RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXX	CASE:  PD-2013-02479
BRANCH OF SERVICE:  AIR FORCE	BOARD DATE:  20150630
SEPARATION DATE:  20050923

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (Education and Training Craftsman) medically separated for bilateral carpal tunnel syndrome (CTS).  The bilateral carpal tunnel condition could not be adequately rehabilitated to meet the physical requirements of her Air Force Specialty (AFS).  She was issued a P4U4 profile and referred for a Medical Evaluation Board (MEB).  “Bilateral carpal tunnel syndrome” was forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123.  No other condition was submitted by the MEB.  The Informal PEB (IPEB) adjudicated “bilateral carpal tunnel syndrome” as unfitting, rated 10% and 10% for a combined 20% rating, citing application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  Hypothyroid was determined to be a category II condition (can be unfitting but not currently compensable or ratable.)  The CI appealed to the Formal PEB (FPEB) which affirmed the findings of the IPEB.  The CI submitted a rebuttal to the FPEB.  Upon review by Secretary of the Air Force Personnel Council (SAFPC), the Board found no compelling objective basis upon which to justify overturning previous Board decisions.  The CI was medically separated.  

CI CONTENTION:  She was not evaluated for scars.  Her condition continues to worsen and negatively impacts her daily activities.  Her complete submission is at Exhibit A.  

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 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:  

SAFPC – Dated 20050812 | VA* - (~4 Days Post-Separation)
Condition | Code | Rating | Condition | Code | Rating | Exam
Bilateral CTS | Left | 8715-8799 | 10% | Left CTS | 8515 | 10% | 20050927
| | | | Scar, Left Wrist (s/p CTS) | 7804 | 10% | 20050927
| Right | 8715-8799 | 10% | Right CTS | 8515 | 10% | 20050927
| | | | Scar, Right Wrist (s/p CTS) | 7804 | 10% | 20050927
Other MEB/PEB Conditions x 0 (Not In Scope) | Other x 5
COMBINED RATING:  20% | COMBINED RATING:  60%
*Derived from VA Rating Decision (VARD) dated 20051202 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY:  

Bilateral CTS.  The first note in the service treatment record was an electrodiagnostic study dated 29 August 2003, which was performed for the CI’s history of bilateral hand pain, tingling and numbness without neck pain.  Motor and nerve conduction studies of the median and ulnar nerves bilaterally were normal and without evidence of CTS.  The CI had continued numbness and tingling of the left hand that awakened her at night.  She felt the test results were not representative of her condition and physical examination on 3 September 2003 revealed mild thenar atrophy and positive Tinel’s and Phelan’s tests (to determine nerve irritation) indicative of left CTS.  Repeat electro-diagnostic studies on 15 September 2003 revealed minimal medial neuropathy at both wrists, which might be consistent with CTS.  With cervical (neck) extension, the CI developed palmar weakness without any upper extremity weakness or major reflex changes, which raised the possibility of cervical root irritation, but an MRI of the cervical spine dated 6 October 2003 was unremarkable with no disc herniation, stenosis or cord compression.  Orthopedic evaluation on 15 October 2003 recommended an electro-diagnostic study of the cervical spine, wearing of a wrist splint 24/7 except when bathing, and continuing an anti-inflammatory medication, Vioxx.  An extended profile to include no repetitive wrist motion, no repeated use of hands, and no work at or above shoulder [level] was recorded at a visit on 18 November 2003.  

