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AF | PDBR | CY2012 | PD2012 00323
Original file (PD2012 00323.rtf) Auto-classification: Approved
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:    BRANCH OF SERVICE: Army
CASE NUMBER: PD1200323   SEPARATION DATE: 20021205
BOARD DATE: 20130426


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SSG/E-6 (63H30/Track Vehicle Repairer), medically separated for right carpal tunnel syndrome (CTS), and chronic pain, neck and right knee (rated as a single unfitting condition). The right CTS, and the chronic pain, neck and right knee conditions could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS) or satisfy physical fitness standards. He was issued a permanent U3/L3 profile and referred for a Medical Evaluation Board (MEB). The MEB forwarded five separately unfitting conditions, and two medically acceptable conditions for Physical Evaluation Board (PEB) adjudication. Notably, bilateral CTS, chronic cervical pain, and right retropatellar pain syndrome (RPPS) were forwarded as three separately unfitting conditions. The rating chart below reflects the conditions forwarded by the MEB and adjudicated by the PEB. The PEB adjudicated the right CTS, and the chronic pain, neck and right knee conditions as two unfitting conditions, rated 10% and 10%, with application of the Veteran’s Affairs Schedule for Rating Disabilities (VASRD), and the US Army Physical Disability Agency (USAPDA) pain policy. The remaining conditions were determined to be not unfitting. The CI made no appeals and was medically separated with a 20% disability rating.
CI CONTENTION: “(Refer to DA Form 3947 Medical Evaluation Board Proceedings) For condition (1) I was rated for carpal tunnel syndrome only in one hand, I should have been rated for both hands. For conditions (2) (3) (6) (7) I was not rated at all by the PEB. I am currently 100% Permanent and Total for condition (7) PTSD. I should have been considered unfit for ALL these condition and rated for retirement.”


SCOPE OF REVIEW: The Board wishes to clarify that the scope of its review as defined in DoDI 6040.44, Enclosure 3, paragraph 5.e. (2) is limited to those conditions which were determined by the PEB to be specifically unfitting for continued military service; or, when requested by the CI, those conditions “identified but not determined to be unfitting by the PEB.” The ratings for unfitting conditions will be reviewed in all cases. All contended conditions as requested for consideration meet the criteria prescribed in DoDI 6040.44 for Board purview and are addressed below. Any conditions or contention not requested in this application, or otherwise outside the Board’s defined scope of review, remain eligible for future consideration by the Army Board for Correction of Military Records. The Board acknowledges the impairment the CI’s service-connected condition continues to burden him with but notes that the Disability Evaluation System (DES) has neither the role nor the authority to compensate members for anticipated future severity or potential complications of conditions resulting in medical separation. That role and authority is granted by Congress to the Department of Veterans Affairs (DVA), operating under a different set of laws. The Board considers DVA evidence proximate to separation in arriving at its recommendations and DoDI 6040.44 defines a 12-month interval for special consideration to post-separation evidence. Post-separation evidence is probative to the Board’s recommendations only to the extent that it reasonably reflects the disability at the time of separation.


 RATING COMPARISON :

Service IPEB – Dated 20021024
 VA (7 Mos. Pre-Separation) – All Effective Date 2002106
Condition
 Code Rating Condition Code Rating Exam
Chronic Pain, Neck & Rt Knee 5099-5003 10% Chronic Neck & Rt Knee Pain 5003 10% 20020425
Rt CTS 8799-8715 10% B/L CTS 8715 10% 20020425
Residual Ulnar Nerve Sxs at the Right Elbow Not Unfitting
Mild Left Ulnar Neuropathy w/ Interval Slowing on Left Not Unfitting No Corresponding VA Entry 20020425
Depressive D/O NOS Not Unfitting Depressive D/O, NOS, & PTSD 9411-9434 10% 20020425
PTSD Not Unfitting
↓No Additional MEB/PEB Entries↓
 0% X 3 / Not Service-Connected x 12 20020425
Combined: 20%
 Combined: 30%
VARD dated 20061017 granted the CI 100% combined rating effective 20060111, and VARD dated 20080212 granted him “permanent and total” disability effective 20070202 (per his contention) .


