RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01245
BRANCH OF SERVICE:  Army	BOARD DATE:  20141015
SEPARATION DATE:  20090704

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SPC/E-4 (11B/Infantryman) medically separated for a right wrist condition.  The right wrist 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 wrist condition characterized as “right wrist pain” was the only condition forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The Informal PEB adjudicated “right wrist pain” as unfitting, rated 10%, with application of the VA Schedule for Rating Disabilities (VASRD).  The CI made no appeals and was medically separated.

CI CONTENTION: The CI writes: “Pain in the wrist and back are getting worse.  Range of motion in wrist is worse since rating was issued and strength in wrist has gotten worse as well.  It is also getting harder to work with my hands for long periods of time.  Hand locks up and lots of pain if worked to long.”

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 wrist condition is addressed below; and, no additional conditions, including the contended back condition, 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 20090527 | VA - (2 Mos. Post-Separation)
Condition | Code | Rating | Condition | Code | Rating | Exam
Right Wrist Pain | 5099-5010 | 10% | Arthritis of the R Wrist w/Residual Surgical Scar | 5010-5215 | 10% | 20090908
Other x 0 (Not in Scope) | Other x 1 | 20090908
Combined:  10% | Combined:  20%
Derived from VA Rating Decision (VARD) dated 20090923 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:  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 Veterans Affairs, operating under a different set of laws.

Right Wrist Pain.  This right hand dominant CI sustained fractures of the distal right arm (radius bone) and one proximate right wrist bone (scaphoid ) with possible injury to a major nerve supplying the motor muscles of the hand (median nerve) on 17 June 2008.  These fractures were operatively repaired with plates and screws (hardware).  Post-operatively the CI developed pain with use in the wrist.  On post-operative evaluation performed on 27 June 2008, the injury to the median nerve was reported to have “resolved.”  The CI underwent a second operation in July 2008, for removal of the scaphoid screw.  At this time sensory and motor exams of the hand were normal and the scaphoid bone was determined to be healed.  Multiple subsequent X-rays from this time through the time of separation from the military revealed good healing of the fracture sites without malunion, arthritic changes or hardware difficulty.  On orthopedic evaluation performed on 2 October 2008, the CI reported “stiffness of the wrist.”  Motor and neurologic evaluations of the hand were normal and operative sites were healing well.  On occupational therapy (OT) evaluation performed on 11 December 2008, the CI reported wrist pain with lifting heavy objects and with gripping.  Evaluation revealed full range-of-motion (ROM) of the hands.  ROM of the right wrist was dorsiflexion (DF-palm down, hand flexed toward the ceiling) of 68 degrees, plantar flexion (PF-palms down, hand flexed toward the floor) of 64 degrees (Normal: 70/80 degrees), and slight reduction in rotation of the wrist to the right and left (ulnar and radial deviation).  Grip strength was noted to be decreased in both hands, the right worse than the left.  The CI was, however, able to perform 10 pushups with pain of 3/10.  On orthopedic evaluation performed on 12 January 2009 stiffness of the wrist with pain on motion of the wrist were reported.  A decrease in active ROM with pain, but with normal motor and sensory evaluations was reported.  On 19 February 2009, a repeat OT evaluation, ROM of the hand was again noted to be “full.”  ROM of the right wrist was unchanged and grip strength remained decreased in both wrists, right worse than left but significantly improved in the right.  No tenderness over the area of the scaphoid bone (“snuff box” sign) was noted.  On OT evaluation for the MEB/narrative summary (NARSUM) performed on 8 April 2008, PF of the right wrist was 64 degrees, DF was 61 degrees.  Strength testing of the both hands is presented in the chart below.

HAND STRENGTH (normal for male in pounds)

OT 
3 Months pre separation (20090408)
            Right Hand                                  Left Hand

Grip (R-121; L-105) | 15 | 50
3-Jaw Pinch(R-27; L-26) | 6 | 10
Tip Pinch(R-18; L-17) | 7 | 9
Lateral Pinch(R-26; L-25) | 8 | 17
Comments | Grip and Pinch tests increased right wrist pain.

At the MEB/NARSUM exam on 15 April 2009, 3 months prior to separation, the CI reported continued right wrist pain with use.  On examination, “decreased ROM in all planes with discomfort” was reported.  Extremity motor and neurologic exams were normal.  