Left CTS.  At an orthopedic follow-up visit on 24 November 2003, the CI was advised there was no electro-diagnostic evidence of left CTS or left cervical radiculopathy and examination revealed a full range-of-motion (ROM) of the left wrist.  The CI was evaluated on 18 December 2003 for bilateral hand numbness and tingling.  Examination revealed no Tinel’s sign and no direct compression test bilateral, full ROM bilaterally with discomfort and no evidence of thenar atrophy bilaterally.  A cortisone injection in the left carpal canal was given to see whether it would help alleviate her symptoms.  On 29 January 2004, the CI indicated she had brief relief of discomfort, but numbness and pain continued.  However, based on clinical findings of a positive Tinel’s with a rapid direct compression test, numbness in the median nerve distribution, and mild, bilateral CTS on the electro-diagnostic study in September 2003, although a subsequent study was normal, a left carpal release was recommended and carried out on 5 April 2004.  Postoperatively, the operative site of the left wrist opened slightly, but was well healed with mild tenderness of the scar site by 2 June 2004 and was to be rubbed with vitamin E cream to desensitize the area.  Re-evaluation electro-diagnostic studies done on 27 September 2004 were within normal limits.  Orthopedic evaluation on 25 October 2004 indicated limited success with the left wrist and the CI was recommended to consider acupuncture or a second opinion for the right wrist.  An MRI of the cervical spine dated 30 November 2004 revealed minimal degenerative disease and no disc herniation or spinal cord narrowing.    

Right CTS.  The CI reported that paresthesias (tingling sensations) worsened over the right radial 3½ fingers.  Evaluation by an orthopedic hand surgeon in January 2005 noted positive tests for right carpal tunnel syndrome and right carpal tunnel release surgery was performed on 9 February 2005.  Within a week the operative site was healing well.  She had no paresthesias and had full digital active ROM.  Two months postoperatively she had full ROM of the wrists with moderate tenderness to palpation on the right wrist operative site and mild tenderness to palpation on the left wrist operative site.  Physical therapy was performed with resolution of pain by 26 May 2005, although the CI reported continued symptoms with repetitive activities especially typing for a long duration.   

The commander’s statement dated 8 April 2005 indicated that while the CI worked in her primary AFS, she spent at least 4 of 12 months performing additional duty because of her inability to perform repetitive motion and had been consistently on profiles since August 2003 and did not meet worldwide mobility qualification standards.  The commander opined that “[g]iven the fact that her current AFSC is one of the least physically demanding in the Air Force and the considerable restrictions of her profile, it is highly unlikely any cross-training opportunities exist.”  A permanent P4/U4 profile was issued on 11 April 2005 with restrictions of no repetitive motion with the wrists or hands, no push-ups, and light duty only.  

The MEB narrative summary (NARSUM) dated 11 April 2005 noted the CI was originally seen at the Flight Medicine Clinic on 5 August 2003 with complaints of bilateral wrist pain related to her job typing and performing computer work and was diagnosed with possible CTS. She was counseled to decrease activity, wear wrists braces and was prescribed NSAIDS (nonsteroidal anti-inflammatory medication) for conservative management.  After a long period of evaluation by orthopedic surgeons and a neurologist she had left wrist carpal tunnel release on 5 April 2004 and a right wrist carpal tunnel release on 9 February 2005.  According to the NARSUM author, the CI had disabling, recurrent persistent weakness and pain of bilateral wrists of such a degree as to definitely interfere with the performance of her duty since her condition had persisted for over 20 months and had not improved despite multiple medications, pain management, and surgical therapies. As a result “her condition preclude[ed] her indefinitely from fitness testing (no pushups) and was not expected to significantly improve.”  

At the VA Compensation and Pension (C&P) examination dated 27 September 2005, performed 4 days after separation, the CI reported bilateral CTS, for which surgeries did not provide any relief. She complained of sharp pain involving the bilateral wrists, which bothered her intermittently three to four times a week and symptoms lasted 24 hours with a severity of 6/10 (10 being the worst pain).  She noted numbness and tingling involving the first through fourth digits, which was associated with weakness and occasional swelling along with fatigue.  She denied stiffness or redness and used Motrin as needed with relief, but denied any flare-ups or the use of wrist braces, but noted the right hand dominant wrist symptoms were worse than the left.  Physical examination of the wrists revealed healed vertical bilateral, surgical wrist scars which measured four centimeters each, which she complained were sore to touch.  There was no adherence and no keloid.  Decreased sensation to light and sharp touch involved the first through fourth digits with normal sensation of the fifth digits, forearms, and remainder of the upper extremities.  Temperature sensation was intact bilaterally.  There was slight weakness of the right grip compared to the left; otherwise motor strength testing of the upper extremities was normal.  Tinel’s sign was positive bilaterally.  Dorsiflexion of the wrists bilaterally was 0 to 70 degrees with pain at the end of the ROM bilaterally; palmar flexion was 0 to 80 degrees bilaterally with pain throughout the ROM; radial deviation was 0 to 20 degrees with pain at the end of the ROM; and left ulnar deviation was 0 to 42 degrees, while right ulnar deviation was 0 to 40 degrees with pain at the end of the ROM bilaterally.  There was no change in the ROM due to pain, fatigue, weakness, or lack of endurance.  

