RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2013-02596
BRANCH OF SERVICE:  Army	BOARD DATE:  20150310
DATE OF PLACEMENT ON TDRL:  19990927
Date of Permanent SEPARATION:  20040927

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-3 (Chemical Operations Specialist) medically separated for a right thumb and right hand condition.  These conditions could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS).  He was authorized to perform an alternate physical fitness test.  He was issued a permanent U3 profile and referred for a Medical Evaluation Board (MEB).  The right thumb and right hand  conditions, characterized as “chronic flexor pollicis longus rupture, right thumb and hypersensitive incision with chronic thumb” and “hand pain secondary to diagnosis 1,” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other conditions were submitted by the MEB.  The PEB adjudicated “chronic flexor pollicis longus rupture, right hand, with hypersensitive incision and chronic thumb and hand pain” as unfitting, rated 40% with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The PEB also found an Axis I condition (major depression per a psychiatric narrative summary [NARSUM]) as not unfit.  The CI did not appeal and was placed on the Temporary Disability Retirement List (TDRL).  Approximately a year later a second Informal PEB (IPEB) conducted a TDRL examination review and determined that the “soldier’s impairment has not sufficiently stabilized to permit final adjudication…”  The CI remained on TDRL until a third IPEB approximately a year later conducted a TDRL examination review and determined that the “soldier’s impairment has not sufficiently stabilized to permit final adjudication…” and thus the CI remained on TDRL.  The final IPEB conducted 2 years later adjudicated the conditions and lowered the original rating from 40% to 0% and changed the rating code from 5399-5307 to 5228 effective on 29 November 2004.  The CI made no further appeals and was medically separated.

CI CONTENTION:  Although the CI elaborated no specific contention in his application, the application appended notes from the CI’s mental health provider which implicated the CI was contending his not unfit MH condition.

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:

Final PEB - 20041129 | VA (~11 Mo. Post-TDRL Entry* and Service Treatment Record (STR)) - Effective 19990927
On TDRL - 19990927 | Code | Rating | Condition | Code | Rating | Exam
Condition | | TDRL | Sep. | | | |
Chronic Flexor Pollicis Longus Rupture, Right Hand, with Hypersensitive Incision and Chronic Thumb and Hand Pain | 5399-5307 | 40% | 0% | Hypersensitive Incision with Chronic Right Thumb and Hand Pain | 7805-8615 | 30% | 20000831
| | | | Chronic Flexor Pollicis Longus Rupture, Right Thumb | 5224 | 20% | 20000831
Major Depression | Not Unfit onto TDRL | Major Depression | 9434 | 0% | STR
Other x 0 (Not in Scope) | Other x 2
Combined:  40% → 0% | Combined 40%
*Reflects VA rating exam proximate to TDRL placement; no VA rating evidence proximate to permanent separation.

ANALYSIS SUMMARY:

