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AF | PDBR | CY2013 | PD2013 00178
Original file (PD2013 00178.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: xxxxxxxxxxxxxxxxxxxx      CASE: PD1300178
BRANCH OF SERVICE: AIR FORCE    BOARD DATE: 20131016
SEPARATION DATE: 20070706


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SRA/E-4 (2TO51/Traffic Management Journeyman) medically separated for bilateral carpal tunnel and bilateral cubital tunnel syndrome. The symptoms developed in May 2006. The carpal and cubital tunnel conditions could not be adequately rehabilitated to meet the physical requirements of his Air Force Specialty or satisfy physical fitness standards. He was issued a temporary U4 profile and referred for a Medical Evaluation Board (MEB). “Bilateral carpal tunnel syndrome” and “bilateral cubital tunnel syndrome,” were forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123. The MEB also identified and forwarded one other condition, overuse syndrome, for PEB adjudication, but this was in reference to the two other conditions. The PEB adjudicated “bilateral carpal tunnel syndrome and bilateral cubital tunnel syndrome” as unfitting, rated 20% wi th likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD). The PEB did not separately address the overuse syndrome. Anxiety disorder, not otherwise specified, was addressed in the MEB narrative summary (NARSUM), but not forwarded by the MEB. The CI made no appeals and was medically separated.


CI CONTENTION: The CI writes: “Carpel tunnel condition has worsen. [sic] My current doctor prescribing pain killers and antidepressants. Neck arthritis hurts more daily.”


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. In addition, the CI was notified by the Air Force that his case may eligible for review of the military disability evaluation of his mental health condition in accordance with Secretary of Defense directive for a comprehensive review of members who were referred to a disability evaluation process between 11 September 2001 and 30 April 2012 and whose mental health diagnoses were changed or eliminated during that process. Since the CI responded to this mailing, it is presumed that he has elected review by the PDBR for the mental health condition although he did not specifically contend for it on the DD Form 294. In accordance with Secretary of Defense directive for a comprehensive review of mental health diagnoses that were changed during the Disability Evaluation System (DES) process, the applicant’s case file was reviewed regarding diagnosis change, fitness determination, and rating of unfitting mental health diagnoses in accordance with the VASRD §4.129 and §4.130. The CI is also eligible for PDBR review of other conditions evaluated by the PEB and has elected review by the PDBR. The rating for the unfitting carpal and cubital tunnel syndromes is addressed below; as is the anxiety disorder. 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:

Service IPEB – Dated 20070504
 VA - (7 Mos. Post-Separation)
Condition
 Code Rating Condition Code Rating Exam
BILATERAL CARPAL TUNNEL SYNDROME AND BILATERAL CUBITAL TUNNEL SYNDROME
 8799-8715 20% CARPAL TUNNEL AND CUBITAL TUNNEL SYNDROME, L WRIST 8616 10% 20080129
CARPAL TUNNEL AND CUBITAL TUNNEL SYNDROME, R WRIST 8616 10% 20080129
No Additional MEB/PEB Entries
 Other x 2 20080129
Combined: 20%
 Combined: 40%
Derived from VA Rating Decision (VA RD ) dated 200 80318 ( most proximate to date of separation [ DOS ] ).


ANALYSIS SUMMARY:

Bicarpel Carpal Tunnel and Bicarpal Carpal Cubital Syndrome. The CI was referred to orthopedics for bilateral wrist pain and seen on 3 May 2006. He was diagnosed with bilateral carpal tunnel syndrome (CTS) and was noted to have normal X-rays. Electrodiagnostic studies on 19 May 2006 were remarkable for left ulnar and median neuropathy, but normal findings on the right. He was treated with medications, steroid injections, duty restrictions, and splinting without benefit. The NARSUM was dictated by the treating orthopedic surgeon on 31 January 2007, 4 months prior to separation. It noted that the CI had a history of a mixed nerve compression pattern (injury) involving the median and ulnar nerves of both wrists and the ulnar nerves of both elbows. Typing and using a computer mouse were the activities which seemed to be the most problematic. On examination, the range-of-motion (ROM) of both wrists and elbows was normal as was the ROM of the fingers. Muscle strength was normal. A Tinel’s test was bilaterally positive at the cubital tunnel (the ulnar nerve track along the elbow) indicative of cubital tunnel syndrome. The carpal tunnel test and Phalen’s test were positive at both wrists consistent with bilateral CTS. Sudomotor changes, a sign of autonomic dysfunction, were absent. He had mild to moderate bilateral thenar (thumb) atrophy, but did not have either hypothenar or interosseous muscle atrophy. This is consistent with CTS and secondary median nerve dysfunction. He was thought to have bilateral CTS based on his history and examination. The final orthopedic clinical note in evidence, written by his treating orthopedist and dated 30 April 2007, 5 weeks prior to separation, noted that the CI had an overuse syndrome with secondary neck pain and bilateral upper extremity neuropathy. The MEB had been performed and the CI was awaiting results. Recommendations included avoidance of activities which aggravated his symptoms including the use of a keyboard. At the VA Compensation and Pension (C&P) general examination performed on 29 January 2008, 8 months after separation, the CI reported that he worked in customer service at a local store and primarily was on the phone. He had been working fulltime for 5 months without any absences due to illness or injury. He was able to use utensils, but had recurrent symptoms if he used a computer mouse or typed for more than a few minutes. He also reported difficulty using tools such as screwdrivers. He continued to use braces at night. On examination, he was observed to not be wearing a brace. His sensation was normal and motor strength reduced to 4/5 for grip bilaterally. Mild atrophy of the interossei muscles of the fourth and fifth fingers was noted. The Tinel’s was positive bilaterally at both the ulnar groove and over the median nerve at the wrist. The ROM of the fingers was noted to be normal. DeLuca criteria were absent. He was diagnosed with mild left median and ulnar neuritis, with carpal and cubital tunnel syndromes. The Board noted though, as did the VA rater, that the CI had bilateral findings on examination.

