RECORD OF PROCEEDINGS

PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXX BRANCH OF SERVICE: ARMY

CASE NUMBER: PD1000124 SEPARATION DATE: 20061211

BOARD DATE: 20110706

SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SGT/E-5 (42A, Human Resources Specialist) medically separated for bilateral carpal tunnel syndrome (CTS) with median nerve neuropathies. Her symptoms began in 2003 and were treated with a broad range of ergonomic interventions and conservative therapies. She did not respond adequately to perform within her military occupational specialty (MOS), was issued a permanent U3 profile, and underwent a Medical Evaluation Board (MEB). Bilateral CTS and neck/right arm pain were forwarded to the Physical Evaluation Board (PEB) as medically unacceptable conditions IAW AR 40-501. The PEB adjudicated the bilateral CTS with neck and arm pain as a single unfitting condition, rated 20% IAW the Veterans Administration Schedule for Rating Disabilities (VASRD). The CI made no appeals and was medically separated with a 20% combined disability rating.

CI CONTENTION: “I was not compensated for my neck pain.” She additionally lists all of her VA conditions and ratings as per the rating chart below. A contention for their inclusion in the separation rating is therefore implied.

RATING COMPARISON:

Service IPEB – Dated 20060831	VA (3 Mo. Pre Separation) – All Effective 20061212
Condition	Code	Rating	Condition	Code	Rating	Exam
Bilateral Carpal Tunnel Syndrome (Specifies R 10% + L 10%)	8799-8715	20%	Left CTS	8599-8515	10%	20060907
			Right CTS	8599-8515	10%	20060907
Neck/Right Arm Pain			Cervical Spine Strain	5237	10%	20060907
↓No Additional MEB/PEB Entries↓	Lumbosacral Strain	5237	10%	20060907
	PFS, Left Knee	5299-5260	10%	20060907
	PFS, Right Knee	5299-5260	10%	20060907
	0% x 2 / Not Service Connected x 3	20060907
Combined: 20%	Combined: 50%

ANALYSIS SUMMARY:

Bilateral Carpal Tunnel Syndrome. The history of the CI’s carpal tunnel syndrome as recorded in the narrative summary (NARSUM) emphasized that her “most bothersome complaint was that of pain versus nerve impingement symptoms,” thus making carpal tunnel release surgery less likely to be beneficial. Serial electrodiagnostic studies confirmed bilateral median neuropathies, right worse than left. The VA examiner noted that the CI had symptoms of numbness of the fingers that improved with the use of wrist braces, and symptoms of pain that radiated from the hands to the shoulders with upper extremity use. No motor deficits were noted by either examiner. The PEB and VA chose similar coding options for the condition and arrived at identical ratings. The PEB’s DA Form 199 indicates that each wrist was rated separately for mild neuralgia in accordance with VASRD §4.124 standards, and that the ratings were combined with application of the bilateral factor to reach the consolidated 20% rating. The PEB’s coding route (bilateral CTS under a single VASRD code) was unconventional, but did not adversely affect rating. The VA choice to code the condition analogous to mild incomplete paralysis of the median nerve is also consistent with VASRD standards. Absent an objective motor impairment component there is no basis for assigning a higher disability rating to this condition. All evidence considered, there is not reasonable doubt in the CI’s favor supporting a change from the PEB’s rating decision for the bilateral carpal tunnel syndrome condition.

Neck Condition. The CI’s application asserts that compensable ratings should be considered for neck and arm pain. The history of this condition as documented in the NARSUM was that symptoms of right upper arm, shoulder and neck pain, as well as spasms and paresthesias, began about two years after the onset of CTS symptoms. She underwent a full diagnostic evaluation prior to separation including magnetic resonance imaging that did not show a structural cause for her symptoms; electrodiagnostic studies that did not show evidence of cervical radiculopathy; as well as specialty consultation with neurology and orthopedic surgery. She was then referred for aggressive physical therapy and “did experience benefit and resolution of her neck and proximal right extremity symptoms, but did not have any change or benefit in her hand symptoms.” To the VA rating examiner the CI reported that these symptoms occurred “usually in conjunction with the carpal tunnel syndrome pain,” and were exacerbated by strenuous activities such as cleaning and vacuuming. The examiner documented an equivocal neck exam and made a diagnosis of chronic cervical strain. The neck condition was initially included in the CI’s permanent profile with the restriction of “no activities involving flex/extension or jarring of neck,” although, at the conclusion of the cervical diagnostic work-up, an updated profile no longer included the neck condition. The commander’s statement, written prior to the profile update, documented pain in her hands, wrist, shoulder and neck which interrupted her typing duties, but additionally noted that the worst pain was in the wrists. The PEB’s DA 199 contained the following entry referencing email communication with the MEB physician.

