RECORD OF PROCEEDINGS
                     PHYSICAL DISABILITY BOARD OF REVIEW

NAME:                                                                 BRANCH
OF SERVICE:  air force
CASE NUMBER:  PD1000360                                    SEPARATION  DATE:
 20060801
BOARD DATE:  20110617


SUMMARY OF CASE:  Data extracted  from  the  available  evidence  of  record
reflects that this covered individual  (CI)  was  an  active  duty  TSgt/E-6
(2T271, Air Transportation Craftsman) medically  separated  for  left  wrist
pain associated with “early degenerative joint disease.”  The  CI  sustained
a left wrist fracture/dislocation (trans-scaphoid, trans-triquestrial  stage
III perilunate dislocation) during a motorcycle accident on 3  August  2002.
The CI  underwent  open  reduction  and  internal  fixation  (ORIF)  of  the
triquetrial and scaphoid fractures, followed by vascularized bone  grafting,
revision of scaphoid fixation, and pinning  of  the  scapholunate  interval.
The CI had an uncomplicated post-operative  course;  however,  he  developed
chronic pain once he began using the left wrist for manual  labor.   Despite
trials of medications and nerve injections, he was  unable  to  perform  any
significant torque or lifting activities with the left  hand.   The  CI  did
not respond adequately to manipulate a weapon, perform within his Air  Force
Specialty (AFS) or meet physical fitness standards.  In August 2003, he  was
placed on a temporary U4 profile and referred for Medical  Evaluation  Board
(MEB).  The MEB forwarded the left wrist condition and two other  conditions
to the Physical Evaluation Board (PEB) as medically unacceptable.   The  PEB
concluded that the CI’s left wrist and right shoulder  conditions  did  “not
prevent him from reasonably performing less strenuous duties”  and  adjudged
the CI fit for return to duty.   Due  to  ongoing  pain,  the  CI  underwent
removal of hardware from the left  wrist  in  December  2004,  but  did  not
respond adequately to perform within his AFS.  In May  2006,  he  was  again
referred for MEB.  The MEB forwarded multiple joint  pains  to  the  PEB  as
medically unacceptable IAW AFI 48-123.  The PEB adjudicated left wrist  pain
associated with early degenerative joint disease as  unfitting,  rated  10%,
IAW the Veterans’ Administration Schedule for Rating  Disabilities  (VASRD).
The CI submitted a rebuttal to the  PEB,  requesting  consideration  of  his
bilateral knee and right ankle conditions; however, he  subsequently  waived
his request for a formal hearing.  The CI made  no  other  appeals  and  was
thus medically separated with a 10% combined disability rating.


CI CONTENTION:  “I wasn’t even evaluated  for  my  knees,  ankle,  back,  or
shoulder and those were the physical conditions  that  were  keeping  me  on
profiles.  (I was 4 weeks post op from having  a  left  knee  ACL  allograph
when I was sent to Travis AFB for evaluation and the doctor stated  that  he
couldn’t even consider the knee due to the fact that the  surgery  had  just
taken place.)… For some reason all of these conditions  were  omitted  while
deciding my fate, and after twelve years of impeccable serv.  I was  shocked
at the results.”  The CI additionally contends for sleep  apnea  and  for  a
higher rating for his left wrist condition.  He also lists  all  of  his  VA
conditions and ratings as per the rating chart below.

