RECORD OF PROCEEDINGS

PHYSICAL DISABILITY BOARD OF REVIEW

NAME: BRANCH OF SERVICE: AIR FORCE

CASE NUMBER: PD201000374 SEPARATION DATE: 20080215

BOARD DATE: 20110621

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SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SRA (2T231, Air Trans Apprentice) medically separated from the Air Force in 2008. The medical basis for the separation was bilateral wrist carpal tunnel syndrome (CTS), status post bilateral carpal tunnel release (CTR) surgery. The CI did not respond adequately to treatment, was unable to perform within his Air Force Specialty, and underwent a Medical Evaluation Board (MEB). Bilateral wrist carpal tunnel syndrome was forwarded to the Physical Evaluation Board (PEB) as medically unacceptable IAW AFI 48-123. The PEB adjudicated the right and left wrist carpal tunnel syndrome condition as unfitting, rated 10% each, with a combined disability rating of 20%. The CI made no appeals, and was medically separated with a 20% combined disability rating.

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CI CONTENTION: “I was medically discharged for bilateral carpal tunnel and rated at 20%, but the carpal tunnel affected different nerves. Right median neuropathy and bilateral ulnar neuropathy. So at the minimum the median neuropathy and left and right ulnar neuropathy should each be rated at 10% independently. According to VA regulations that would put me at 27% without the bilateral factor. Therefore putting me at 30%.”

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RATING COMPARISON:

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ANALYSIS SUMMARY:

Carpal Tunnel Syndrome (Median Neuropathy) Status Post Carpal Tunnel Release. The CI experienced bilateral hand and wrist pain with intermittent numbness beginning in 2002. In 2003 he was diagnosed with CTS, compression of the median nerve at the wrist. Conservative non-operative treatment was not successful and he underwent surgical CTR on the right wrist on December 13, 2006, and on the left wrist on August 8, 2007. The MEB narrative summary on October 31, 2007 summarized that CI was recovering from symptoms of CTS following CTR, and was undergoing occupational therapy for weakness in grip strength. Despite CTR surgery, there was continued complaint of wrist pain, 2/10 at rest and 4/10 with activity. Clinical assessment by occupational therapy on November 21, 2007 recorded that the CI had no pain (0/10) at rest, and occasionally 3/10 short-lived pain on the left side, noted on grasping. There were “no paresthesia or numbness reported.” On examination, there was tenderness at the surgical site. There was no loss of sensation identified. The CI could make a full complete fist; however, grip strength was decreased (right 50 pounds, left 60 pounds). The occupational therapist reported that “Pt only complained of pain and tenderness, and was able to function normally without hindrance of ADLs.” Wrist range of motion (ROM) measurements by occupational therapy, November 28, 2007, demonstrated non-compensable mild loss of flexion and extension (65° and 55°, respectively). On VA compensation and pension examination on June 13, 2008 four months after separation, it was noted that his symptoms of paresthesias had improved after his surgery in 2007; however, he continued to have some hand weakness. Exam revealed “good” grip strength that weakened over prolonged use. Sensory examination was normal. ROM of the wrists was near normal (flexion 80°, extension 50°, pronation 85°, supination 80°); “does not have pain with movement of any significance.” The Board concluded that IAW §4.124a, 8715 neuralgia of the median nerve, a separation rating of 10% for right CTS status post CTR surgery and 10% for left CTS status post CTR surgery was supported by the evidence of record and application of reasonable doubt. Rating under 5125 or 5123 for loss of wrist ROM would not attain a minimum rating of 10%, providing no benefit to the CI.

Contended Ulnar Neuropathy Condition. The CI’s application asserts that compensable ratings should be considered for bilateral ulnar neuropathy in addition to the right median neuropathy. Note was made that the VA coded the CI’s CTS using the diagnostic code for ulnar neuropathy rather than the code for the median nerve; however, no difference in rating resulted. Nerve conduction velocity (NCV) studies in 2006 revealed changes affecting both ulnar nerves. Occupational therapy examination on November 21, 2007 recorded no complaint of numbness or paresthesia, and examination revealed no sensory loss to correlate with 2006 NCV results. The CI’s treating orthopedic surgeon only performed surgery to relieve compression of the median nerve in the carpal tunnel and proposed no specific treatment for the NCV changes of the ulnar nerve. Although ulnar motor conduction was delayed, no impairment distinct from the CTS was in evidence. Regardless, the rating for CTS noted above includes any impairment that may have resulted from any contribution from an ulnar neuropathy to the decreased grip strength. Providing ratings for two different diagnoses based on the same manifestations is prohibited by VASRD rules (§4.14 avoidance of pyramiding). This condition was reviewed by the action officer and considered by the Board. There was no evidence for concluding this condition separately interfered with duty performance to a degree that could be argued as unfitting for separate rating. The Board determined therefore that this condition was not subject to a service disability rating.

Remaining Conditions. Other conditions identified in the Disability Evaluation System (DES) file were obesity, and migraines. Obesity is not a disability that is ratable or compensable under the rules of the DES. Migraine headache was not clinically or occupationally significant during the MEB period, did not carry an attached profile, and was not 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. Additionally, irritable bowel syndrome and several other non-acute conditions were noted in the VA rating decision following separation, but were not documented 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.

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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 CTS, the Board unanimously recommends a separation rating of 10% for right CTS status post release surgery, and 10% for left CTS status post release surgery IAW VASRD §4.124a using code 8515, with application of the bilateral factor for calculating the combined rating IAW §4.26. In the matter of ulnar neuropathy 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.

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RECOMMENDATION: The Board therefore recommends that there be no recharacterization of the CI’s disability and separation determination.

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The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20100411, 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-2010-00374.

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 appropriate. Accordingly, the Board recommended no re-characterization or modification 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 and their conclusion that re-characterization of your separation is not warranted. Accordingly, I accept their recommendation that your application be denied.

Sincerely,

Director

Air Force Review Boards Agency

Attachment:

Record of Proceedings