The Board directs attention to its rating recommendation based on the above evidence. The PEB rated left and right CTS and cubital tunnel syndrome at 10% each and coded the conditions analogously as 8799-8715, neuralgia of the median nerve. The VA coded the two conditions as 8616, neuritis of the ulnar nerve, but also rated them at 10% each. The Board considered that the MEB and C&P examinations had slightly different findings and were separated by almost exactly a year. The MEB examination was more proximate to separation, and by an orthopedic surgeon who was also the treating physician. It is therefore assigned higher probative value in the adjudication of the case. The examiner diagnosed bilateral CTS and noted that on examination, the findings were much more significant for the median nerve than the ulnar nerve bilaterally. The evidence does not support a finding that the bilateral cubital tunnel syndrome and attendant ulnar neuropathy were separately unfitting at separation. The Board then considered the appropriate rating for the bilateral CTS. IAW VASRD §4.123 and 4.124, the findings are more consistent with neuritis than neuralgia and a code of 8615 would better describe the unfitting CTS condition in comparison to 8715. This impacts the maximum rating which can be assigned, but in this case, it did not affect the recommended rating. The Board observed that the CI had bilateral pain and thenar atrophy but normal strength. It also noted that the CI was able to find fulltime employment after separation and had not missed work secondary to injury or illness. The Board determined that this would best fit the mild incomplete paralysis level of disability bilaterally which is a 10% level of disability. 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 bilateral carpal tunnel and bilateral cubital tunnel conditions.

Contended PEB Conditions. The CI responded to the USAF mailing regarding review of mental health conditions. The Board’s main charge is to assess the fairness of the PEB’s implied determination that the anxiety disorder condition was not unfitting. 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 anxiety disorder was treated with medications and the MEB psychiatrist gave an S2 profile, but no duty limitations were imposed. It was not implicated in the commander’s statement or judged to fail retention standards. There is no evidence in the record that it was changed during the DES process to a less severe diagnosis; rather, the CI maintained an S1 profile until after he entered the DES process. The SRP determined that no mental health diagnoses were changed to the applicant's possible disadvantage in the disability evaluation process. Accordingly, this applicant did not meet the inclusion criteria in the Terms of Reference of the Mental Health Diagnosis Review. A psychiatric assessment for the MEB specifically noted that the CI remained world-wide qualified from a psychiatric standpoint. The MEB did not forward the anxiety disorder as a medically unacceptable condition; neither did the PEB adjudicate it as unfitting. It was reviewed by the action officer and considered by the Board. There was no performance based evidence from the record that the anxiety disorder 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 the addition of the anxiety disorder as an additional unfitting condition and so no additional disability rating is 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 bilateral carpal and cubital tunnel syndrome conditions and IAW VASRD §4.124a, the Board unanimously recommends no change in the PEB adjudication. In the matter of the contended anxiety disorder condition, the Board unanimously agrees that it cannot recommend it for additional disability rating. 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
Bilateral Carpal Tunnel Syndrome and Bilateral Cubital Tunnel Syndrome 8799-8715 20%
COMBINED (w/ BLF) 20%


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20130420, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans’ Affairs Treatment Record





XXXXXXXXXXXXXXXXXXXX, DAF
President
Physical Disability Board of Review
SAF/MRB
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD 20762
Dear XXXXXXXXXXXXXXXXXXXX :

          Reference your application submitted under the provisions of DoDI 6040.44 (Title 10 U.S.C. §  1554a), PDBR Case Number PD-2013-00178.
         After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was appropriate. Accordingly, the Board recommended no re-characterization or modification of your separation.
         I have carefully reviewed the evidence of record and the recommendation of the Board. I concur with that finding and their conclusion that re-characterization of your separation is not warranted. Accordingly, I accept their recommendation that your application be denied.
                                                               Sincerely,





 XXXXXXXXXXXXXXXXXXXX
Director
Air Force Review Boards Agency
Attachment:
Record of Proceedings

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