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AF | PDBR | CY2012 | PD-2012-00025

Original file (PD-2012-00025.rtf) Auto-classification: Approved

RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXX CASE: PD-2012-00025
BRANCH OF SERVICE: Army BOARD DATE: 20150414

SEPARATION DATE: 20050903

SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reserve E-4 (Motor Transport Operator) medically separated for wrist and ankle conditions. The conditions could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty. Her profile allowed for an alternate aerobic event to satisfy physical fitness standards. She was issued a permanent U3L3 profile and referred for a Medical Evaluation Board (MEB). The wrist and ankle conditions, characterized as “right wrist fracture with carpal tunnel syndrome” and “right talar osteochondritis,” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. The MEB also identified and forwarded two other conditions (gastroesophageal reflux disease and ovarian cyst) for PEB adjudication. The Informal PEB adjudicated the right wrist and right ankle as unfitting, rated 10% and 10%. The remaining conditions were considered by the PEB and found to be not unfitting and therefore not ratable. The CI made no appeals and was medically separated.

CI CONTENTION: “Soldier received surgeries after the narrative medical review. Soldier during which time was receiving treatment for PTSD, and was diagnosed at her local Vet center in Anaheim, CA. PTSD was not noted in narrative medical review.”

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 when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting. Any conditions outside the Board’s defined scope of review and any contention not requested in this application may remain eligible for future consideration by the Board for Correction of Military/Naval Records. Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate. The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards to the unfitting medical condition at the time of separation. The Board has neither the role nor the authority to compensate for post-separation progression or complications of service-connected conditions. That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws. The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation.

RATING COMPARISON :

Service IPEB – Dated 20050525	VA - (18 Mos. Post-Separation)
Condition	Code	Rating	Condition	Code	Rating	Exam
Closed Distal Radial Fracture and Tear Of the Triangular Fibrocartilage Complex, S/P ORIF	5099-5003	10%	Residuals Carpal Tunnel Syndrome w/Reflex Sympathetic Dystrophy (RSD) Right Wrist	8615	30%	20070309
			Residuals, S/P Right Wrist Fracture	5214-5215	10%	20070309
Chronic R/Ankle Pain …Defect of the Talus	5099-5003	10%	S/P Right Ankle Surgeries with Residuals of Arthritis and RSD	5271-8524	30%	20070309
Other x 0 (Not In Scope)	Other x 10
Combined: 20%	Combined: 80%

Derived from VA Rating Decision (VA RD ) dated 200 70329 ( most proximate to date of separation [ DOS ] ).

ANALYSIS SUMMARY: The Board makes note that the original VARD was not available in the evidence; and, could not be located after the appropriate inquiries. Members judged that the missing evidence would not materially alter the Board’s recommendations.

Right Wrist Condition. The narrative summary (NARSUM) notes while deployed the CI was thrown off the back of a trailer approximately 60 feet into the air and fractured the distal radius of her right dominant upper extremity. Notes in the service treatment record (STR) indicated the CI underwent open reduction and internal fixation of the fracture and was medically evacuated. The CI was improving in therapy, but fell on her wrist on 4 January 2004 and subsequently reported new thumb and wrist pain and sensory disturbances to the fingertips. Repeat X-rays were unchanged. Despite additional therapy, ulnar sided wrist pain continued and an arthrogram showed a possible ligament tear on the ulnar side of wrist and the CI was referred to a hand specialist. The hand evaluation on 5 April 2004 noted the CI was having difficulty with daily use of the hands including lifting or grabbing and was on multiple types of medication, including for nerve related pain. The examination noted weakness of the index finger flexion, decreased wrist range-of-motion (ROM), and decreased sensation in the median and ulnar nerve distributions. The examiner recommended electromyogram (EMG)/nerve conduction velocity studies to evaluate what was thought to be irritation from the surgical hardware and carpal tunnel syndrome (CTS). Physical medicine evaluation on 20 April 2004 noted signs of CTS with tenderness to palpation (TTP) over the median nerve and decreased sensation. The EMG was reported as within normal, but noted mild differences between the median and ulnar nerve and the CI had carpal tunnel release surgery on 23 April 2004, which did not improve her wrist pain. At an occupational therapy visit on 10 May 2004 the CI reported pain that radiated up the entire arm and exam noted inability to make a fist, especially with the index finger. The hand specialist opinion was that the triangular fibrocartilage complex tear was not the problem. A pain management evaluation on 1 June 2004 noted the absence of typical changes of RSD, currently known as chronic regional pain syndrome (CRPS), such as skin changes, swelling, or increased sensitivity to pain, but noted that treatment with stellate ganglion nerve block (SGNB) may work for nerve related pain with a sympathetic component. He proceeded with SGNB and significant improvement was noted. The CI then transferred and was re-evaluated by multiple orthopedic and physical medicine specialists and opinions were divided as to whether the CI had RSD or bone pain. Evaluation by another pain specialist on 10 November 2004 again noted the absence of typical symptoms of RSD. Examination noted no skin or vascular abnormality, normal reflexes and mildly decreased strength of the right hand. The assessment was that the pain was due to both trauma residual and a sympathetic nerve component (responded to SGNB) and additional SGNBs were performed. A primary care note on 25 January 2005 indicated the CI was receiving median nerve blocks and SGNB at a civilian facility and the final orthopedic evaluation in record prior to separation on 27 January 2005 indicated the CI “…does in fact have reflex sympathetic dystrophy on the right and I agree with the treatments that she is undergoing”. The permanent profile listed “right wrist fracture and surgery with residual neuropathy.”

