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AF | PDBR | CY2013 | PD-2013-02144
Original file (PD-2013-02144.rtf) Auto-classification: Approved
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXX  CASE: PD-2013-02144
BRANCH OF SERVICE: Army  BOARD DATE: 20140702
SEPARATION DATE: 20050407


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SPC/E-4 (11C10/Indirect Fire Infantryman) medically separated for chronic pain, right small finger, right inguinal pain of neuralgia and chronic thoracolumbar back pain. The conditions could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty or satisfy physical fitness standards. He was issued a permanent P3/U3/L2 profile and referred for a Medical Evaluation Board (MEB). The chronic pain, right small finger, right inguinal pain of neuralgia and chronic thoracolumbar back pain conditions were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. No other conditions were submitted by the MEB for PEB adjudication. The Informal PEB adjudicated “chronic pain, right small finger; right inguinal pain of neuralgia and chronic thoracolumbar back pain” as unfitting, rated at 0%, 0% and 0% respectively. The CI made no appeals and was medically separated.


CI CONTENTION: “My finger is worse than if it had been totally removed….after 3 operations it should have been rated 20% the amount it would be rated if I could get it cut off. My finger hurts all the time, effects every aspect of my life and causes pain and weakness by stressing Rt. rist [sjc] and has caused lateral epiconditis (tenis [sic] elbow) in my right arm . . . ”


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 chronic pain, right small finger, right inguinal pain of neuralgia and chronic thoracolumbar back pain conditions are addressed below; no additional conditions are 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.


 RATING COMPARISON :

Admin Correction to IPEB Dated 20050314 VA - (8 Mos. Post-Separation)
Condition Code Rating Condition Code Rating Exam
Chronic Pain, Right Small Finger 5230 0% Total Joint PIP Arthroplasty w/ Prosthetic Joint Replacement; Right Small Finger 5227 0% 20051208
Right Inguinal Pain of Neuralgia 8730 0% Right Inguinal Hernia Repair w/ Neuropathic Pain 7338 0% 20051208
Chronic Thoracolumbar Back Pain 5237 0% Mild Spondylosis of the Thoracic Spine and Myofascial Pain of the Thoracic & Lumbar Spine 5299-5237 0% 20051208
No Additional MEB/PEB Entries Other x 3 20051208
Combined: 0% Combined: 20%
Derived from VA Rating Decision (VA RD ) dated 200 60120 ( most proximate to date of separation )

ANALYSIS SUMMARY: The Board acknowledges the impairment with which the CI’s service-connected conditions continue to burden him, but notes 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. Additionally, the Board considers VA evidence within 12 months of separation only to the extent that it reasonably reflects the disability at the time of separation.

Chronic Pain, Right Small Finger Condition. The CI is right hand dominant. In September 2002, he suffered a comminuted (smashed) fracture to his right hand small finger while playing football. Initially he underwent a closed reduction and application of an external fixator (surgical treatment used to stabilize bone and soft tissues at a distance from the operative or injury focus). Eventually, he developed a fixed malunion type deformity that required reconstruction with implant of the small finger proximal interphalangeal (PIP) joint. The operative summary did not document surgical fusion, but rather passive range-of-motion (ROM) to full extension and flexion to 65 degrees. A follow-up examination 2 months post-surgery revealed similar ROM at the PIP joint, but no active motion at the distal joint of the small finger. Both the DD Form 2808 of November 2004 and the MEB narrative summary (NARSUM) of December 2004 simply summarized past conditions without physical examination comments.

The VA Compensation and Pension (C&P) examination performed in December 2005 (8 months post-separation) also did not specifically address the right hand little finger as part of the physical examination.

The Board directs attention to its rating recommendations based on the above evidence. Absent any degree of digit amputation coupled with the evidence of ankylosis at the distal interphalangeal joint, the unequivocal VASRD §4.71a code for this condition is 5227 (ankylosis of either the ring or small finger). This code was applied by the VA and yields only a 0% rating regardless of hand dominance. The PEB rated the condition under code 5230 (limitation of motion; ring or little finger) also yielding only a 0% rating. There is no justification for code substitution or any other §4.71a compliant pathway to a compensable rating for this condition. After due deliberation, the Board concluded that there was insufficient cause to recommend a change in the PEB’s 0% adjudication of the right small finger condition.

Right Inguinal Pain of Neuralgia Condition. While deployed, the CI developed a right-sided inguinal hernia after lifting a heavy object. In October 2003, he underwent uncomplicated surgery to repair the hernia. In regards to healing, he did well post-operatively, but a localized dull groin pain remained, without local radiation. A post-operative ultrasound revealed a “fluid collection” directly beneath the scar. Pain management examination (approximately 8 months after surgery) did not reveal any local tenderness, but rather a symptomatic dull ache with prolonged pressure over the top portion of the surgical scar. There was no hernia present. The examiner noted that the CI’s current symptoms were less on a pain scale than before and that his primary site irritation stemmed from wearing “tight belts.” Having no particular diagnosis, the examiner performed local anesthetic injections about the painful scar with improvement of symptoms on 8 week follow-up.

