RECORD OF PROCEEDINGS

PHYSICAL DISABILITY BOARD OF REVIEW

NAME: BRANCH OF SERVICE: Army

CASE NUMBER: PD1100294 SEPARATION DATE: 20050129

BOARD DATE: 20120214

SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty member, E-4 SPC (15T10/Helicopter Mechanic), medically separated for persistent left wrist pain with degenerative changes. His initial injury occurred in April 2000 after he fell on his left wrist while playing football. Despite surgery, physical therapy and pharmacotherapy the CI’s left wrist condition did not respond adequately to treatment and he was unable to perform within his Military Occupational Specialty (MOS) or meet physical fitness standards. The CI was issued a permanent U3 profile and underwent a Medical Evaluation Board (MEB). Persistent left wrist pain and degenerative changes on the wrist joint were forwarded to the Physical Evaluation Board (PEB) as two separate medically unacceptable conditions IAW AR 40-501. No other conditions appeared on the MEB’s submission. Other conditions included in the Disability Evaluation System (DES) packet will be discussed below. The PEB adjudicated the left wrist pain condition as unfitting, rated 0%, with application of the US Army Physical Disability Agency (USAPDA) pain policy. The CI made no appeals, and was medically separated with a 0% combined disability rating.

CI CONTENTION: “The condition did not only rendered myself unfit for duty, it ended my military career. A career that started in March 1989 in the Tennessee Army National Guard. After serving in the Army National Guard for over 10 years. I decided to transfer to Active Duty Army. This was not a job change but a career change. It all ended at my first duty station at Fort Hood, TX. Fort Hood had "Sports Day" every Tuesday. I asked my platoon sergeant, SSG Hargrove, if I could run instead of playing football. He responded "You are playing football. Everyone is playing football." I incurred an injury during PT playing football because it was a Direct Order from my supervisor. I did not go to the TMC till [sic] two days later. I was hoping it was only sprung [sic]. I did go to the TMC. They just gave me some pills and a no pushup profile and told me to come back in two weeks if the wrist still bothered me. I went back two weeks later. They did send me to get an x-ray. The person looking at the x-ray said it looks good. I was then sent to physical therapy. There they made me move my hand while I was in extreme pain. After four months of physical therapy of moving my hand on a machine, they sent me to the surgeon. The surgeon looked at the x-ray and said "They should have seen that you had legiment damage from the x-ray." The only choice now was surgery. After surgery, I told the surgeon that my wrist still bothered me. He told me that if it still bothered me in a year to get it checked out. After a year, I was in Korea. I went to a surgeon there. He did a bone scan. He recommend that I get a full fusion. At this time I had PCS orders to Fort Campbell, Ky. Even though, I should have went to the MEB since he gave me a P3 profile. The Army still let me PCS. At my new duty station the Doctor's would not clear me to deploy unless I went to the MEB. I did not want to go to the MEB I wanted to get my hand fix. So, I can take a record PT test to get promoted and continue my Army career. I went to a Army Doctor in Fort Gordon. He suggested that I get a four-corner fusion. I did the surgery. After that, I was sent to the MEB and medically discharged.”

RATING COMPARISON:

ANALYSIS SUMMARY:

Left Wrist Pain Condition. The CI developed left, non-dominant, wrist pain after injuring his wrist while doing unit physical training in April 2000. This was initially treated as tendonitis but he failed to improve. Evaluation in November 2000, to include magnetic resonance imaging (MRI) revealed a scapholunate ligament tear. In January 2001 the CI underwent surgery to repair the torn ligament, but his symptoms failed to improve in spite of the surgery and aggressive occupational therapy. In August 2003 the CI underwent left wrist fusion surgery in an attempt to alleviate his wrist pain. After this surgery and subsequent rehabilitation, the CI continued to have wrist pain which worsened with activities as well as decreased motion and strength in the left wrist. In August 2004 the CI was assigned a permanent U3 profile with restrictions to include no pushups and no lifting greater than 10 pounds with the left hand. At the 6 October 2004 MEB narrative summary (NARSUM) evaluation, three months prior to separation, the CI had persistent left wrist pain, weakness, and loss of motion that interfered with his duty as an aircraft mechanic. His surgical scar was well healed. The wrist was tender to palpation, and motion was limited as per the chart below. Grip strength was 65 pounds in the left, 135 pounds in the right. The left arm and hand were neurologically intact. Radiographs revealed that the wrist fusion was intact, with hardware in place, and there were some slight degenerative changes in the wrist as well. The examiner noted the CI’s pain rating was in the range of slight to moderate in intensity with intermittent frequency, and noted that the CI’s wrist condition was stable but medically unacceptable. The 23 November 2004 PEB found the CI unfit at 0% for persistent left wrist pain with degenerative changes, VA code 5099-5003, using the USAPDA pain policy.