At the MEB examination on 2 March 2005, 6 months prior to separation, the CI reported right wrist pain. The MEB physical exam cited the DD Form 2808, Report of Medical Examination, on 2 October 2004, 11 months prior to separation, and noted the CI was right hand dominant and wore a right wrist brace. There was TTP of the joint and decreased ROM in all planes and decreased strength. Wrist range of motion (ROM) cited from 17 August 2004, 13 months before separation, was palmar flexion of 50, 50, 48 degrees (normal 80) and extension (dorsiflexion) of 38 degrees times three (normal 70), with painful motion. There was subjective numbness of the fingers, with no limitation of ROM. The MEB examiner noted that the CI could not write or open a door with the right hand and that immobilization decreased the pain. A note in the STR indicated the wrist hardware was removed 25 April 2005.

VA outpatient treatment notes, post-separation, indicated the CI continued with SGNBs after separation for RSD. Physical medical evaluation on 9 November 2005 noted a mottled appearance of the skin, pain with minimal touch, and weak right hand strength, with normal sensation and the assessment was RSD. Repeat wrist magnetic resonance imaging (MRI) performed on 15 November 2005 noted irregularity of the radius at the radio-ulnar joint and swelling around the ulna. An occupational therapy note on 18 November 2005 indicated the CI had a total of 11 SGNBs with temporary relief for several weeks and she could do some therapy, which she would stop when symptoms returned. During therapy the CI could not carry more than a bottle of water and was having difficulty with daily activities because of the need to use her left hand. The therapist noted that upper extremity ROM was within functional limits, with minor limitation of wrist ROM, strength testing was limited by pain and the CI reported numbness and tingling of the thumb, decreased sensation over the whole hand, and hypersensitivity to cold. The therapist recommended that the CI should be encouraged to accept the limitations as chronic and the focus should be retraining with the left hand, including writing, to improve her ability to function. VA notes between 6 and 12 months after separation indicated the CI continued with right hand pain, but made progress in returning to daily and leisure activities using the left hand.

At the VA Compensation and Pension (C&P) examination on 22 November 2006, 15 months after separation, the CI reported constant wrist pain, numbness and tingling, and weakness of the fingers. She reported that she could not type, write, or lift objects for more than a few minutes, and occasionally dropped things. She denied any episodes of incapacitation and reported that she could function with the pain with medication. The exam noted wrist swelling, tenderness, with flexion of 65 degrees and extension of 50 degrees, without additional loss of ROM with repetition. There was mild weakness of the right wrist with normal reflexes and sensation. Right wrist X-ray noted post-surgical changes and no other abnormality.

