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AF | PDBR | CY2012 | PD2012 01747
Original file (PD2012 01747.rtf) Auto-classification: Approved
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:    BRANCH OF SERVICE: Army
CASE NUMBER: PD1201747   SEPARATION DATE: 20031021
BOARD DATE: 20130403


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SPC/E-4 (63B10/Light Weight Vehicle Mechanic), medically separated for bilateral carpal tunnel syndrome (CTS), without any specific history of trauma or injury, and asthma. Despite non-surgical treatment for her CTS, the CI could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty (MOS) or satisfy physical fitness standards. She was not able to wear a protective mask due to her asthma and was therefore not deployable. She was issued a permanent P3U3 profile and referred for a Medical Evaluation Board (MEB). Migraine headaches with aura, adjustment disorder with depressed mood and borderline personality disorder conditions, identified in the rating chart below, were forwarded by the MEB as ‘not disqualifying.’ The Physical Evaluation Board (PEB) adjudicated the CTS and asthma conditions as unfitting, rated 10% for the left CTS, 0% for the right CTS, and 0% for the asthma, with likely application of the Veteran’s Affairs Schedule for Rating Disabilities (VASRD). The remaining conditions were determined to be not unfitting. The CI appealed for an Informal Reconsideration Board (IRB) of her case. She submitted a rebuttal statement outlining that her Albuterol had been provided by her unit during her deployment in the 6 month window cited by the PEB as her “not getting refills.” The PEB noted this information and changed the asthma rating from 0% to 10%. The 10% + 0% rating for the left and right CTS was upheld. The CI was then medically separated with a 20% combined disability rating.
CI CONTENTION: The CI attached a two page statement outlining five major contentions for her application: 1. Lumbar Spine Diffuse Spondylosis Levoscoliosis and Facet Arthropathy L5-S1 and Thoracic Spine Dextroscoliosis; 2. Bilateral CTS; 3. Hiatal Hernia with GERD; 4. Migraine Headaches; and, 5. Fibroid Tumors of the Uterus. Additionally, she contends she should have been retired and given access TRICARE, DEERS ID, and PX or Commissary facilities. These contentions and her entire statement were reviewed by the Board and considered in its recommendations.


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 condition(s) “identified but not determined to be unfitting by the PEB.” The ratings for unfitting conditions will be reviewed in all cases. The unfitting bilateral CTS and asthma conditions, as requested for consideration, meet the criteria prescribed in DoDI 6040.44 for Board purview and are addressed below; as well as the not unfitting migraine headache condition. The other requested conditions (spine, GERD and fibroid tumor of the uterus) are not within the Board’s purview. These and 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 CI’s assertions that she should have been retired and given access to TRICARE, DEERS ID and PX or Commissary facilities. The Board also 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 (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, operating under a different set of laws.


RATING COMPARISON :

Service Informal Recon IPEB – Dated 20030805
 VA (1 Mos. Pre -Separation) – All Effective Date 20031022
Condition
 Code Rating Condition Code Rating Exam
Bilateral CTS 8799-8715 10% Lt CTS 8799-8715 10% 20030911
Rt CTS 8799-8715 10% 20030911
Asthma 6602 10% Bronchial Asthma 6602 30% 20030911
Migraine HAs with Aura Not Disqualifying Migraine Headaches 8100 30% 20030911
Adjustment D/O... Not Disqualifying Adjustment D.O... 9440 0% 20030910
Borderline Personality D/O Not Disqualifying No VA Entry 20030910
No Additional MEB/PEB Entries
 Other x 4 20030911
Combined: 20%
 Combined: 70%
Derived from the VA Rating Decision (VARDs) , dated 20031216 (Most proximate to the date of separation)


ANALYSIS SUMMARY: She has had bilateral wrist pain and hand paresthesias for over a year (since September 2002); and was diagnosed by her primary care provider with CTS. She was treated with non-steroidal anti-inflammatory drugs (NSAIDS), wrist splints and elected to continue with non-surgical treatment only. In 2002, she first started experiencing chest tightness, wheezing and the inability to catch her breath when running; she had no prior history of breathing problems as a child or up until that point. A pulmonary function test (PFT) in September 2002 showed a mild restrictive pattern with no bronchodilator response; however, a Methacholine challenge test (MCT) performed in January 2003 revealed a marked degree of airway hyperactivity consistent with asthma.