Right Thumb and Right Hand Condition.  Treatment records evidence that the CI sustained a right thumb injury prior to service.  The CI reinjured that right thumb during a basic training exercise in October 1997.  A magnetic resonance imaging study of the right wrist and hand performed on 4 November 1997 revealed a “previous trauma and/or at least partial tear of the flexor pollicis longus” (FPL) tendon.  The CI was treated with activity modification, splinting, and occupational therapy with relief of his right thumb pain.  On 4 March 1998 the CI underwent surgical exploration of the right flexor pollicis longus tendon with placement of a Hunter rod.  A post-operative diagnosis of “old disruption that is complete of the right” FPL tendon was rendered.  At the VA Compensation and Pension (C&P) examination dated 7 December 1998 (performed 9 months prior to TDRL placement), the CI reported that he was evaluated by a hand Specialist at Walter Reed Army Medical center for his ruptured right FPL tendon and was presented with the option for (a tendon transfer reconstruction or joint fusion) additional right hand surgery; which he declined.  He reported twitching of the thumb muscles, pain in the index finger, and the surgical scar pain with wrist flexion and hypersensitivity.  The physical examination was significant for decreased, painful, right wrist palmar and dorsiflexion, decreased right hand strength.  The CI was able to make a fist.  Diagnoses of right thumb with flexor tendon dysfunction due to trauma and surgery right hand with placement of hardware were rendered.  At the time of the NARSUM examination dated 29 January 1999, the CI reported persistent pain and loss of function of the right hand due to pain, hypersensitivity at the surgical scar, and numbness in the palm and thumb.  The physical examination revealed  a hypersensitive surgical incision with tethering to underlying skin, tenderness along flexor sheath of the thumb, positive carpal tunnel testing (Tinel’s), no active flexion of joint tip of the thumb (interphalangeal [IP] joint), flexion of the joint at the base of the thumb (metacarpophalangeal [MCP] joint), and full extension of the IP and MCP.  He was able to oppose the thumb to all fingers except the small finger.  Diagnoses of chronic FPL rupture, right thumb and hypersensitive incision with chronic thumb and hand pain secondary to diagnosis one.  The examiner opined that independent of the tendon rupture the pain secondary to the hypersensitive scar and probable scarring of the underlying digital nerve prevented full use of the hand.  At an orthopedic evaluation dated 19 March 1999 the CI reported a 6 month-history of worsening numbness, tingling, and burning sensation of the right palm.  The physical examination was significant for hypersensitivity to touch of the right thumb and wrist; loss of right hand grip secondary to hypersensitivity; and decreased right thumb and wrist range-of-motion (ROM).  The two point discrimination (sensory innervation) examination was normal for the right thumb and digits.  Diagnoses of right thumb FPL disruption and post-surgery induced carpal tunnel syndrome (nerve compression) secondary to scarring of the right wrist were rendered.  At the VA C&P Hand, Thumb and Fingers examination dated 31 August 2000 the CI reported continuous throbbing right thumb pain, decreased grip strength, decreased thumb range of motion.  The physical examination was significant for atrophy of the thenar eminence (thumb muscles) and surgical scar keloid adherence to the superficial thumb muscle.  There was additional thumb weakness with repeated thumb flexion.  The examiner noted that the CI was able to use the hand to “grasp, push, pull, twist, probe, touch and for expression.”

At the TDRL evaluation dated 25 January 2001, the CI continued to report right thumb weakness and mild and intermittent right hand pain.  He expressed a desire for surgical intervention.  The physical examination was significant for atrophy of the right thenar musculature, positive nerve compression (Tinel’s) testing, and full active right wrist ROM.  The CI was continued on TDRL.  At the TDRL evaluation dated 25 September 2002, the CI continued to report an inability to flex the right thumb IP joint and loss of use of the right hand.  The physical examination demonstrated atrophy of the right thumb muscles (thenar musculature), decreased sensation, and no motion at the IP joint.  There was tenderness to palpation at the site of the Hunter rod.  The CI was continued on TDRL for Phase II of his right FPL tendon reconstruction.  The examiner presumed that the CI would be able to return to duty after the surgery.  On 29 November 2004 the PEB determined that the CI’ right thumb condition remained unfit and was stable.  The CI was medically separated 27 September 2004 after 5 years on TDRL.

The Board directs attention to its rating recommendation based on the above evidence.  The PEB adjudicated the chronic FPL rupture right hand with hypersensitive incision and chronic right thumb and hand pain as a single unfitting condition and unstable with a TDRL rating of 40% for severe involvement of the dominant hand, coded 5399-5307 (analogous to muscle Group VII injury).  The VA separately rated the hypersensitive incision with chronic right thumb and hand pain at 30%, coded 7805-8615 (scars other-neuritis of the median nerve) and chronic FPL rupture, right thumb at 20% coded 5224 (right thumb unfavorable ankylosis of); a combined 40% disability rating.

The PEB combined the chronic right hand flexor pollicis longus rupture, hypersensitive incision, and chronic right thumb and hand pain conditions under a single disability.  The combination of multiple conditions as a single disability reflects the PEB’s determination that each was unfitting, but the functional impairment could not be rated separately.  Fitness determinations are intrinsic to the services and outside of the scope of the VASRD; therefore, recommendations for separate VASRD codes and ratings can only be rendered if Board members determine that each condition could be reasonably justified as separately unfitting.  The Board’s initial charge in this case was therefore directed at determining if the PEB’s single rating was justified in lieu of separate unfit determinations and ratings.

Chronic FPL and painful, hypersensitive scar right palm and forearm conditions were permanently profiled.  The commander’s statement implicated the permanent profile restrictions as resulting in the CI inability to perform the duties of his MOS.  The NARSUM and multiple treatment notes documented an inability to use the right hand secondary to pain associated with the hypersensitive scar and scarring of the underlying digital nerve.  Members agreed that the chronic right hand pain with hypersensitive scar condition and chronic FPL rupture with thumb pain conditions were reasonably justified as separately unfitting.

