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AF | PDBR | CY2012 | PD2012 00572
Original file (PD2012 00572.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:    CASE: PD1200572
BRANCH OF SERVICE: Army  BOARD DATE: 20130516
SEPARATION DATE: 20030819


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SPC/E-4 (77F10/Petroleum Supply Specialist) medically separated for wrist and knee conditions. The right wrist injury occurred in June 2001 when she fell onto an outstretched right hand. Her bilateral knee condition began in basic training and has persisted. These conditions could not be adequately rehabilitated with conservative treatment and anti-inflammatory pain medication to meet the physical requirements of her Military Occupational Specialty (MOS) or satisfy physical fitness standards. She was issued a permanent U3/L3 profile and referred for a Medical Evaluation Board (MEB). The chronic pain, right wrist status post (s/p) fracture and retropatellar pain syndrome (RPPS) bilateral knees conditions were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. No other conditions were submitted by the MEB. The PEB adjudicated chronic pain, right wrist and bilateral knees as unfitting, rated 10%, with cited application of the US Army Physical Disability Agency (USAPDA) pain policy. The CI made no appeals, and was medically separated.


CI CONTENTION: “I have had to have 2 subsequent surgeries from my wrist injury. I have had multiple issues with my back; I went to a chiropractor while in the service and now pay for one. My knees do not allow me to play sports, hike or climb stairs.”


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 those conditions identified but not determined to be unfitting by the PEB when specifically requested by the CI. The ratings for the unfitting right wrist and bilateral knee conditions are addressed below and are within the DoDI 6040.44 defined purview of the Board. The back condition, as per the contention, was not identified by the MEB or PEB, and thus is not within the DoDI 6040.44 defined purview of the Board. This, and any other condition or contention not requested in this application, remain eligible for future consideration by the Board for Correction of Military Records.

The Board acknowledges the CI’s information regarding the significant impairment with which her service-connected conditions continue to burden her; but, must emphasize that the Disability Evaluation System 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, operating under a different set of laws.



RATING COMPARISON:

Service IPEB – Dated 20030610
 VA - (5 Mos. Pre-Separation)
Condition
 Code Rating Condition Code Rating Exam
Chronic Pain, Right Wrist
 5099-5003 10% S/P Right Scaphoid Ligament Repair 5010-5215 10%* 20030307
Scar, Residual of Right Wrist Surgery 7805 0%* 20030307
Chronic Pain, Both Knees
 Retropatellar Pain Syndrome, Right Knee 5260 0%* 20030307
Retropatellar Pain Syndrome, Left Knee 5260 0%* 20030307
No Additional MEB/PEB Entries
 Other x 5 20030307
Combined: 10%
 Combined: 10%
Derived from VA Rating Decision (VA RD ) dated 200 30823 (most proximate to date of separation )
*No change to rating s derived from subsequent C&P exams


ANALYSIS SUMMARY: The PEB combined chronic right wrist pain and chronic bilateral knee pain as the single unfitting and solely rated condition, coded analogously to 5003. Although this approach complies with AR 635.40 (B.24 f.); the Board must apply separate codes and ratings in its recommendations, if compensable ratings for each condition are achieved IAW Veterans Affairs Schedule for Rating Disabilities (VASRD) §4.71a. If the Board judges that two or more separate ratings are warranted in such cases, however, it must satisfy the requirement that each ‘unbundled’ condition was unfitting in and of itself. Not uncommonly this approach by the PEB reflects its judgment that the constellation of conditions was unfitting; and, that there was no need for separate fitness adjudications, not a judgment that each condition was independently unfitting. Thus the Board must exercise 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.

Chronic Right Wrist Pain Condition. The right hand dominant CI fell on her outstretched hand in June 2001, causing a non-displaced scaphoid fracture. After 12 weeks of casting, magnetic resonance imaging suggested injury to the scapho-lunate ligament injury, avascular necrosis of the proximal scaphoid fragment and a non-displaced triquetral fracture. A scapho-lunate ligament repair was performed on 6 March 2002 and, with post-operative occupational therapy, range-of-motion (ROM) improved but pain only improved slightly.

The goniometric ROM evaluations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.

“
Right Wrist ROM
(Degrees)
 VA C&P ~ 5 Mo. Pre-Sep NARSUM ~ 4 Mo. Pre-Sep
Dorsiflexion (70 Normal)
 70Full”
Palmar Flexion (80)
 80 75
Ulnar Deviation (45)
 45 --
Radial Deviation (20)
 20 --
Comment
 +Painful motion +Painful motion, tenderness
§4.71a Rating
 10%* (VA 10%) 10%*
  * IAW §4.59 (Painful motion )

An orthopedic note on 22 October 2002 (7 months after surgery and 10 months prior to separation) stated that the CI’s wrist was doing well except for an inability to do push-ups. Examination showed mild tenderness over the scapho-lunate ligament. At the VA Compensation and Pension (C&P) exam approximately 5 months prior to separation, the CI reported wrist pain in cold weather or when performing push-ups, pull ups or carrying items heavier than 20 pounds. She was able to perform activities of daily living, including pushing a lawnmower and taking out the trash. She did not require the use of a brace. Physical exam showed that pain occurred at the maximal ROM reflected in the above table. X-ray showed abnormal widening of the scapho-lunate space and mild narrowing of the radiocarpal joint.