ANALYSIS SUMMARY: The PEB combined the back and neck condition as a single unfitting condition, coded analogously to 5003 and rated 10%. The Board’s initial charge in this case was therefore directed at determining if the PEB’s approach of combining conditions under a single rating was justified in lieu of separate ratings. The Board must apply separate codes and ratings in its recommendations if compensable ratings for each condition are achieved IAW applicable VASRD sections. If the Board judges that two or more separate ratings are warranted in such cases, however, it must satisfy the reasonable requirement that each “unbundled” condition was unfitting in and of itself or an indispensable element of a de facto combined effect rating. Thus the Board maintains the prerogative of separate fitness recommendations in this circumstance, with the caveat that its recommendations may not produce a lower combined rating than that of the PEB.

Right Carpal Tunnel Syndrome Condition. According to the narrative summary (NARSUM) dated 9 August 2002, this right hand dominant CI’s right wrist, right elbow, and neck pain symptoms presented in October 2000 after being handcuffed by police. His right wrist pain was accompanied by numbness and decreased sensation in dorsum of the right hand. The CI was treated with a wrist brace and anti-inflammatory medication. (He later developed pain in the left wrist.) The CI was evaluated in the orthopedic clinic on 21 May 2001 for report of right hand pain. On examination, tests for nerve irritation were positive and suggested CTS. CTS and radial neuritis of the right hand was diagnosed. A clinic note dated 24 January 2001 recorded report of pain in both wrists. Physical examination revealed full range-of-motion (ROM) of both hands, with normal motor strength, negative tests for nerve irritation for carpal tunnel, bilaterally, and no deformity or swelling of either hand. On 28 December 2001, approximately a year prior to separation, the CI returned to orthopedics with reported improvement in hand symptoms with use of braces. The examiner noted surgery was not indicated; “cubital tunnel syndrome” was mild and improving. On 2 April 2002, approximately 8 months prior to separation, an orthopedic examination recorded mild bilateral CTS symptoms were improved based on interval electromyography study (EMG), with residual right cubital tunnel symptoms. An EMG on 1 February 2001 revealed mild right median neuropathy, mild left median neuropathy, mild right ulnar neuropathy with notation of possible residuals from previous ulnar nerve entrapment (the CI had undergone right ulnar release nerve surgery in 1998). The CI underwent interval EMGs, the last one recorded on 13 September 2002. Results of this EMG recorded mild bilateral CTS, chronic on left and somewhat worse on the right but with signs of repair; residual ulnar nerve symptoms at the right elbow, appearing to be of chronic nature since 1998 and somewhat improved since the August 2002 EMG study; and, mild left ulnar neuropathy. The commander’s statement indicated the CI was not able to perform a single duty related to his MOS due to physical restrictions and medications to treat his physical and mental conditions. The CI also had a profile dated 30 September 2002 (2 months prior to separation) for arm/neck/knee pain that restricted heavy lifting, no running, no pull-ups, no jumping, no sit-ups and no ruck marching. (No psychiatric condition was noted.)

At the MEB evaluation on 9 August 2002, approximately 3 months prior to separation, the CI rated wrist pain at 7/10 without his braces at both wrists and 4/10 with his braces. On physical examination, tests for the presence of CTS were negative in the right wrist but testing for nerve irritation was positive (indicating possible neuropathy but not due to CTS). (The left wrists tests were all negative for nerve condition.) There was no evidence of ulnar nerve compression at the elbow and no evidence of atrophy or deformity of the hands or fingers. Motor strength was normal in both hands. A neurological NARSUM addendum dated 13 September 2002, approximately 2 months prior to separation, noted results of the EMG referenced above and opined, “I think ongoing brace treatment of the right carpal tunnel would certainly be reasonable, as he has had good success with that. The changes on the left side appear to be chronic and stable and of mild symptomology. The left ulnar nerve also seems to be of mild symptomology. I do not feel that surgical intervention is absolutely necessary at this time.” An orthopedic medical addendum dated 16 October 2002 noted no atrophy or weakness of the right hand and the examiner stated, “There is no significant dysfunction.” At the VA Compensation and Pension (C&P) evaluation on 25 April 2002, approximately 7 months prior to separation, the CI reported recurrent bilateral wrist pain and right elbow pain. The examiner noted full ROM bilaterally of the wrists, and elbows, and negative neurological examination of both wrists. No motor impairment was noted. The Board directs attention to its rating recommendation based on the above evidence. The PEB and VA chose the same coding options for the condition and arrived at identical ratings; however, the PEB rated for the single condition of right CTS and the VA rated bilateral CTS. Both the PEB and VA rated the condition at 10% under code 8715 (mild incomplete paralysis of the median nerve). 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 right hand CTS.