RATING COMPARISON:

|Service IPEB – Dated 20060606  |VA (2 Mo. After Separation) – All        |
|                               |Effective Date 20060802                  |
|Condition       |Code          |Rating                                   |
|Obesity         |CAT III       |Not in VARD                              |
|Multiple Joint  |MEB Dx to PEB |Not in VARD                              |
|Pains           |              |                                         |
|↓No Additional MEB/PEB Entries↓|Thoracolumbar Spine, Strain …     |5237   |
|Combined:  10%                 |Combined:  90%*                          |


*6847 Sleep Apnea increased from 0%  to  50%  effective  20070702  (combined
100%)


ANALYSIS SUMMARY:  The Board acknowledges the  sentiment  expressed  in  the
CI’s application regarding the significant impact that his  service-incurred
conditions have had on his current  earning  ability  and  quality  of  life
reflected in his higher  VA  disability  rating.   However,  the  Disability
Evaluation System (DES) is responsible  for  maintaining  a  fit  and  vital
fighting force.  While  the  DES  considers  all  of  the  service  member's
medical conditions, compensation can  only  be  offered  for  those  medical
conditions that cut short a service member's career, and then  only  to  the
degree of severity present at the time of final  disposition.  However,  the
VA, operating under a different set of laws, is  empowered  to  periodically
re-evaluate veterans for the purpose  of  adjusting  the  disability  rating
should the degree of impairment vary  over  time,  as  well  as  considering
service incurred conditions that were not unfitting for continued service.

Left Wrist Condition.  The CI was  right  hand  dominant.   There  were  two
wrist examinations with goniometric range of motion measurements  which  the
Board weighed in arriving at its rating recommendation.   These  exams  were
the orthopedic addendum to the MEB narrative summary (NARSUM) and the  post-
separation VA compensation and pension (C&P) exam.  The  exam  findings  are
summarized in the following chart.




|Goniometric ROM –     |Ortho Addendum ~ 4   |VA C&P ~ 2 Mo. After-Sep|
|Left Wrist            |Mo. Pre-Sep          |                        |
|Dorsiflexion          |0-20⁰                |0-10⁰                   |
|(Extension)   (0-70)  |                     |                        |
|Palmar Flexion (0-80) |0-50⁰                |0-40⁰                   |
|Ulnar Deviation (0-45)|Not measured         |0-8⁰                    |
|Radial Deviation      |Not measured         |0-10⁰                   |
|(0-20)                |                     |                        |
|Comment               |Pain with ulnar and  |Atrophy w/ swelling &   |
|                      |radial deviation;    |tender over wrist; pain |
|                      |decreased L grip     |prevents repetitive     |
|                      |strength, WHSS       |motion; stiffness and   |
|                      |                     |weakness in wrist;      |
|                      |                     |numbness L middle       |
|                      |                     |finger; tender scar L   |
|                      |                     |wrist, daily            |
|                      |                     |incapacitating episodes |
|§4.71a Rating         |10%                  |20%                     |
|§4.124a               |N/A                  |10%                     |

Plain radiographs in November 2004 revealed severe degenerative  changes  in
multiple carpal joints (L-C, S-L, R-S joints) and  residual  dysfunction  of
the scapholunate ligament, consistent with  scapholunate  advanced  collapse
wrist.  The commander’s statement noted that, “due to the  lack  of  agility
in his  left  wrist,  [CI]  cannot  properly  fire  an  M-16  weapon.   This
limitation, along with  other  conditions,  prevents  him  from  deploying.”
Both exams documented painful, limited ROM and significant weakness  of  the
left hand grip.  The CI had  declined  wrist  fusion  which  was  considered
reasonable.  At the VA C&P exam, the CI  complained  of  daily  pain  flares
resulting in the inability to move the wrist and he complained of  numbness,
pain and color changes in the left hand brought on by  cold  exposure.   The
examiner documented that the CI was unable to perform repetitive motion  due
to pain (DeLuca criteria).