Bilateral Carpal Tunnel Condition: On the MEB narrative summary (NARSUM) on 23 Jun 2003, 5 months prior to separation the right handed CI was diagnosed with bilateral CTS. She had maximal medical therapy with NSAIDs, splints, occupational medicine, and physical medicine evaluations. Electrodiagnostic testing was positive for CTS in both wrists. She elected not to have surgical decompression. She reported significant difficulty with repetitive movements of the wrists, lifting, and twisting which prevented her from performing many duties of her MOS. The NARSUM cites an examination performed on 10 March 2003 that reported left wrist tenderness with palmar flexion and rotation of wrist. There was a tender palmar wrist surface, and a positive Tinel’s sign for CTS with paresthesias in median nerve distribution. Profile limitations were no back pack (40 pounds), no KP/Mopping/Mowing Grass, and no lifting more than 10 pounds. There were three goniometric range-of-motion (ROM) evaluations in evidence, with documentation of additional ratable criteria, which the Board weighed in arriving at its rating recommendation; as summarized in the chart below.

Wrist ROM
In degrees (Normal)
 MEB/Occ Therapy ~ 7 Mo. Pre-Sep
(200 30318 )
VA C&P ~ 1 Mo. P re -Sep
(200 30911 )
RT LT RT LT
Dorsiflexion (70 )
 55 55 70 70
Palmar Flexion (80 )
 70 70 80 80
Ulnar Deviation (45 )
 30 30 45 45
Radial Deviation (20 )
 15 15 20 20
Comment
 + Bilateral Tinel’s
+ Bilateral Phalen’s		 + Bilateral Tinel’s
 + Bilateral Phalen’s
§4.71a Rating
10 %
 10 % 10 % 10 %

On 18 March 2003, an occupational therapy exam, 8 months prior to separation, noted the ROMs as documented above with a positive Tinel’s and Phalen’s sign for CTS. She was diagnosed with bilateral CTS. On the MEB specialist summary, 26 April 2003, held 7 months prior to separation; the CI reported a year history of bilateral hand paresthesias. The physical examination revealed positive Tinel’s and Phalen’s sign test for CTS at both right and left wrists, normal strength, sensation, and deep tendon reflexes (DTRs). At the VA Compensation and Pension (C&P) exam on 11 September 2003, a month prior to separation, the CI reported numbness, tingling, and pain mainly in the thumb and index fingers; it was not specified if this was limited to one hand or bilateral. She reported her grip had been affected by this condition. She was noted to be able to sustain heavy physical activities without immediate distress. She was taking Gabapentin, which was helpful, and wearing braces, which were not beneficial. The physical exam revealed a positive Tinel’s and Phalen’s test on both hands. ROM was normal in all planes as noted above. There was no heat, redness, tenderness, effusion, or muscle atrophy present. Sensation, vascular supply, and tendon function were normal. No specific comment was made regarding strength. A C&P examination in mental health the day prior noted that she did the child care for her three year old daughter, the cooking and the cleaning. It noted that she liked to clean a lot.

The Board directed attention to its rating recommendation based on the above evidence. Both the PEB and the VA applied the same VASRD codes 8799-8715 (rated analogous to neuralgia of the median nerve, and rated as mild). The PEB combined the conditions and rating with a bilateral factor as left 10% + right 0% = 10% + 1 (BLF) = 11% = 10% and added there were no physical findings reported for the right wrist. The PEB did not find the physical findings from the NARSUM specialty addendum, nor the medical record that described very similar bilateral findings, as ratable evidence, and relied on the MEB physical exam described in the NARSUM for adjudication. The VA examiner noted that the CI was able to sustain heavy physical activity without immediate distress and documented an essentially normal examination other than a positive Tinel’s and Phalen’s which demonstrated median nerve ‘irritability’. No atrophy was present. The CI told the VA mental health examiner that she cleaned a lot and did the child care and cooking. The Board examined the evidence, and agreed that the moderate rating was not approached in either the left or right CTS, and found the condition to be compatible with mild CTS of right and mild CTS of the left. Because the CI continued to report subjective tingling and weakness and on examination, both the Tinel’s and Phalen’s were positive. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a combined disability rating of 20% (10 + 10% with bilateral factor) for the bilateral CTS condition.

Asthma Condition: The CI was seen in family practice for occupational stress in September of 2002. She noted that she had shortness of breath (SOB) with exercise and was started on Albuterol and referred to mental health. At the mental health appointment on 21 October 2002, she stated that she had not used the Albuterol for a month. She was again seen in family practice in November complaining of SOB and given a refill of the Albuterol and a Prednisone burst. She continued to complain of SOB and was seen in pulmonary medicine on 29 January 2003 and diagnosed with asthma with a positive MCT. She was placed on maximal medical therapy after that testing including daily Advair, a steroid and bronchodilator inhaler. She reported no prior history of breathing problems. She was given a P3 profile to restrict physical exertion. Prior to this, she had been identified for deployment in February 2002 and given refills of the Albuterol. The Board noted that she had last filled the Albuterol prescription on 19 November 2002 (note: this is not consistent with daily use). She did not refill the Advair until 5 months later in June although she was having other medications refilled. The commander’s statement implicated the asthma condition as preventing the CI from deployment in a real world mission and repair vehicles. There were four PFT evaluations in evidence, with documentation of additional ratable criteria, which the Board weighed in arriving at its rating recommendation; as summarized in the chart below.