The only entry in the Department of Veterans’ Affairs (DVA) treatment record that is available to the Board is an entry dated 16 April 2005. This does not appear to be a Compensation and Pension examination. At that evaluation, the CI complained of right elbow and right wrist muscle cramps, joint pain and stiffness. A cursory examination stated that the upper extremities were “normal.” The 11 May 2005 Veterans Administration Rating Decision (VARD) assigned a 10% disability evaluation for the left wrist condition based on its review of the service medical records and VA treatment notes. “Normally the range-of-motion (ROM) would be evaluated as 0% disabling. However, the examination findings are accompanied by degenerative changes and functional limitations/impairment….The condition is considered painful and warranting a minimum evaluation of ten percent.” The VARD also assigned a 10% evaluation for the left dorsal wrist scar, since the MEB noted that the scar was tender to palpation. No additional treatment notes are available to the Board. A VARD dated 28 May 2008 referenced a treatment report from Dr. S---, dated 6 January 2005, and stated that “after review of this treatment report, there is no evidence which would substantiate a higher evaluation….” An evaluation of 10 percent is assigned for dorsiflexion of the wrist less than 15 degrees or for palmar flexion limited in line with the forearm. You are receiving the maximum benefit allowed by the rating schedule for this disability.” In the treatment record, two goniometric ROM evaluations were in evidence, which the Board weighed in arriving at its rating recommendation. These two exams are summarized in the chart below.

The Board directs its attention to its rating recommendations based on the evidence just described. The limited motion in the left wrist fails to reach the 10% rating criteria under VA code 5215 (wrist, limitation of motion), since the CI has greater than 15 degrees of dorsiflexion, and palmar flexion is greater than zero (in line with the forearm). However, the Board is in agreement that there is adequate evidence of painful limited motion, which does meet the criteria under §4.59 (painful motion) for a 10% rating, coded analogous to 5003. VASRD §4.71a further specifies for 5003 that “satisfactory evidence of painful motion” constitutes limitation of motion and specifies application of a 10% rating “for each such major joint or group of minor joints affected by limitation of motion.” The Board explored all wrist joint coding options that would achieve a higher rating than 10%; however, there was no clinical or radiologic evidence in the examinations done proximate to separation that suggested wrist ankylosis, either favorable or unfavorable. While the CI did have degenerative changes in the wrist joint, there was no x-ray evidence of involvement of two or more major or minor joint groups, which is the requirement for a 20% rating for code 5003 (arthritis). After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a separation rating of 10% for the left wrist pain condition

Remaining Conditions. Other conditions identified in the DES file were hypertension, septoplasty, pilar cyst removal from scalp, photorefractive keratectomy (PRK) of the eyes, depression, and right knee pain. 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. Additionally left wrist fusion, left wrist scar, depression, and several other non-acute conditions were noted in the VA rating decision proximal to 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. 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. As discussed above, PEB reliance on the USAPDA pain policy for rating the left wrist pain condition was operant in this case and the condition was adjudicated independently of that policy regulation by the Board. In the matter of the left wrist condition, the Board unanimously recommends a rating of 10% coded 5099-5003 IAW VASRD §4.71a. In the matter of the hypertension, septoplasty, pilar cyst, photorefractive keratectomy, depression and right 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:

______________________________________________________________________________

The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20110415, w/atchs

Exhibit B. Service Treatment Record

Exhibit C. Department of Veterans' Affairs Treatment Record

President

Physical Disability Board of Review

SFMR-RB

MEMORANDUM FOR Commander, US Army Physical Disability Agency

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation

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 10% 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

Deputy Assistant Secretary

(Army Review Boards)