Carpal tunnel syndrome is associated with neck and right arm pain that the clinician states occur as a result of carpal tunnel syndrome. The clinician felt that the neck and upper extremity pain would not be present were it not for chronically having to compensate for the bilateral carpal tunnel syndrome.

The cervical and proximal extremity symptoms, both by the pain pattern and by clinical opinion, would appear to be integral to, rather than separate from, the unfitting CTS condition. The Board deliberated therefore whether a separately ratable disability was present. It was considered that there was no evidence of additional pathology accounting for the associated cervical and proximal extremity symptoms, and that these symptoms presented no separate or additional impairment to the performance in MOS duties. All evidence considered, there is not reasonable doubt in the CI’s favor supporting addition of a neck/shoulder/arm condition as a separate unfitting condition for service rating.

Remaining Conditions. Other conditions identified in the Disability Evaluation System file were low back pain, knee pain, and right foot bunion. Several additional non-acute conditions or medical complaints were also documented. None of these conditions were clinically active during the MEB period, none carried attached profiles and none were implicated in the commander’s statement. These conditions were reviewed by the action officer and considered by the Board. It was determined that none could be argued as unfitting and subject to separation rating. No other conditions were service connected with a compensable rating by the VA within twelve months of separation or contended by the CI. The Board therefore has no reasonable basis for recommending any additional unfitting conditions for separation rating.

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 condition, the Board unanimously recommends that each wrist be separately adjudicated as follows: an unfitting right carpal tunnel syndrome condition coded 8715 and rated 10%, and an unfitting left carpal tunnel syndrome condition coded 8715 and rated 10%, both IAW VASRD §4.124. In the matter of the neck/shoulder/arm pain condition, the Board unanimously agrees that it cannot recommend a finding of unfit for additional rating at separation. In the matter of the low back pain, knee pain, and right foot bunion conditions or any other medical conditions eligible for Board consideration, the Board unanimously agrees that it cannot recommend any findings of unfit for additional rating at separation.

RECOMMENDATION: The Board therefore recommends modification of the disability description without recharacterization of the CI’s disability and separation determination, as follows:

UNFITTING CONDITION	VASRD CODE	RATING
Left Carpal Tunnel Syndrome	8715	10%
Right Carpal Tunnel Syndrome	8715	10%
COMBINED (Incorporating BLF)	20%

______________________________________________________________________________

The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20100304, w/atchs.

Exhibit B. Service Treatment Record.

Exhibit C. Department of Veterans' Affairs Treatment Record.

Deputy Director

Physical Disability Board of Review

SFMR-RB

DEPARTMENT OF THE ARMY

ARMY REVIEW BOARDS AGENCY

1901 SOUTH BELL STREET 2ND FLOOR

ARLINGTON, VA 22202-4508

11 AUG 2011

MEMORANDUM FOR Commander, US Army Physical Disability Agency

(TAPD-ZB / WRAMC, Building 7, Washington, D.C. 20307-5001

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation

for AR20110015876 (PD201000124)

1. I have reviewed the enclosed Department of Defense Physical Disability Board of

Review (000 PDBR) recommendation and record of proceedings pertaining to the

subject individual. Under the authority otTitle 10, United States Code, section 1554a,

I accept the Board's recommendation to modify the individual's disability description

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

CF:

( ) 000 PDBR

( ) OVA

Deputy Assistant Secretary

(Army Review Boards)