The PEB and VA chose different coding which did bear  on  the  rating.   The
PEB  chose  5299-5215-5003,  analogous  to  wrist  limitation   of   motion,
analogous to degenerative arthritis, and  rated  at  10%  for  painful  ROM,
without incapacitating episodes.  The VA chose 5010-5214, arthritis  due  to
trauma, analogous to ankylosis of the wrist, favorable, minor, and rated  at
20% for painful ROM and inability  to  complete  ROM  with  repetitive  use.
Additionally the VA coded 7804 for tender scar  left  wrist,  and  8516  for
ulnar entrapment secondary to left wrist surgery, rated at  10%  each.   The
PEB choice of coding was supported by radiographic evidence  of  involvement
of two or  more  minor  joint  groups.   The  orthopedic  narrative  summary
(NARSUM) addendum did not comment on incapacitating  episodes  or  decreased
ROM,  fatigue,  or  incoordination  following  repetitive   motion   (DeLuca
criteria); however, the VA C&P exam  noted  severe,  daily  flares  of  pain
resulting in the inability to move or use the left wrist  and  inability  to
move the wrist following repetitions.

The Board considered §4.63, loss of use of hand or  foot;  however,  the  CI
had retained functional use of the left hand.  The Board considered  the  VA
exam of higher probative value as the VA exam was  closer  to  the  date  of
separation and the MEB exams did not document consideration  of  the  DeLuca
criteria which were significant in this case.  In DeLuca  v.  Brown  (1995),
the United States Court of Appeals for Veterans Claims  ruled  that  the  VA
must separately consider any additional functional loss due to pain,  flare-
ups, deformity, tenderness, and arthritis,  loss  of  motion  on  repetitive
use, weakened movement, excess fatigability or  incoordination  when  rating
disabilities.  The VA C&P exam proximate to separation  documented  loss  of
ROM with repetitive motion equivalent to  favorable  ankylosis  (zero  ROM).
Analogous coding under 5214 (wrist, ankylosis of)  was  supported  based  on
the DeLuca criteria.

The Board then considered whether or not there was  compelling  evidence  of
associated peripheral nerve impairment.  Both exams  documented  significant
grip weakness but neither attributed the  weakness  to  a  peripheral  nerve
condition.   The  orthopedic  NARSUM  exam  did  not  include  a  neurologic
evaluation.  The VA exam noted numbness in the left middle finger while  the
service treatment records (remote from time  of  MEB)  documented  vasomotor
complaints with decreased two-point discrimination in the  middle  and  ring
fingers, numbness over the dorsum of the  thumb  webspace,  and  a  positive
Tinel’s.  While these sensory symptoms may  have  been  caused  by  a  mixed
median/radial/ulnar nerve neuropathy, sensory symptoms alone  would  not  be
unfitting.  The VA  diagnosed  ulnar  entrapment  secondary  to  left  wrist
surgery and rated at 10% due to  decreased  middle  finger  sensation.   The
Board  concluded  that  the  CI’s  weak  left  hand  grip  was  most  likely
attributable to painful wrist ROM, already considered in the overall  rating
for the unfitting left wrist condition.

The left wrist scar was noted to be  well-healed  at  the  orthopedic  exam;
while the C&P examiner documented the  scar  as  disfiguring,  adherent  and
tender.  The scar was not implicated in the commander’s  statement  and  did
not result in any duty limitations.  Any limitations of motion of the  wrist
or hand due to the scar were considered in the CI’s primary unfitting  wrist
condition and coding above.  There is no link to  fitness  in  evidence  for
the left wrist scar as separately unfitting or ratable.

After due deliberation, considering all  of  the  evidence  and  mindful  of
VASRD §4.3 (reasonable doubt), the Board recommends a separation  rating  of
20% for the left  wrist  condition,  coded  5010-5214;  with  no  additional
coding for peripheral nerve impairment.