A Physical Medicine and Rehabilitation (PM&R) consultation was performed on 15 June 2006, almost 9 months post separation, for numbness and tingling in both hands.  The CI believed “that the carpal tunnel is due to a combination of hypothyroidism as well as her job.”  Examination of the hands revealed surgical scars at the bilateral wrists, no evidence of atrophy in the hand muscles, positive Tinel’s and Phalen’s signs bilaterally, and impaired sensation in bilateral median nerve distribution.  The impression was recurrence of symptoms post bilateral carpal tunnel release most likely due to recurrence of the CTS.  Bilateral splints were given and follow-up electro-diagnostic studies were ordered, which were normal.

The ROM evaluations proximate to separation in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.

Wrist ROM
(Degrees)

Ortho ~11 Mo. Pre-Sep

Ortho ~6 Mo. Pre-Sep

VA C&P ~4 days. Post-Sep

Dorsiflexion (70 Normal) | FROM right wrist | FAROM bilaterally | 70/70
Palmar Flexion (80) | | | 80/80
Ulnar Deviation (45) | | | 42/40
Radial Deviation (20) | | | 20/20
Comment: | Mild dorsal right wrist tenderness; no Tinel’s or direct compression test | No paresthesias right, occasional paresthesias left | Pain at the end of ROM bilaterally DF, UD, and RD bilaterally; pain throughout ROM PF bilaterally.
§4.71a Rating | - | - | 10% and 10%

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB assigned a 20% rating, which took into account a 10% rating for the left wrist and a 10% rating for the right wrist as well as the bilateral factor, for bilateral CTS using the analogous code 8715-8799 (neuralgia median nerve, mild). The VA assigned a 10% rating, coded 8515 for both the right and left CTS, for a combined 20% rating.  The Board sought a route to higher rating, but since there was no ankylosis or limitation of motion of the wrists the VASRD wrist codes were not applicable.  The Board considered a 30% rating using the code 8515 (moderate) since the CI was right hand dominant, had slight decreased right grip strength compared to the left, although there was no thenar atrophy; her right hand digits had a full ROM; there was no reported defective opposition and abduction of the thumb; and post-separation electro-diagnostic studies were normal.  Therefore, there was no other route to a higher rating for the bilateral CTS.  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 bilateral carpal tunnel syndrome condition.  

The Board notes that the contended bilateral wrist scarring was neither referred by the MEB nor adjudicated by the PEB.   IAW DoDI 6040.44, as mentioned above, the contended conditions are not in scope and therefore were not adjudicated by the Board.

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 bilateral carpal tunnel syndrome conditions and IAW VASRD §4.124a, 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 20131121, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

XXXXXXXXXXXXXXXXX
President
Physical Disability Board of Review

SAF/MRB
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD  20762

XXXXXXXXXXXXXXXXX

Dear XXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2013-02479.

After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was appropriate.  Accordingly, the Board recommended no re-characterization or modification of your separation.

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding and their conclusion that re-characterization of your separation is not warranted.  Accordingly, I accept their recommendation that your application be denied.

Sincerely,

XXXXXXXXXXXXXXXXX
Director
Air Force Review Boards Agency

Attachment:
Record of Proceedings

cc:
SAF/MRBR

PD-2013-02479