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AF | PDBR | CY2012 | PD2012 01581
Original file (PD2012 01581.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:    CASE: PD1201581
BRANCH OF SERVICE: Army  BOARD DATE: 20130521
SEPARATION DATE: 20011220


 SUMMARY OF CASE : Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SGT/E-5 ( 92Y20 / Supply Sergeant ) medically separated for chronic pain in the right wrist, left leg, and low er back . The CI experienced persistent left tibial pain following biopsy of a tibial lesion which was diagnosed as fibrous dysplasia. Onset of her lower back pain was after a motor vehicle accident (MVA) in 1999; no specific diagnosis was made and no surgery was indicated. Initial onset of right wrist pain was during a push-up activity in 2000 and her working diagnosis was possible carpal tunnel syndrome (CTS) . The above conditions could not be adequately rehabilitated 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 left leg, lower back and right wrist conditions, characterized as “ f ibrous dysplasia of the left proximal tibia, Status Post ( S/P ) excision and biopsy of the tumor mass , ” “ b ack pain, p ain is mild to moderate intensity, increased with activities, and occasional frequency ” and “ r ight wrist pain, possible carpal tunnel syndrome” 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 to include right wrist, left leg, and low back rated as moderate/constant ” as unfitting, rated 20 % with application of the US Army Physical Disability Agency (USAPDA) pain policy . The CI made no appeals, and was medically separated.


CI CONTENTION: “I was awarded a combined 20% rating by the Army PEB. The VA awarded me a higher combined rating for multiple medical conditions that the PEB should have assessed as unfitting and should have rated in excess of 30% and I should have been medically retired.” The CI also attached a statement to her application which was reviewed by the Board and considered in its recommendations.


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, left leg, and lower back conditions are addressed below. The requested mental health condition (depression) and service-connected left patella formal syndrome were not identified by the MEB or PEB, and thus are not within the DoDI 6040.44 defined purview of the Board. 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 Board for Correction of Military Records. The Board acknowledges the CI’s contention that suggests a higher rating should have been granted on the unfitting medical condition documented at the time of separation. IAW DoDI 6040.44, the Board’s authority is limited to making recommendations on correcting disability determinations. The Board’s role is thus confined to the review of medical records and all evidence at hand to assess the fairness of PEB rating determinations, compared to Veterans Affairs Schedule for Rating Disabilities (VASRD) standards, based on ratable severity at the time of separation; and, to review those fitness determinations within its scope (as elaborated above) consistent with performance-based criteria in evidence at separation.

RATING COMPARISON:

Service IPEB – Dated 20011009
 VA* - (4 Mos. Post-Separation)
Condition
 Code Rating Condition Code Rating Exam
Chronic Pain Right Wrist, Left Leg, and Low Back
 5099- 5003 20% Status Post (S/P) Excision of a Right Dorsal Wrist Ganglion 5215-5010 10% 20020411
S/P Excisional Biopsy of a Benign Left Tibial Shaft Lesion Resolving 5214-7804 10% 20020411
Lumbosacral Strain 5295-5292 20% 20020411
No Additional MEB/PEB Entries
 Other x 11 20020411
Combined: 20%
 Combined: 70%
* Derived from VA Rating Decision (VA RD ) dated 20020607 ( most proximate to date of separation )


