1993, he continued to have difficulty of right arm being able to fully extending / flexion and the inability to throw a punch without difficulties or discomfort.  The following evaluation dated 7 July 1995, was for right elbow pain after lifting heavy object.  During the physical examination, the examiner noted tenderness of the medial elbow without edema or deformity and the CI had full ranges-of-motion (ROM).

The service treatment record documents that the CI injured his right arm after falling approximately 5-6 feet off a bunk bed onto outstretched hands on 8 March 2003.  Physical examination found tenderness and full extension, with flexion to 90 degrees without wrist tenderness.  During the follow up evaluation dated 12 March 2003, the examiner noted edema (swelling) of the CI’s upper right extremity from the elbow to fingertips.  He was referred to and seen by occupational therapy on 19 March 2003; at consultation he reported to the examiner deceased pain and swelling, difficulties straighten right arm and lifting objects that weight more than five pounds.  The examiner noted decreased ROM and positive Tinel’s sign of the right ulnar nerve; pain upon tapping the ulnar nerve at the medial right elbow.  While deployed, the CI was evaluated by orthopedics in Kuwait in May 2003.  The orthopedic noted CI’s right arm ROM was 3 degrees to 135 degrees and also that the right elbow was unstable to Valgus Stress Test.  It was questionable if the CI’s right arm condition met retention standards, therefore he was returned to CONUS for further evaluation and care.

A magnetic resonance imaging (MRI) study obtained on 17 June 2003 showed heterotrophic calcification adjacent to epicondyles with associated bone marrow edema within the course of the ulnar collateral ligament, worrisome for a partial ulnar collateral ligament tear.  On 10 July 2003, the CI underwent an ulnar nerve subcutaneous transposition and ulnar collateral ligament reconstruction using palmaris longus autograft of the right elbow for symptomatic ulnar collateral ligament laxity with symptomatic ulnar neuritis, right arm.  At the post operatively orthopedics evaluation dated 17 October 2003, the CI reported that he was having constant pain.  On a subsequent follow up orthopedics visit dated 24 November 2003, the CI reported continuous pain and stated it felt as if his elbow was locked.  During physical examination, the examiner noted that the CI’s ROM was 0 degrees to 130 degrees; experienced pain with all movements and strength was 5 out of 5.  During the physical medicine evaluation dated 2 December 2003, the examiner noted decreased sensation of the right distal lateral forearm, right medial forearm, right thumb, thenar and hypothenar eminence.  There was no edema, no muscular atrophy and normal strength.  The examiner also cited the positives (normal) results of the nerve conduction studies of the median, ulnar sensory and motor nerves, as well as a normal “numb thumb” study comparing the right to the left.  The final assessment findings were chronic pain and paresthesias of the right upper extremity with no electrodiagnostic evidence of neuropathy or plexopathy.  The examiner further opined that the neurologic symptoms would continue to improve.

The narrative summary (NARSUM) dated 14 January 2004 (4 months prior to separation), notes the CI described pain as present 100% of the time, causing sleep disturbance, requiring no medications, but does limited his ability to run, perform pushups or sit-ups, lift more than 10 pounds, carry a backpack and carry or fire a weapon.  Pain was described as slight and constant.  The NARSUM reference the physical medicine evaluation that reported strength as normal.  The NARSUM physical examination revealed tenderness over the medial epicondyle of the right elbow and decreased sensation over the right distal lateral forearm, right thumb, thenar and hypothenar eminence.  The ROM was 0 degrees to 130 degrees with pain upon resisted pronation.  The MEB physical examination (DD Form 2808), noted right elbow full ROM, decreased strength on supination 4 / 5 and decreased grip strength 4+/5.

The VA compensation and pension (C&P) examinations was omitted.

The Board directs attention to its rating recommendation based on the above evidence.  The Board considered the PEB assigned VASRD diagnostic analogously code 5099-5003 (arthritis, degenerative).  The Board did not find compensable ROM deficits under codes 5206 (forearm, limitation of flexion of) or 5207 (forearm, limitation of extension of).  The Board found sufficient evidence of painful motion in the treatment record for a 10% rating in consideration of VASRD §4.59 (painful motion).  The Board also considered code 8616 (ulnar neuritis), undoubtedly used by the VA for a 10% rating.  The Board did not find objective evidence of organic changes such as muscular atrophy or abnormal electrodiagnostic studies of the muscles or nerves for a rating in the CI’s favor under code 8616 (ulnar neuritis) as an alternate code.  As an additional code, 8616 (ulnar neuritis) did not overcome the VASRD §4.14 (avoidance of pyramiding) rule which states that the evaluation of the same disability under various diagnoses is to be avoided.  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 right elbow 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 right elbow condition was operant in this case and the condition was adjudicated independently of that policy by the Board.  In the matter of the right elbow 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 recharacterization of the CI’s disability and separation determination.

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20131118, 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 XXXXXXXXXXXXXXX, AR20150002947 (PD201302455)

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