The Board then deliberated the TDRL placement and removal ratings for the chronic right hand (including the thumb) pain condition.  The Board noted that the right hand, surgical scar, and thumb pain could not be rated separately IAW VASRD §4.14 (avoidance of pyramiding).  The Board considered that multiple treatment notes and the NARSUM evidenced a hypersensitive surgical scar with chronic right hand pain, decreased hand strength, and limitation of wrist motion.  The Board noted that there was a diagnosis of post-surgery induced carpal tunnel syndrome.  The Board determined that a rating for carpal tunnel syndrome analogous to median nerve neuritis (muscle atrophy, sensory disturbances, and constant pain) most closely approximated the CI’s disability.  The Board determined that the decreased grip strength and decreased ability to perform activities of daily living skill rose to the level of moderate functional impairment for a 30% TDRL placement rating.  At the time of TDRL examination most proximate to TDRL exit the CI reported decreased hand pain; described as mild and intermittent.  The Board noted that there was objective evidence of continued decreased grip strength; however, the CI had improved use of the right hand.  The Board determined that the functional impairments secondary to the chronic right hand pain condition rose to the level of mild for a 10% TDRL exit rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a TDRL placement disability rating of 30% and a TDRL removal rating of 10% for the chronic right hand pain condition.

The Board next considered the TDRL placement rating for the chronic right hand FPL rupture.  The Board noted that the NARSUM examiner documented that the CI was able to oppose the thumb to all fingers except for the small finger and the VA examination dated 7 December 1998 documented that the CI was able to make a fist.  The Board determined that criteria for favorable ankylosis of the right thumb was met for a 10% TDRL placement rating of the chronic right hand FPL rupture.  The Board noted that the chronic right hand FPL rupture condition was unchanged during TDRL and that the CI did not undergo Stage II tendon reconstruction prior to TDRL exit.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a TDRL placement and removal disability rating of 10% for the chronic right hand FPL rupture condition.

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that major depression, single episode, treated and improved condition was not unfitting.  The Board’s threshold for countering fitness determinations is higher than the VASRD §4.3 (reasonable doubt) standard used for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  Treatment records evidence that the CI requested an addendum to his MEB evaluation to include depression.  The NARSUM addendum noted that the CI received psychiatric care between April 1998 and March 1999 for symptoms of poor concentration, poor sleep, depressed mood, confusion, and withdrawal.  The CI was treated with a one-month trial of Prozac and then Wellbutrin.  In March 1999 the CI reported improvement in his depression symptoms and that he was no longer taking medications.  The NARSUM mental status examination was normal and a diagnosis of major depression, single episode, treated and improved was rendered.  The major depression was not profiled or implicated in the commander’s statement and was not judged to fail retention standards.  The VA service-connected the major depression with a disability rating of 0%.  All were reviewed by the action officer and considered by the Board.  There was no performance based evidence from the record that major depression significantly interfered with satisfactory duty performance.  After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the contended major depression and so no additional disability ratings are recommended.

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 right hand FPL rupture condition, the Board unanimously determined that it was separately unfitting and recommends a  TDRL placement and removal disability rating of 10%, coded 5224 IAW VASRD §4.71a.  In the matter of the chronic right thumb and hand (hypersensitive incision) pain, the Board unanimously determined that it was separately unfitting and recommends a TDRL placement rating of 30% and a TDRL removal disability rating of 10%, coded 7805-8615 IAW VASRD §4.124a.  In the matter of the contended major depression condition, the Board unanimously recommends no change from the PEB determination as not unfitting.  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 his prior medical separation:

UNFITTING CONDITION | VASRD CODE | RATING
| | TDRL | PERMANENT
Chronic right thumb and hand (hypersensitive incision) pain | 7805-8615 | 30% | 10%
Chronic right hand flexor pollicis longus rupture | 5224 | 10% | 10%
COMBINED | 40% | 20%

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20131205, 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 XXXXXXXXXXXXXXXX, AR20150012715 (PD201302596)

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		XXXXXXXXXXXXXXX
			Deputy Assistant Secretary of the Army
			   (Review Boards)

CF: 
(  ) DoD PDBR
(  ) DVA

PD-2013-02596