Four relevant VA Compensation and Pension (C&P) exams were performed on 8 September 2009, 2 months after separation:  1) On the VA C&P General Exam, the CI reported no “hand problems” and no upper extremity symptoms.  On neurologic exam right sided motor and sensory findings were normal.  2) On the VA C&P Joints Exam, the CI reported a “good” response to his wrist brace which he used intermittently and occasionally.  He noted pain and stiffness of the wrist without weakness or instability and that the condition did not affect the motion of the joint.  The CI offered that it was challenging for him to write a lot because his hand starts to hurt.  He further noted no difficulties with activities which would require good hand function: feeding, bathing, dressing, toileting and grooming.  On ROM examination of the wrist, DF was reduced to 25 degrees and PF to 24 degrees with pain.  No joint ankylosis was noted.  3) On the VA C&P spine exam, extensive motor strength evaluation of each individual muscle/muscle groups in the wrist and right hand were reported normal.  Neurologic exam of the upper extremity was normal.  4) On the VA C&P scar exam, the CI reported the surgical scar to be non-painful and to provide no limitation to his employment or routine daily activities.  On physical exam, the surgical scar on the right wrist was well healed, non-adherent to underlying structures, stable and not painful.

The Board directs attention to its rating recommendation based on the above evidence.  The PEB and VA both rated the wrist condition 10% using different codes: the PEB coded 5099-5010, (Arthritis, due to trauma), citing painful motion IAW §4.59; the VA coded 5010-5215, (Wrist, limitation of motion) citing arthritis with painful motion.  The Board unanimously agreed the preponderance of evidence in record supported a rating of 10%, but no higher, for painful motion IAW §4.40.  The Board considered a rating under code 5215, (Wrist, limitation of motion).  A 10% rating under this code requires dorsiflexion of less than 15 degrees or plantar flexion limited in line with the forearm.  The Board unanimously agreed that the preponderance of evidence in record supported no rating under this code.  The Board further considered a rating under code 5214, (Wrist, ankylosis), not supported by the evidence in record.  The Board noted the possible injury to the median nerve which was reported to be resolved after the initial surgery.  However, a second surgery was performed thereafter without mention of this nerve.  The Board noted the OT evaluations for the MEB performed in April 2009, demonstrating severe decreased strength in the both hands, the right greater than the left suggesting a possible injury to the median nerve.  The Board under took to determine if the hand condition was unfitting for this and subject to rating under code 8515, (Median nerve paralysis) IAW §4.124 (Neuralgia) or under hand muscle codes 5308 (Muscle Group VII) or 5309 (Muscle Group IV), IAW §4.56 (Muscle injury), for possible trauma incurred during the two hand operative procedures.  The Board noted the severe reduction in grip strength for both the right and left hand.  The record provided no elucidation of why strength was decreased bilaterally in the absence of defined left arm or hand injury.  The Board opined that this might represent a new condition (ZB: cervical spine) outside the Board’s scope of review.  The Board agreed that the difference in strength between the right and left hands was related to the increasing wrist pain reported for the right hand during grip and pinch testing.  The Board agreed that the if the severe reduction in right hand grip strength reported on the April 2009 exam 3 months prior to separation were accurate, it would be reflected in significant clinical dysfunction of the hand.  The Board noted the C&P exams, 3 months after separation, where the CI adjured no hand related difficulties and the extensive clinical examination of the individual muscles of the hand and digits which was normal.  The Board agreed the preponderance of evidence in the record supported no significant dysfunction of the hand and, thus, gave higher probative valve to the VA C&P evaluation in its decision making.  After discussion, the Board unanimously agreed the right hand condition was not unfitting per se and not subject to additional rating.  The Board considered a rating under code 7804 (Scars, unstable or painful) IAW §4.118.  The Board unanimously agreed that it could not recommend a rating under this code as the surgical scars were described as well-healed, stable, non-painful and non-adherent to underlying tissue. 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 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 right wrist condition, the Board unanimously recommends a disability rating of 10%, coded 5099-5010 IAW VASRD §4.71a.  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 20140219, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

				
XXXXXXXXXXXXXXXXXX
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 XXXXXXXXXXXXXXXXXX, AR20150007666 (PD201401245)

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

PD-2014-01245