Chronic Neck and Right Knee Pain. The PEB bundled the two conditions as discussed above. The Board majority agreed that the evidence reasonably supports that each condition was separately unfitting, and undertook to evaluate each condition separately for rating purposes.

1) Neck Pain Condition. The CI related the onset of this condition began in 2000 and was related to the police incident. The pain was constant and caused shooting pain down under the right radius. Pain was noted more on the right side of the neck. There was no paresthesia or weakness. The CI underwent a full diagnostic evaluation prior to separation including magnetic resonance imaging (MRI) of the cervical spine that did not show a structural cause for his symptoms, electrodiagnostic studies that suggested possible mild cervical radiculopathy, and specialty consultation with neurology and orthopedic surgery. Neurological examination on 1 February 2001, revealed localized discomfort during ROM testing with moderate decrease in side bending bilaterally. There was no clinical evidence of neuropathy. There were no additional entries in the treatment records within a year of separation that recorded limited ROM of the cervical spine. Additionally, there was no evidence of clinical manifestation of radiculopathy, incapacitating episodes, spasms, or decreased motor strength. The CI’s profile listed neck pain as limiting condition, although he was allowed to perform neck and shoulder stretches. At the NARSUM evaluation on 9 August 2002, 3 months prior to separation, the CI reported neck pain and knee pain not related to the police incident. On physical examination of the neck, the examiner recorded normal forward flexion with pain on full extension; lateral bending was limited to 30 degrees with pain radiating into the shoulder. The examiner diagnosed chronic cervical pain without evidence of radiculitis or radiculopathy. The C&P exam on 25 April 2002, 7 months prior to separation, recorded tenderness to palpation of the cervical spine with forward flexion of 40 degrees, extension of 40 degrees and reported pain with rotation and lateral bending to the right. The examiner diagnosed chronic cervical strain. The Board directs attention to its rating recommendation based on the above evidence. Both the PEB and VA coded the condition under 5003 and both rated the condition at 10% for pain, and both combined neck and right knee pain as a single condition. In accordance with DoDI 6040.44, the Board is required to recommend a rating IAW the VASRD in effect at the time of separation. Applicable diagnostic codes for rating the neck at that time included 5003 (degenerative arthritis), 5290 (limitation of cervical spine motion) and 5293 (intervertebral disc syndrome). The Board considered that in the absence of radiographic findings and incapacitating episodes there was no basis for assigning a higher than the minimal compensable disability rating to the neck pain condition. Therefore, after due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board majority recommends a disability rating of 10% for the neck pain condition.

2) Knee Pain Condition. The Board next considered rating of the right knee pain condition. There were two goniometric ROM evaluations in evidence which the Board weighed in arriving at its rating recommendation. The C&P examination recorded full ROM, with mild crepitus, tenderness, and normal motor strength. This finding was generally consistent with the ROM recorded at the NARSUM (forward flexion slightly reduced-120 degrees), and orthopedic examination on 16 May 2002 (120 degrees, forward flexion), 6 month prior to separation. Treatment records are silent for right knee condition beyond the three exams noted. The Board considered rating code options 5257 (subluxation), 5258 (dislocation, cartilage), and 5260 (limitation of flexion) and determined the preponderance of evidence did not support a rating under any of these codes. There was no recorded ratable limitation in ROM in any of the treatment records prior to separation. Additionally, there was no evidence of knee instability. There was no other applicable VARSD codes allowing a higher rating. The Board further noted the application of VASRD §4.59, painful motion or §4.40 (functional loss) was not supported by the evidence. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board majority recommends a disability rating of 0% for the right knee pain condition. Therefore, because the “unbundling” was of no rating benefit to the CI, the Board recommends no re-characterization for the combined neck and right knee pain conditions.

Contended PEB Conditions. The contended conditions adjudicated as not unfitting by the PEB were residual ulnar nerve symptoms at the right elbow, mild left ulnar neuropathy, left carpal tunnel (included as bilateral CTS in the MEB but not addressed by the PEB), depressive disorder not otherwise specified (NOS), and posttraumatic stress disorder (PTSD). The Board’s first charge with respect to these conditions is an assessment of the appropriateness of the PEB’s fitness adjudications. The Board’s threshold for countering fitness determinations is higher than the VASRD §4.3 (reasonable doubt) standard used for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.