The Board directed attention to its rating recommendation based on the above evidence. The PEB rated the right wrist condition 10%, coded 5099-5003 (analogous to degenerative arthritis). The original VARD was not available in the records as noted above. The VARD on March 2007 rated two conditions of the wrist: CTS with arthritis and RSD, 30%, coded 8615 (median nerve neuritis) and residuals of right wrist fracture 10%, coded 5214-5215 (limited wrist motion with ankylosis), both effective the day after the DOS. The Board first considered the rating of the wrist condition coded IAW §4.71a (musculoskeletal conditions) and agreed with the PEB and VA that the wrist condition met a 10% rating for painful, limited wrist motion IAW §4.59 (Painful motion) and there was no higher evaluation possible coding IAW §4.71a. The Board next considered if the disability due to the wrist condition was better coded IAW §4.124a (neurological conditions). The evidence supports that the CI had persistent right upper extremity (RUE) pain following her wrist injury and related surgeries, that was significantly, but temporarily, improved by repeated injections for sympathetic nerve pain. Although there were different diagnostic opinions rendered throughout the CI’s treatment course, the consensus of multiple treating specialists both before and after separation was that the CI did have nerve related disability of the RUE. The permanent profile noted a residual neuropathy of the RUE. Thus, the Board agreed that coding IAW §4.124a best fit the CI’s disability related to the wrist condition and was medically well supported. The Board next deliberated what specific nerve code was the most appropriate to rate the wrist and agreed with the VA choice of 8516 (median nerve neuritis), but chose to code analogously as 8699-8615 for CRPS or nerve complication following the wrist fracture and CTS surgery. The Board considered that the rating criteria for 8615 are subjective with a 10% rating for “mild,” 30% for “moderate,” and 50% for “severe” incomplete paralysis of the median nerve of the dominant extremity. The Board agreed that the evidence of pain and weakness that limited, but did not preclude the CI’s use of her dominant hand supports that the wrist condition was best described as moderate, not mild or severe, and rated 30%.

The Board also considered if there was evidence to support a recommendation of more than one unfitting condition of the wrist, but the Board concluded that the pain, weakness, and limited wrist ROM could only be rated once IAW §4.14 (Avoidance of pyramiding) despite possible multiple contributing factors, and were subsumed in the §4.124a rating for the peripheral nerve impairment. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 30% for the right wrist condition, coded at 8699-8615.

Right Ankle Condition. The NARSUM notes the CI also injured her right ankle in the accident noted above. Notes in the STR indicate that X-rays were repeatedly negative and MRI on 21 May 2004 showed a bone bruise. Orthopedic evaluation on 17 June 2004 noted full painful ROM, tenderness, normal sensation and no instability. The CI had arthroscopy on 22 June 2004 which noted a bone bruise, intact cartilage, and ligament impingement (tibiotalar ligament). Following surgery treatment notes indicate the CI had decreased ankle pain, with the final physical therapy (PT) note prior to a transfer indicating the ankle was pain free. Following a transfer the CI was evaluated by physical medicine and reported ongoing pain in the ankle with use. There was TTP of the lateral ankle and mildly limited dorsiflexion (DF) and the exam was otherwise normal. The pain specialist’s assessment was that the ankle pain was related to degenerative joint disease or tendinitis. Bone scan on 19 October 2004 noted increased activity in the area of the CI’s pain, but the pain specialist did not think the scan supported RSD of the ankle. Repeat ankle MRI on 2 November 2004 was consistent with an ostechondral impaction injury with osteochondritis dissecans (OCD). The CI was evaluated by multiple orthopedic specialists and after the MEB examination underwent repeat surgery for the OCD on 3 February 2005. A PT note on 15 August 2005 noted the CI reported doing “pretty well,” with improved ability to walk and decreased pain. At the MEB examination the CI reported right ankle pain. The MEB physical exam cited the DD Form 2808, Report of Medical Examination on 2 October 2004, 11 months prior to separation, and noted an antalgic gait favoring the right, decreased ankle ROM in all planes and decreased strength. ROM cited from 17 August 2004, 13 months prior to separation, was DF of 9 degrees, 8 degrees, 9 degrees and plantar fasciitis (PF) of 50 degrees, 48 degrees, 48 degrees.

At a VA outpatient physical medicine evaluation on 9 November 2005, 2 months after separation, the CI reported right ankle pain despite two surgeries and exam noted tenderness of the ankle joint and full ROM and normal reflexes. The examiner noted the CI was “dragging her foot with ambulation” and had difficulty walking on heels and toes. The physical medicine specialist diagnosed osteochodritis of the ankle. Repeat MRI on 15 November 2005 was normal. An orthopedic consult indicated the CI would get numbness of the forefoot with prolonged walking. At the orthopedic evaluation on 2 December 2005 the exam noted full ROM, with TTP and decreased sensation limited to the big toe. The examiner noted previous diagnoses of osteochondritis and RSD. A podiatry evaluation on 23 January 20006 noted no signs of RSD, normal sensation except numbness of the top of the great toe, equal reduced strength of the bilateral legs and feet, with painful ankle ROM and tenderness of the ankle joint. Bone scan on 7 March 2006 noted focal increased activity of the lateral aspect of the ankle. At an orthopedic evaluation on 17 July 2006, 11 months after separation, the CI reported the ankle pain was getting worse and described sharp shooting pain to touch. The exam showed strength of the lower leg and foot was 4/5 and there was TTP of the lateral aspect of the ankle and the diagnosis was dorsal cutaneous nerve neuritis. The CI had injection of the ankle nerve with complete temporary relief of her pain and underwent surgery for nerve entrapment 13 months after separation.