At the narrative summary (NARSUM) exam 4 months prior to separation, the CI reported she could perform the basic activities of daily living, but had difficulty lifting heavy items or opening jars with her right hand, and could not do pushups. Examination showed diffuse t enderness of the right wrist. Extension of the right wrist was described as “full” but the CI reported discomfort at the endpoint. Grip strength was “intact.” Wrist discomfort was reported with abduction and adduction of the right wrist against resistance. A permanent profile included no push-ups, pull-ups, or lifting greater than 20 pounds. The commander’s statement indicated that her wrist problem hindered her from performing her duties. At a C&P exam on 2 October 2004 (13 months after separation) , the CI reported that she could not type as well with her right hand and had difficulty taking notes and performing extensive repetitive hand movements. Examination revealed 80 degrees of flexion, 70 degrees of extension, 20 degrees of radial deviation and 45 degrees of ulnar deviation. Supination was 85 degrees (normal 85 degree s) and pronation was 80 degrees (normal 80 degrees). There was no evidence of painful motion and no tenderness; there was no pain or limitation after repetitive motion. The only abnormality was mild weakness of wrist extension. The e xaminer concluded there was no limitation in function. An X-ray was normal.

The Board directs attention to its rating recommendation based on the above evidence. The Board first considered if chronic right wrist pain, having been de-coupled from the combined PEB adjudication, remained independently unfitting as established above. All members agreed that the wrist pain, as an isolated condition, would have rendered the CI incapable of continued service within her MOS; and, accordingly merits a separate rating. The VA’s 10% rating was assigned for painful motion. There was no ankylosis to justify a rating under 5214 (wrist, ankylosis of); and no limitation of motion to support a compensable rating under the 5215 code (wrist, limitation of motion of) or 5213 code (supination and pronation, impairment of). The Board debated whether the CI’s symptoms and findings of pain at extremes of motion and some tenderness at the pre-separation exams were severe enough to warrant application of §4.40 (Functional loss) or §4.59 (Painful motion); and also considered the completely normal exam findings, including no evidence of pain, at the C&P exam 13 months after separation. Board members concluded that the evidence at hand did support this approach, and thus a 10% rating was justified. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (Reasonable doubt), the Board recommends a disability rating of 10% for the chronic right wrist pain condition, coded 5009-5003.

Chronic Bilateral Knee Pain Condition. The knee condition began in 1999 while in basic training, and was not a consequence of injury or associated with a surgical indication. Anti-inflammatory pain medications, physical therapy and a permanent L3 profile specifying running at own pace and no jumping were not sufficiently helpful. Review of the service treatment record noted that during the year prior to separation there were no visits for knee pain.

At the C&P exam 5 months prior to separation, the CI reported that bilateral knee pain was constant and that the condition “has not required bed rest or the attention of a physician.” Periodically she experienced a grinding or popping sensation. Carrying heavy objects or climbing stairs was difficult if she was experiencing a flare of discomfort. Anti-inflammatory pain medications were not helpful. She could perform gardening, drive a car, take out the trash, and push a lawnmower. She did not use assistive devices for ambulation. Physical examination noted negative instability and meniscal tests, and no locking pain, effusion or crepitus. Flexion was 140 degrees in each knee (normal 140 degrees) and extension was 0 degrees (0 degrees normal). ROM was “not additionally limited by pain.” The examiner concluded that there was no evidence of joint pathology or dysfunction of either knee. Bilateral knee X-rays were normal.

At the NARSUM exam the CI reported that knee pain was exacerbated by running, prolonged walking, standing or squatting. Physical examination revealed a normal gait. Tests for ligament stability and meniscal pathology were negative. ROM of the knees was not sufficiently specified, but tenderness of each patella was noted. The commander’s statement indicated that her knee problem hindered her from performing her duties.

The Board directs attention to its rating recommendation based on the above evidence. All members agreed that there was reasonable justification that each knee, as an isolated condition, would have rendered the CI incapable of continued service within her MOS; and, accordingly merits a separate rating. Based on normal examination findings, the VA assigned a 0% rating for each knee under the 5260 code (limitation of flexion). The Board considered the bilateral patellar tenderness noted on the NARSUM exam, and the C&P examination findings (including no painful motion) supporting a conclusion that there was no evident joint pathology or dysfunction of either knee. The Board agreed that there was no limitation of motion and no radiographic evidence of degenerative changes, and debated whether this evidence depicted a sufficiently severe objective functional impairment to warrant application of §4.40 or §4.59. The option of rating both lower extremities together at 10% was also carefully considered. Ultimately the Board majority concluded there was insufficient evidence for either approach, and that a 0% rating was therefore justified for each knee. The Board decided that since a 10% rating for the wrist and 0% ratings for each knee results in no change in the rating assigned by the PEB, there is no point in proposing a change to the PEB’s adjudication. 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 wrist pain and bilateral knee pain 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. As discussed above, PEB reliance on the USAPDA pain policy for rating the right wrist and bilateral knee conditions was operant in this case and the condition was adjudicated independently of that policy by the Board. In the matter of the chronic right wrist pain and bilateral knee pain condition, the Board recommends, by a vote of 2:1, no change in the PEB adjudication. The single voter for dissent (who recommended 10% for the wrist pain condition and 10% for the bilateral knee pain condition) did not elect to submit a minority opinion. There were no other conditions within the Board’s scope of review for consideration.


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

UNFITTING CONDITION
 VASRD CODE RATING
Chronic Right Wrist Pain and Chronic Bilateral Knee Pain
 5099-5003 10%
COMBINED
 10%



The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20120606, 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 AR20130012152 (PD201200572)

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 and hereby deny the individual’s application.
This decision is final. The individual concerned, counsel (if any), and any Members of Congress who have shown interest in this application have been notified of this decision by mail.

BY ORDER OF THE SECRETARY OF THE ARMY:




Encl                                                 
                                                      (Army Review Boards)

CF:
( ) DoD PDBR
( ) DVA

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