1) Left Carpal Tunnel Syndrome. The Board noted the condition was not specifically profiled, and was not specifically mentioned in the commander’s statement, but was forwarded by the MEB as unfitting. A careful review of the evidence documented treatment of the left wrist with a hand brace. Orthopedic consult and EMG findings included the left wrist, and there were multiple entries of “bilateral CTS,” including in the NARSUM. The Board noted EMG findings reported left nerve irritation as chronic and mild (less than on the right which was considered mild as well). The record documented pain of the left hand with full ROM, but no evidence of muscle atrophy or deformity. The neurologist opined, “The changes on the left side appear to be chronic and stable and of mild symptomology.” The Board majority concluded by preponderance of the evidence, the left hand condition was separately unfitting at the time of separation. The Board then considered rating the left hand condition. There was no evidence of decreased ROM, neurological deficits, or decreased motor strength of the left hand. A ganglion cyst was noted to be present and tender on both MEB and C&P examinations without other hand deformity. The Board considered rating the condition under coding 8715 (neuralgia) but the evidence did not support a compensable rating under this code. The left hand condition was milder than the right hand condition; the CI initially sought care for the right hand, and only the right wrist had been profiled. Additionally, there were no objective findings of painful motion, or muscle atrophy to support the use of any other VASRD code. The Board further noted the application of VASRD §4.59, painful motion, and §4.40, functional loss, were not supported by the evidence. Therefore, after due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board majority recommends a disability rating of 0% for the left carpal tunnel condition.

2) Left and Right Ulnar Nerve Conditions. The left and right ulnar neuropathies were mild, had no impact on motor function, and their minor sensory changes in the hands were discussed above. These conditions were never profiled, not implicated in the commander’s statement, and were not judged to fail retention standards. They were reviewed by the action officer and considered by the Board. There was no indication from the record that these conditions interfered with satisfactory duty performance.

3) PTSD and Depressive Disorder Conditions. The CI self- referred to mental health with report of PTSD and depressive symptoms incurred from physical assault by the police. The CI received civilian psychiatric treatment and was prescribed medication that he reported was of benefit. The psychiatric NARSUM recorded a normal mental status examination (MSE), and indicated the CI’s psychiatric conditions of PTSD and depressive disorder NOS, caused slight impairment for social and industrial adaptability and indicated the CI’s condition at the time of separation was medically acceptable. These conditions were not profiled, not implicated in the commander’s statement and not judged to fail retention standards. They were reviewed by the action officer and considered by the Board. There was no indication from the record that these conditions interfered with satisfactory duty performance.

After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the contended left and right ulnar nerve, or PTSD and depressive disorder conditions: therefore no additional disability ratings are recommended.
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 was operant in this case and all conditions were adjudicated independently of that policy by the Board. In the matter of the combined chronic neck/right knee condition and the right wrist carpal tunnel condition, both IAW VASRD §4.71a, the Board recommended no change in the PEB adjudication for either condition. In the matter of the left carpal tunnel condition, IAW VASRD §4.71a, the Board by split decision of 2:1 recommended a disability rating of 0%. The dissenting voter concluded the condition was not separately unfitting but elected not to submit a minority opinion. In the matter of all other contended conditions, the Board unanimously recommended no change from the PEB determinations as not unfitting. 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, effective as of the date of his prior medical separation:

UNFITTING CONDITION
 VASRD CODE RATING
Right Carpal Tunnel Syndrome 8517 10%
Chronic Neck/Right Knee Pain 5099-5003 10%
Left Carpal Tunnel Syndrome 8517 0%
COMBINED
 20%

The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20120326, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans’ Affairs Treatment Record




         Physical Disability Board of Review


 SFMR-RB                                                                         


MEMORANDUM FOR Commander, US Army Physical Disability Agency
(TAPD-ZB),


SUBJECT: Department of Defense Physical Disability Board of Review Recommendation
for AR20130011109 (PD201200323)
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 description without modification of the combined rating or 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                                                 
                                                      (Army Review Boards)

CF:
( ) DoD PDBR
( ) DVA

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