At the VA C&P examination on 22 November 2006, 15 months after separation, the CI reported lateral right ankle pain, weakness, and stiffness. She reported she could function with the pain with medication. The exam noted a limp. There was tenderness of the ankle without swelling or deformity. Ankle ROM was DF of 20 degrees and PF of 36 degrees, without additional loss of ROM with repetition. There was decreased strength ankle flexion and extension graded 4/5, with normal sensation and reflexes.

The Board directed attention to its rating recommendation based on the above evidence. The PEB rated the right ankle condition 5099-5003 10%, coded 5099-5003 for degenerative arthritis with limited joint motion. The original VARD was not available in the records as noted above. The VARD on 29 March 2007 continued a 30% rating, coded 5271-8524 (incomplete paralysis of the tibial nerve with limited ankle motion), with an effective date of the day after separation. The Board noted that the VA rated the ankle condition utilizing a nerve code based on the C&P examination 15 months after separation. There was apparent worsening of the ankle condition post-separation and at the VA further diagnostic consideration was given to possible nerve related diagnoses of neuritis versus CRPS. As noted the CI underwent surgery for nerve entrapment 13 months after separation with more remote records indicating a diagnosis of CRPS, suggesting that the diagnosis was unclear more than 12 months after separation. The Board consensus was that although notes in the STR indicated consideration was given to a diagnosis of RSD of the ankle as well as the wrist, a nerve related diagnosis of the ankle was not made during the service or proximate to separation. The Board noted that the VA physical medicine evaluation 2 months after separation suggested significant weakness of the ankle/foot, but noted full ROM. The Board opined that the observation of full ROM at the exam and also at the orthopedic exam a month later supported the Board’s interpretation of the abnormal gait, heel and toe walking as likely secondary to pain and not weakness. The podiatry examination a couple months later also supports a musculoskeletal, rather than a nerve diagnosis of the ankle. Members, therefore, returned their attention to rating the ankle condition at the time of separation according to §4.71a criteria. The Board agreed that the evidence in record supported a 10% rating coded either as 5003 for degenerative changes in a single major joint with limited motion or as 5271 for moderate limited ankle ROM. The Board reviewed to see if a higher evaluation was achieved with any applicable code but there was no evidence of marked limited motion, ankyloses, deformity, or malunion to provide a higher rating. 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 right ankle 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 30%, coded 8699-8615 IAW VASRD §4.124a. In the matter of the right ankle condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication. There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION: The Board recommends that the CI’s prior determination be modified as follows; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective as of the date of her prior medical separation:

UNFITTING CONDITION	VASRD CODE	RATING
Right Wrist Condition	8699-8615	30%
Right Ankle Condition	5099-5003	10%
COMBINED	40%

The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20111003, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans Affairs Treatment Record

XXXXXXXXXXXXXXX
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 XXXXXXXXXXXXXXX, AR20150011051 (PD201200025)

1. Under the authority of Title 10, United States Code, section 1554(a), I approve the enclosed recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) pertaining to the individual named in the subject line above to recharacterize the individual’s separation as a permanent disability retirement with the combined disability rating of 40% effective the date of the individual’s original medical separation for disability with severance pay.

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:

         a. Providing a correction to the individual’s separation document showing that the individual was separated by reason of permanent disability retirement effective the date of the original medical separation for disability with severance pay.

         b. Providing orders showing that the individual was retired with permanent disability effective the date of the original medical separation for disability with severance pay.

         c. Adjusting pay and allowances accordingly. Pay and allowance adjustment will account for recoupment of severance pay, and payment of permanent retired pay at 40% effective the date of the original medical separation for disability with severance pay.

         d. Affording the individual the opportunity to elect Survivor Benefit Plan (SBP) and medical TRICARE retiree options.

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                       XXXXXXXXXXXXXXX
                                    Deputy Assistant Secretary of the Army
                                    (Review Boards)

CF:
( ) DoD PDBR
( ) DVA

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AF | PDBR | CY2012 | PD-2012-00025

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