ANALYSIS SUMMARY: The PEB combined right wrist, left leg and low back pain (LBP) 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 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. At an occupational therapy exam in June 2000, the right handed CI complained of intermittent right hand weakness and tingling, and pain on the volar aspect of the forearm, which was increased with prolonged use, e.g. writing, computer use, and carrying heavy objects. Although a history of right dorsal ganglion cyst removal 16 years previously was noted, pain in the wrist had only been present for a month. X-rays of the right wrist were normal. A bone scan of the wrist and hand were normal; and a bone scan (August 2001) showed no degenerative changes in the wrists or hands. An electrodiagnostic study performed in August 2000 did not show evidence of CTS. A clinical evaluation by physical medicine in January 2001 noted tenderness and pain at the end of flexion and extension of the right wrist, but a Tinel’s sign for median nerve irritation was negative. Repeat electrodiagnostic studies revealed no evidence of CTS. An orthopedic surgery note in September 2000 reported “markedly improved” pain and residual tingling after acupuncture. At an orthopedic exam in April 2001, the CI complained of occasional numbness in the wrist and referred pain to the middle and ring fingers. The examiner noted tenderness of the flexor retinaculum, the anatomical “snuff box” and the distal radio-ulnar joint. There was no sign of instability. The Tinel’s sign was negative, strength was 5 out of 5 (normal) and no muscle atrophy was observed. The commander’s statement on 30 May 2001 was silent regarding the wrist condition, although it stated that the CI was “physically capable of reasonably performing her duties as a 92Y Supply Sergeant.” The MEB narrative summary (NARSUM) dated 11 September 2001 (3 months prior to separation) indicated that the wrist pain originally began while performing pushups. Symptoms waxed and waned, and were aggravated by weight bearing and repetitive wrist motion. Physical exam of the wrist noted a well-healed scar. There was no tenderness of the carpal bones, no atrophy of the thenar eminence (palmar muscles at base of thumb), and the extensor and flexor tendons were intact. The Phalen test and Tinel sign were both positive, suggesting possible CTS. The neurovascular exam was normal. An X-ray of the wrist was reportedly normal; and a magnetic resonance imaging (MRI) reportedly showed no ganglion cysts.

At the VA Compensation and Pension (C&P) exam in April 2002 (4 months after separation) the CI reported a diffuse and “constant aching discomfort” mainly in the volar radial carpal area rated as 6 out of 10, and tingling in the ring and middle fingers. The symptoms increased with writing, lifting, gripping, typing, and use of a keyboard. The examiner noted a recurrent right dorsal ganglion cyst which was visible and mildly tender to palpation. The Tinel’s, Phalen, and Finkelstein (tenosynovitis) tests were negative bilaterally; and the hand exam was normal. X-rays of the right wrist and bilateral hands were normal. The goniometric range-of-motion (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)
 MEB ~3 Mo. Pre-Sep VA C&P ~ 4 Mo. Post-Sep
Dorsiflexion (70 Normal)
 70 70
Palmar Flexion (80)
 80 80
Ulnar Deviation (45)
 20 45
Radial Deviation (20)
 15 20
Comment
§4.71a Rating
 10% * 10% *
                  *Conceding painful motion

The Board directs attention to its rating recommendation based on the above evidence. The Board first considered if the right wrist condition, having been de-coupled from the combined PEB adjudication, remained independently unfitting as established above. The CI’s permanent U3 profile documented limitations due to the right wrist condition, which included the inability to fire individual assigned weapon, to perform any upper body weight training, or to perform push-ups. A Board majority agreed that chronic right 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 assigned a 10% rating under a combination 5215-5010 code (wrist, limitation of motion, of; arthritis, due to trauma) based on painful or limited motion rated under 5003 rating criteria. There was no ankylosis or limitation of motion to warrant a minimum rating under the respective codes 5214 (wrist, ankylosis of) or 5215. The Board considered the evidence of pain-limited movement and unanimously agreed that this case supports a rating of 10% IAW VASRD §4.59 (Painful motion) at the time of separation. 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.

Chronic Low Back Pain Condition. The Board next considered if the low back condition, having been de-coupled from the combined PEB adjudication, remained independently unfitting as established above. In analyzing the intrinsic impairment for appropriately coding and rating the low back condition, the Board is left with a questionable basis for arguing that this condition was indeed independently unfitting. After the low-speed MVA in February 1999 that led to low back pain, the condition was temporarily profiled in April 1999 and September 2000, each for one month or less. There were no other profiles for the back condition until the MEB process began. During the year prior to separation, there was one outpatient visit in evidence that mentioned back pain. Finally, the commander’s statement was silent regarding functional impairment due to back pain, stating that only a leg condition prevented participation in some activities. After due deliberation, a Board majority agreed that evidence does not support a conclusion that LBP would have rendered the CI incapable of continued service within her MOS, and accordingly cannot recommend a separate disability rating for it.