The Board directs its attention to its rating recommendation based on the above evidence. As previously mentioned, the DD Form 2808 and NARSUM reflected limited examination findings, although it was noted the CI had a normal gait. Board members considered both codes selected by the PEB and the VA. The PEB coded the condition 8730 (neuralgia; ilio-inguinal nerve), whereas the VA coded it 7338 (inguinal hernia); both rated it 0%. Rating under the peripheral nerve code is the optimal VASRD approach for this case. In considering 7338, a surgically corrected hernia, even with painful residual, does not warrant more than a 0% rating. The applicable peripheral nerve codes for this case and relevant VASRD directions are excerpted below.

Ilio-inguinal nerve:
8530 Paralysis: 8630 Neuritis: 8730 Neuralgia
Severe to complete…….10%
         Mild or moderate………0%
§4.123 Neuritis: is to be rated on the scale provided for injury of the nerve
involved, with a maximum equal to severe, incomplete, paralysis.
§4.124 Neuralgial: is to be rated on the same scale, with a maximum
equal to moderate incomplete paralysis.

For code 8730 (neuralgia) as applied by the PEB, §4.124 applies and mandates the 0% rating achieved. Board members then considered if the symptomatology could favor a rating under the 8630 neuritis code, thereby invoking §4.123 to achieve a 10% rating (assuming “severe” best characterizes the symptoms in evidence). The action officer concluded that the clinical evidence of pinpoint achiness only associated with prolonged pressure (over the scar), coupled with a normal gait and no episodes of incapacitation does not support a level of “severe” condition. 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 of a 0% rating for the right inguinal pain condition.

Chronic Thoracolumbar Back Pain. In June 2003, upon heavy lifting, the CI developed low back pain (LBP) that radiated into his left leg. Subsequent physical examination in October 2003 revealed no motor deficits, and serial X-rays in October 2003 and May 2004 were normal. Despite multiple physical therapy modalities, his painful symptoms remained throughout his service career. His condition was eventually diagnosed as myofascial LBP. Multiple service treatment record entries documented the absence of lumbar tenderness or radicular motor or strength deficits. However, there was one orthopedic examination in May 2004 that documented both lumbar tenderness and painful motion. There were no documented periods of incapacitation. The MEB NARSUM physical examination (4 months pre-separation), revealed normal neurologic findings in the lower extremities and a normal gait. The diagnosis was “chronic back pain.”

At the VA C&P examination (8 months post-separation), the CI reported a transient non-radiating pain about his “entire back.” His musculoskeletal and spinal examination was completely normal. The list of VA diagnoses included lumbar myofascial pain. 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.
DOS 20050407
Thoracolumbar ROM
(Degrees)		 MEB ~ 04 Mo. Pre-Sep
(20041202)
VA C&P ~ 08 Mo. Post-Sep
(20051208)
Flexion (90 Normal) 90 90
Extension (30) 20 10
R Lat Flexion (30) 20 15
L Lat Flexion (30) 25 15
R Rotation (30) 30 30
L Rotation (30) 30 30
Combined (240) 215 190
§4.71a Rating 10% 10%

The Board directs attenti on to its rating recommendation based on the above evidence . Although the PEB and VA titled the unfitting back condition slightly differently, they both utilized the same primary code of 5237 (lumbosacral strain) with a 0% rating; citing full, non-painful ROM and a normal examination respectively. Board members agreed that the combined thoracolumbar ROM measurements near the time of separation support ed the 10% rating criteria under the VASRD General Rating Formula for Diseases and Injuries of the Spine. Additionally, Board members considered if the symptomatic left lower extremity radiculopathy (pain) warranted additional disability rating but agreed that the requisite link of the neuropathy symptoms with functional impairment was not in evidence. The pain component of a radiculopathy is subsumed under the general spine rating as specified in §4.71a. 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 LBP 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. In the matter of the painful right small finger condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication. In the matter of the right inguinal pain condition and IAW VASRD §4.124, the Board unanimously recommends no change in the PEB adjudication. In the matter of the thoracolumbar back pain condition, the Board unanimously recommends a disability rating of 10%, coded 5237 IAW VASRD §4.71a. 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
Chronic Pain; Right Small Finger 5230 0%
Right Inguinal Pain of Neuralgia 8730 0%
Chronic Thoracolumbar Back Pain 5237 10%
COMBINED 10%


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20131101, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans’ Affairs Treatment Record







                  XXXXXXXXXXXXXXXXX
President
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 XXXXXXXXXXXXXXXXX, AR20150002629 (PD201302144)
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 rating to 10% without 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                                                  XXXXXXXXXXXXXXXXX
                                                      Deputy Assistant Secretary of the Army
                                                      (Review Boards)

CF:
( ) DoD PDBR
( ) DVA

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