RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX		CASE:  PD1301060
BRANCH OF SERVICE:  ARMY		BOARD DATE:  20140130
SEPARATION DATE:  20060331

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SGT/E-5 (11B20/Infantryman) medically separated for left (non-dominant) cubital tunnel syndrome with continued pain and numbness after submuscular ulnar nerve transposition surgery.  The CI began having trouble with left hand numbness in January 2005 and had surgery in July 2005.  Postoperatively, he had continued difficulty and was on profile for over a year.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS) or satisfy physical fitness standards.  He was issued a permanent U3 profile and referred for a Medical Evaluation Board (MEB).  The left elbow condition, characterized as left cubital tunnel syndrome with continued pain and numbness after submuscular ulnar nerve transposition was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other conditions were identified by the MEB.  The Informal PEB adjudicated left cubital tunnel syndrome with continued pain and numbness after submuscular ulnar nerve transposition as unfitting, rated 10%, citing criteria of the VA Schedule for Rating Disabilities (VASRD).  The CI made no appeals and was medically separated.

CI CONTENTION:  “I could no longer carry a weapon or lift the minimum amount of weight required for military 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.  In addition, the CI was notified by the Army that his case may be eligible for review of the military disability evaluation of his mental health (MH) condition in accordance with Secretary of Defense directive for a comprehensive review of Service members who were referred to a disability evaluation process between 11 September 2001 and 30 April 2012 and whose MH diagnoses were changed or eliminated during that process.  The CI, also eligible for PDBR review of the unfitting left elbow condition, elected review by the PDBR and the rating for that condition is addressed below.  In addition, in accordance with Secretary of Defense directive for a comprehensive review of the MH diagnoses that were changed or eliminated during the Disability Evaluation System (DES) process, the applicant’s case file was reviewed regarding any MH diagnosis change or elimination, associated fitness determination, and rating of any unfitting MH diagnoses in accordance with the VASRD §4.129 and §4.130.  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 20060302 | VA - (~ 2.5 Mos. Post-Separation)
Condition | Code | Rating | Condition | Code | Rating | Exam
Left (Non-Dominant) Cubital Tunnel Syndrome S/P Submuscular Ulnar Nerve Transposition | 8516 | 10% | Cubital Tunnel Syndrome, Left, S/P Submuscular Ulnar Nerve Transposition | 8599-8515 | 20% | 20060728
No Additional MEB/PEB Entries | Post-Traumatic Stress Disorder (PTSD)* | 9411 | NSC* | 20060728
| Other x 4 | 20060728
Combined:  10% | Combined:  30%
Derived from VA Rating Decision (VARD) dated 20060728 (most proximate to date of separation [DOS])
*VARD dated 20100114 granted depressive disorder to include anxiety disorder with PTSD features at 50% effective 20091030

ANALYSIS SUMMARY:  IAW DoDI 6040.44, the Board’s authority is limited to making recommendations on correcting military disability determinations.  The Board’s role is thus confined to the review of medical records and available evidence to assess the fairness of PEB rating determinations, compared to VASRD standards, based on ratable severity at the time of separation; and, to review those fitness determinations within its scope (as elaborated above) consistent with performance-based criteria in evidence at separation.

Left Cubital Tunnel Syndrome Status Post (S/P) Submuscular Ulnar Nerve Transposition Condition.  The applicant is a right hand dominant male who developed numbness and tingling of the left 4th and 5th fingers in January 2005.  There was no identified injury, although the record notes that his spouse reported he had been having dreams at night; she would awaken and find him leaning on his left elbow (especially prior to the surgery and onset of symptoms) as if talking on the radio (this would occur for hours a night).  The patient endorsed a traumatic experience during deployment, during which he was on the radio.  In March 2005 he underwent a nerve conduction study (NCS) that revealed “Tardy Ulnar Syndrome,” decreased amplitude and conduction velocity of the ulnar nerve around the elbow.  He underwent a transposition of the left ulnar nerve in July 2005.  He had a repeat NCS in November 2005 that contained the following excerpts from the conclusion:

“This electrophysiologic examination (and the clinical history) is most consistent with a mild to moderate demyelinating ulnar neuropathy of the left upper extremity at or about the elbow, involving both motor and sensory fibers, with borderline slowing of conduction velocity across the elbow.  While these findings may support a mild improvement in the ulnar neuropathy overall, there is little significant change and the prognosis remains guarded.”

Despite occupational therapy and post-surgical rehabilitation, the numbness, tingling and weakness of the left hand continued and the CI was issued a permanent profile and referred into the DES.  The MEB narrative summary (NARSUM) accomplished 2 months prior to separation documented continued numbness in the ring and small fingers of his left hand as well as the posterior aspect of his forearm along with left elbow pain and stiffness.  Examination of the left arm revealed that sensation to light touch was decreased in the left ring finger and small finger.  Two-point discrimination (normal is 2-4mm on the fingertips) was 7-8mm in the small finger, 6mm in the right finger and 6mm or less in the remaining digits.  Motor strength was 4/5 in finger abduction (spreading fingers apart).  Motor strength was 5/5 in grip, thumb extension, wrist extension, elbow flexion, extension and shoulder abduction.  There was atrophy of the first dorsal interosseus muscle (first web space of the hand) as well as the hypothenar muscle mass (muscle group that forms the pad of the palm just below the little finger).  There was a well-healed surgical scar at the medial aspect of the left elbow.  There was no range-of-motion (ROM) documented, however, an orthopedic exam of the left arm performed 2 weeks earlier documented an elbow ROM of 5 degrees – 130 degrees (normal 0-145 degrees).  The NARSUM examiner concluded that the CI’s left cubital tunnel syndrome with continued pain and numbness after submuscular ulnar nerve transposition was medically acceptable.  Nevertheless, the MEB and PEB found it unfitting based on the documented functional limitations.  The VA Compensation and Pension (C&P) exam performed 2 months after separation, confirmed the history as noted above.  The physical exam documented decreased light touch of the left 4th and 5th fingers with normal strength and reflexes of the left upper extremity.  The examiner did not note any atrophy or motor impairment of the left hand and no joint impairment due to the nerve disorder.