Pulmonary Exam
 PFT 13 Mo. Pre- Sep
(200 200920 )
 PFT 9 Mo. Pre-Sep
(20030129)		 PFT 4 Mo. Pre- Sep
(200 30612 )		 PFT 1 Mo. Pre-Sep
(200 30916 )
FVC
 74% 74% 75% 89%
FEV1 (% Predicted)
 72% 65% 69% 83%
FEV1/FVC
 86% 87.5 80% 84%
Meds
 No bronchodilator response +Methacholine challenge FEV1 to 51.2% Four puffs Albuterol given Advair
Albuterol
Singulair
§ 4.97 Rating
 10% 30% 30% 30%

At the MEB NARSUM pulmonology addendum examination on 30 January 2003 , 9 months prior to separation , the CI reported no history of breathing problems as a child, high school, basic training or Advanced Individual Training ( AIT ) . In 2002 she began to experience wheezing, chest tightness, and inability to catch her breath while running, nocturnal cough, and early morning shortness of breath. A PFT in September 2002 showed mild restrictive pattern, MCT showed a marked degree of airway hyperreactivity consistent with asthma. Examination of the lungs was normal. On the MEB NARSUM on 23 Jun 2003, 5 months prior to separation, the CI reported taking Albuterol, Advair, and Singulair for a sthma after she was diagnosed with the MCT in Jan uary 2003 . Prior to that , she was taking Albuterol as needed. At the C&P exam on 11 September 2003, a month prior to separation , the CI reported symptoms since May 2002 of wheezing, tightness of the chest, and shortness of breath. She was diagnosed as having br onchial asthma and was using Advair twice daily, Singulair once daily, and four puffs of A lbuterol per day. She reported she could sustain heavy physical activities without immediate distress. Lung examination was normal . PFT results , referenced in an addendum from a n exam 5 days later, on 16 September 2003, were not ideal due to the fact she used a bronchodilato r three h ours prior to testing ; the results are noted in the chart above .

The Board directed attention to its rating recommendation based on the above evidence. Both the PEB and the VA used VASRD code 6602 (bronchial asthma). The Board agreed that the 60% rating was not met by either medications, PFTs, or documented exacerbations requiring visits to a physician in the medical treatment records. The Board considered the evidence at the time of the PEB adjudication on 9 April 2002. The PFT results in January and June of 2003 of FEV-1 predicted of 65% and 69%, respectively, met the 30% rating criteria of FEV-1 of 56% to 70% predicted. The later PFT examination on 16 September 2003 showed improved FEV1 measurements on an inhaled daily bronchodilator/anti-inflammatory medication (Advair) and had just taken a bronchodilator before the test, thus also meeting the 30% criteria by medication use. 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 asthma condition.
Contended PEB Conditions: The contended condition adjudicated as not unfitting by the PEB was migraine headaches. The Board’s first charge with respect to this condition 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. The CI gave a year history of migraine headaches, lasting an hour, about three times per week that responded to medication. The migraine condition was not profiled, implicated in the commander’s statement, or judged to fail medical retention standards. There was no indication from the record that this condition significantly 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 migraine headache condition; and, therefore, no additional disability ratings can be 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. 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 left CTS condition, the Board recommends a disability rating of 10%, coded 8799-8715 IAW VASRD §4.124. In the matter of the right CTS condition, the Board recommends a disability rating of 10%, coded 8799-8715 IAW VASRD §4.124 by a vote of 2:1. In the matter of the asthma condition, the Board recommends a disability rating of 30%, coded 6602 IAW VASRD §4.97. In the matter of the contended migraine headache condition, the Board recommends no change from the PEB determination as not unfitting. There were no other conditions within the Board’s scope of review for consideration. The single voter for dissent (who recommended 0% for the right wrist CTS condition) did not elect to submit a minority opinion.
RECOMMENDATION: The Board recommends that the CI’s prior determination be modified as follows; and, that the discharge with severance pay be recharacterized to reflect permanent disability retirement, effective as of the date of her prior medical separation:

UNFITTING CONDITION
 VASRD CODE RATING
Left Carpal Tunnel Syndrome 8799-8715 10%
Right Carpal Tunnel Syndrome 8799-8715 10%
Asthma 6602 30%
COMBINED (w/ BLF)
 50%



The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20120825, 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 AR20130009609 (PD201201747)


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 50% 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 50% 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                                                 
                                                      (Army Review Boards)

CF:
( ) DoD PDBR
( ) DVA

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