Other  PEB  Conditions  (Right  Shoulder  Impingement,  Right  Wrist  Occult
Ganglion Cyst, Gastroesophageal Reflux Disease [GERD],  Tobacco  Habituation
and Obesity).  The CI was diagnosed with chronic  right  shoulder  pain  and
recurrent impingement following arthroscopy in  2004.   He  developed  right
wrist pain in 1994 and was subsequently diagnosed with  an  occult  ganglion
cyst on magnetic resonance imaging in  2003.   The  condition  of  GERD  was
noted to be well controlled with proton-pump inhibitors at time of  the  MEB
NARSUM  exam.   None  of  these  conditions  was  permanently  profiled   or
implicated in the commander’s statement.  These conditions were reviewed  by
the action officer and considered by the Board.   There  was  no  indication
from the record that any of these conditions significantly  interfered  with
satisfactory performance  of  AFS  duty  requirements.   The  conditions  of
obesity and tobacco habituation do  not  constitute  physical  disabilities,
IAW the DoDI 1332.38 E5.  All evidence considered, there is  not  reasonable
doubt in the CI’s favor supporting recharacterization  of  the  PEB  fitness
adjudication for any of the stated conditions.

Other Contended Conditions (Right Knee Pain, Right  Ankle  Pain,  Left  Knee
Pain, Back Pain, Obstructive Sleep Apnea).  The CI was diagnosed  with  mild
osteoarthritis of the right knee following  removal  of  a  benign  mass  in
2005.  The CI developed  chronic  right  ankle  pain,  with  tibiotalar  and
subtalar osteoarthritis, following ORIF of a talar dome  fracture  in  1998.
Neither of these conditions was permanently profiled or  implicated  in  the
commander’s  statement.   These  conditions  were  reviewed  by  the  action
officer and considered by the Board.   There  was  no  indication  from  the
record  that  either  of  these  conditions  significantly  interfered  with
satisfactory performance of AFS duty requirements.  It was  determined  that
neither the right knee  nor  right  ankle  conditions  could  be  argued  as
unfitting and subject to separation rating.

The CI developed chronic left  knee  pain  with  instability  following  two
major left knee injuries which temporarily limited his  ability  to  perform
his duties.  In December 2004, the CI sustained a left knee medial  meniscus
tear and grade II posterior collateral ligament sprain during  a  motorcycle
accident.  He underwent arthroscopic meniscectomy for repair in March  2005.
 In late 2005, the CI reinjured  his  knee  in  a  motor  vehicle  accident,
sustaining  a  complete  anterior  collateral  ligament  (ACL)   tear.    He
underwent  ACL  reconstruction  in  March  2006.   At  time   of   follow-up
orthopedic  evaluation  in  May  2006,  he  was  felt  to   be   progressing
satisfactorily, despite  continued  anterior-posterior  laxity  due  to  the
(unrepaired) posterior  cruciate  ligament  insufficiency.   The  orthopedic
surgeon commented, “We are  hopeful  that  the  recent  anterior  collateral
ligament reconstruction will give him a functional  [left]  knee.”   At  the
time of the orthopedic addendum to the NARSUM, the CI  was  only  two  weeks
post-op from his ACL repair.  The left knee condition was mentioned  in  the
NARSUM evaluation; however, the condition was  not  addressed  by  the  PEB.
The left knee condition was implicated in the  commander’s  statement,  with
the commander noting that the CI “must perform light duties residing from  a
desk.”  The commander further commented that “even with his AFSC  in  CONUS,
lifting, some machinery operation and hours of standing on an aircraft  ramp
would  prove  too  difficult.”   The  VA  exam  two  months  post-separation
documented flexion to 100° (normal 140°) with “gait is mildly  antalgic  and
stiff,” left knee “does wear a brace”  and  “laxity  in  anterior  posterior
motion, not with lateral movement.  Grind with movement. +weakness.”