The Board directs attention to its rating recommendation based on the above evidence.  The PEB adjudicated the left ulnar nerve condition by applying VASRD code 8516, paralysis of the ulnar nerve, and rated it 10% for mild, incomplete paralysis.  The VA applied the analogous code of 8599-8515, paralysis of the median nerve, and rated it 20% for moderate, incomplete paralysis of the non-dominant hand.  There was no compensable ROM impairment of the left elbow.  The documentation is unequivocal that the involved nerve is the left ulnar nerve and it is appropriately rated under code 8516 as utilized by the PEB.  Rating under 8516 requires differentiation between the subjective descriptors of mild, moderate or severe incomplete paralysis and is copied below for convenience:

8516 Paralysis of Ulnar Nerve:
Complete; the ‘‘griffin claw’’ deformity, due to flexor contraction of ring and little fingers, atrophy very marked in dorsal interspace and thenar and hypothenar eminences; loss of extension of ring and little fingers cannot spread the fingers (or reverse), cannot adduct the thumb; flexion of wrist weakened …... 60…… 50

Incomplete:
Severe .................................................. 40…… 30
Moderate ............................................. 30…... 20
Mild ...................................................... 10…... 10

The NARSUM examination was deemed to be the most probative based on being prior to separation, more detailed, and it was accomplished by the operating orthopedic surgeon.  That exam documented sensory deficits and some mild motor weakness of the intrinsic muscles of the CI’s non-dominant left hand.  The commander’s statement stated that the CI was unable to perform in his MOS related duties because of the left hand impairment.  The Board agreed that a fair threshold for the “moderate” rating entails functionally significant motor and/or sensory impairment encroaching on some occupational tasks.  Board consensus was that there was sufficient evidence in this case that this threshold was met.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board majority recommends a disability rating of 20% for the left ulnar nerve condition.

Contended MH/Posttraumatic Stress Disorder (PTSD) Condition.  The Board determined that it was appropriate that no MH diagnosis was identified by the MEB or adjudicated by the PEB and therefore, no MH diagnoses was changed to the applicant's possible disadvantage during the DES process.  This applicant therefore did not meet the inclusion criteria in the Terms of Reference of the MH Review Project.  The Board adjudged this to constitute a “de facto” determination by medical providers that no duty limiting the MH condition existed.  One mention of a MH condition (PTSD) was when the applicant documented on his MEB DD Form 2807 where he annotated “yes” for “Frequent trouble sleeping” and “Received counseling of any type.”  Further annotation by the provider was “came back from Afghanistan w/ PTSD had trouble sleeping.”  There was one other mention of PTSD on a C&P exam in January 2006.  Although PTSD was mentioned, there was no indication that it caused any duty impairment.  The well-established principle for fitness determinations is that they are performance-based and the Board’s threshold for countering PEB not-unfit determination requires a preponderance of evidence.  There was no mention of PTSD on any treatment record.  The Board considered evidence related to “fitness” for an indication of any service related functional impairment caused by a MH condition prior to separation.  No MH condition was ever profiled or implicated by the commander’s statement.  The MEB physical exam did not contain any annotations in the psychiatric section.  There were no psychiatric hospitalizations for any MH condition.  The CI did undergo a PTSD evaluation during the 2 month post-separation C&P exam.  The VA provider concluded that there was no diagnosis of PTSD and assigned a Global Assessment of Functioning of 80, if symptoms are present they are transient and expectable reactions to psychosocial stressors; no more than slight impairment in social, occupational or school functioning.  The Board agreed that it would be undue speculation to determine that an MH condition existed and was unfitting.  After due deliberation in consideration of the preponderance of the evidence, the Board agreed that there is insufficient cause to recommend that an unfitting MH condition be added to the applicant’s DES record and, therefore, no additional disability rating can be 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.  In the matter of the left cubital tunnel syndrome s/p submuscular ulnar nerve transposition condition, the Board, by a 2:1 vote, recommends a disability rating of 20%, coded 8516 IAW VASRD §4.124a.  The single voter for dissent, who recommended a 10% rating, elected not to submit a minority opinion.  In the matter of the contended MH condition, the Board unanimously recommends it not be included in the CI’s DES record and therefore cannot recommend an additional disability rating.  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
Left (Non-Dominant) Cubital Tunnel Syndrome | 8516 | 20%
COMBINED | 20%

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20130723, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

			
XXXXXXXXXXXXXXXXXX, DAF
President
Physical Disability Board of Review

SFMR-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 XXXXXXXXXXXXXXXXXX, AR20140006905 (PD201301060)

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						     XXXXXXXXXXXXXXXXXX
						     Deputy Assistant Secretary
						         (Army Review Boards)

CF: 
(  ) DoD PDBR
(  ) DVA

PD1301060