Chronic Left Leg Pain. According to the NARSUM examiner, the CI experienced the onset of left leg pain while running in 2000. However, the record does not clearly establish a correlation between the chronic leg pain leading to separation and a history of running or of trauma. Likewise, there is no evidence that chronic leg pain preceded excision of the tibial lesion that was incidentally discovered on a bone scan performed for evaluation of back pain in October 2000. After further evaluation with magnetic resonance imaging, the CI underwent excisional biopsy of the mass in February 2001, which revealed the lesion to be fibrous dysplasia. Post-biopsy swelling improved, but pain and tenderness persisted. At an orthopedic surgery exam, the CI rated her tibial pain as a constant 7 out of 10 (on a scale of 1-10); and a physical therapist noted that the persistent pain was limiting rehabilitation. Because of pain out of proportion to the surgical intervention, a follow-up bone scan in August 2001 was performed, which did not reveal other causes of pain. The NARSUM noted the CI’s report of persistent dull and achy, moderate-severe left leg pain, which was worse after prolonged activities. On physical exam of the left leg, a well-healed but very tender scar was noted. The muscle compartments were soft and no mass was palpated. The distal neurovascular exam was normal. The NARSUM reported X-rays of the left leg as normal. At the C&P exam, the CI reported diffuse 7 out of 10 pains in the anterior tibial area and scar, which increased with standing more than 10 minutes. She reported subjective post-operative left leg weakness and described anterior swelling distal to the incision site. On physical exam she was noted to have a slight limp, but did not use external supports. The left leg displayed a tender, two-inch midline tibial scar with slight edema that did not adhere to the underlying tissue. The examiner noted active ROM was guarded on the left, although the left knee ROM was only slightly decreased (0-130 degrees) compared to the right knee ROM (0-140 degrees). The examiner observed a “stocking distribution” of hyperesthesia below the left knee; and noted rapid fatiguing on the left with toe-walking. An X-ray of the left tibia was reported to show non-specific residual changes in the area of the biopsy.

The Board directs attention to its rating recommendation based on the above evidence. The Board first considered if left leg pain, having been de-coupled from the combined PEB adjudication, remained independently unfitting as established above. All members agreed that the leg 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 under the 7804 code (scar(s), unstable or painful). This code was erroneously combined with 5214 (wrist, ankylosis of), but this had no effect on the rating. The Board agreed with the VA that once a scar coding pathway is chosen, assigning a separate rating for leg pain is not defensible in this case. There was no limitation of leg motion which met minimal criteria for codes 5260 (leg, limitation of flexion of) or 5261 (leg, limitation of extension of); but the Board agreed that there was sufficient evidence of Functional loss (§4.40) and Painful motion (§4.59) to support a 10% rating via the PEB’s 5003 coding pathway. Finally, the Board concluded that a peripheral nerve pathway using the 8523 code (anterior tibial nerve) provided no route to a rating higher than 10% (“moderate” incomplete paralysis). 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 left tibia pain condition.

It is noted that the 10% ratings recommended by the Board for the respective right wrist and left leg pain conditions offer no benefit to the CI, since the PEB arrived at the same overall 20% rating. Accordingly, the Board unanimously concludes there is no point in recommending a change in the bundled conditions as adjudicated by the PEB.


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 right wrist pain, LBP and left leg pain was operant in this case and the conditions were adjudicated independently of that policy by the Board. In the matter of the chronic pain right wrist, left leg and low back condition, 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, therefore, recommends that there be no recharacterization of the CI’s disability and separation determination, as follows:

UNFITTING CONDITION
 VASRD CODE RATING
Chronic Pain Right Wrist, Left Leg and Low Back
 5099-5003 20%


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20120816, 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), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557

 SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for AR20130012147 (PD201201581)

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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