With regard to the left knee condition,  it  is  not  uncommon  for  service
members to  be  separated  for  an  established  unfitting  condition,  with
pending treatment issues for conditions unrelated to the reason for  a  MEB.
The service’s responsibility in such cases is to assure that  there  are  no
safety concerns with transfer of care, not to see all conditions through  to
their maximal resolution.  When assessing the fitness implications of  these
collateral  conditions,  the  PEB  acknowledges  that  the  member  is   not
remaining on active duty for other reasons.  It  must  therefore  anticipate
the typical clinical course and expected impact  on  duty  performance.  The
Board must judge the fairness of the  PEB’s  fitness  adjudication  in  such
cases on the basis of that principle, not on the particulars  in  effect  on
the day of separation.   The  Board  considered  that  the  CI’s  left  knee
condition would “not prevent him from reasonably performing  less  strenuous
duties of his office, grade, rank or rating.”  In fact, the VA C&P  examiner
noted that the “patient is currently employed at Travis  AFB  working  as  a
civilian in previous military job.”  All evidence considered, there  is  not
reasonable doubt in the CI’s favor supporting addition of left knee pain  as
an unfitting condition for separation rating.  The conditions of  back  pain
and obstructive sleep apnea were  not  mentioned  in  Disability  Evaluation
System (DES) file.  The  Board  does  not  have  the  authority  under  DoDI
6040.44 to render fitness or rating recommendations for any  conditions  not
considered by the DES.

Remaining Conditions.  There were four other conditions  identified  in  the
VA rating decision  and  the  DES  file.   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.  The condition of left elbow epicondylitis was identified in the  VA
rating decision, but was not mentioned in the DES file.  The Board does  not
have  the  authority  under  DoDI  6040.44  to  render  fitness  or   rating
recommendations for any conditions not considered by  the  DES.   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 left wrist condition, the Board, by a  vote
of 2:1, recommends a rating of 20%, coded 5010-5214, IAW VASRD §4.71a.   The
single voter for dissent (who recommended the addition of  peripheral  nerve
coding for left wrist median nerve  neuropathy,  8515  rated  10%)  did  not
elect to submit a minority opinion.  In the matter  of  the  right  shoulder
impingement, right wrist occult ganglion  cyst,  GERD,  tobacco  habituation
and   obesity   conditions,   the   Board    unanimously    recommends    no
recharacterization of the  PEB  adjudications  as  not  unfitting.   In  the
matter of the right  knee  pain,  right  ankle  pain,  and  left  knee  pain
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 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 Wrist Pain Associated w/Early            |5010-5214       |20%     |
|Degenerative Joint Disease                    |                |        |
|COMBINED        |20%     |


____________________________________________________________________________
_

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20100318, w/atchs.
Exhibit B.  Service Treatment Record.
Exhibit C.  Department of Veterans' Affairs Treatment Record.




                                        Deputy Director
                                                                    Physical
Disability Board of Review
SAF/MRB
1500 West Perimeter Road, Suite 3700
Joint Base Andrews NAF Washington, MD 20762



      Reference your application submitted under the provisions of DoDI
6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2010-00360.

      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 not appropriate under the guidelines of
the Veterans Administration Schedule for Rating Disabilities.
Accordingly, the Board recommended modification of your assigned
disability rating without re-characterization of your separation with
severance pay.

      I have carefully reviewed the evidence of record and the
recommendation of the Board.  I concur with that finding, accept their
recommendation and direct that your records be corrected as set forth in
the attached copy of the Memorandum for the Chief of Staff, United States
Air Force.  The office responsible for making the correction will inform
you when your records have been changed.

                                        Sincerely,







                                       Director
                                       Air Force Review Boards
                                       Agency

Attachments:
1.  Directive
2.  Record of Proceedings

cc:
SAF/MRBR
DFAS-IN
PDBR PD-2010-00360




MEMORANDUM FOR THE CHIEF OF STAFF

      Having received and considered the recommendation of the Physical
Disability Board of Review and under the authority of Section 1554, Title
10, United States Code (122 Stat. 466) and Section 1552, Title 10, United
States Code (70A Stat. 116) it is directed that:

      The pertinent military records of the Department of the Air Force
relating xxxxxxxxxxxxxx, be corrected to show that the diagnosis in his
finding of unfitness was Left Wrist Pain Associated With Early
Degenerative Joint Disease, VASRD Code 5010-5214, rated at 20% rather
than 10%.






  Director

  Air Force Review Boards Agency