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AF | PDBR | CY2014 | PD-2014-00492
Original file (PD-2014-00492.rtf) Auto-classification: Approved
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXX  CASE: PD-2014-00492
BRANCH OF SERVICE: Army  BOARD DATE: 20150310
SEPARATION DATE: 20040716


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an activated Reserve SGT/E-5 (88M20/Motor Transport Operator) medically separated for left sided cubital tunnel syndrome due to ulnar nerve injury. The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty. He was issued a permanent U3 profile and referred for a Medical Evaluation Board (MEB). Ulnar neuropathy of the left ulnar nerve was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. No other condition was submitted by the MEB. The Informal PEB (IPEB) adjudicated “left sided cubital tunnel syndrome due to ulnar nerve injury” as unfitting, rated 20% with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD). The CI made no appeals and was medically separated.


CI CONTENTION: “It should be changed because I had a year and a half till Retirement and never got the chance. Now they let soldiers stay in to Retire who are hurt way worse than I was.” His complete submission is at Exhibit A.


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 rating for the unfitting left ulnar nerve injury condition is addressed below. No additional condition is within the DoDI 6040.44 defined purview of the Board. Any condition or contention not requested in this application, or otherwise outside the Board’s defined scope of review, may remain eligible for future consideration by the Board for Correction of Military Records.


 RATING COMPARISON :

IPEB – Dated 20040706
 VA* - (~5 Mos. Post-Separation)
Condition
 Code Rating Condition Code Rating Exam
Left Sided Cubital Tunnel Syndrome due to Ulnar Nerve Injury 8516 20% Fracture, Left Distal Radius and Ulnar Styloid, Post Operative, Major 5211 10% 20041221
Tender Scar, Left Elbow associated with Left Ulnar Neuropathy, Post Release, Major 7804 10% 20041221
Left Ulnar Neuropathy, Post Release, Major 8515 10% 20041221
Other x 0
 Other x 14
RATING: 20%
 RATING: 50%
*Derived from VA Rating Decision (VARD) dated 20050308 (most proximate to date of separation (DOS))


ANALYSIS SUMMARY: 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.

Left Ulnar Nerve Injury. The earliest note in the service treatment record (STR) was the CI’s initial entry physical examination from 1985 on which he indicated he was left-handed. Subsequent entries in the STR indicated the CI was alternatively determined to be right hand dominant, left hand dominant, left arm dominant, left wrist dominant, and ambidextrous. A note dated 27 November 2003 indicated the CI, who was deployed, complained of worsening numbness of the left little and index fingers for 5 weeks, associated with decreasing grip strength. He was placed on light duty and restricted from physical training for 30 days. A clinic note dated 23 December 2003 indicated the CI had a history of a left wrist fracture surgically repaired in 1993 with strength and sensation intact post-surgery. Magnetic resonance imaging (MRI) demonstrated an interbody fusion between the C4 and C5 vertebrae, but was otherwise normal. An orthopedic consultant noted the CI’s history of weakness of the left hand with decreased grip strength. Examination revealed a normal range-of-motion (ROM) of the neck without any areas of tenderness. The left hand had a slight claw deformity as well as atrophy. He had good proximal strength and mass, but weakness in the intrinsic (muscles) of the left hand as well as atrophy with a normal thenar eminence (palmar area of the hand below the first metacarpal bone). He had normal reflexes and hypoesthesia (decreased sensation) in the 4th and 5th digits; and sensation was normal above the wrist. The examiner opined the symptoms were consistent with an ulnar neuropathy, but did not see any significant findings on the MRI of the cervical spine. Electro-diagnostic studies revealed a conduction block at the elbow indicative of moderate to severe entrapment of the left ulnar nerve at the elbow. Another orthopedic surgeon noted the CI’s history of his wrist injury with fractures of the radius and ulna bones at the wrist in 1992. As a truck driver, the CI spent his days driving with his left arm resting on the window. He had a full ROM of the elbow without an effusion. There was a positive Tinel’s test (pain when the nerve is tapped) at the ulnar nerve at the left cubital tunnel (at the elbow) with a negative flexion compression test of the right elbow. The left ulnar nerve was palpable but not mobile. Grip and pinch strength were decreased and sensation was decreased in the ulnar nerve distribution with intrinsic wasting with loss of the hypothenar muscles as well as the first dorsal interosseous muscle (between the thumb and index finger). A surgical nerve transposition at the elbow was recommended and was carried out on 23 January 2004. Post-operatively, the CI was healing well on day 3 and lacked approximately 5 degrees of extension and 10 degrees of flexion. Occupational therapy evaluation at 10 weeks post-operatively noted improvement in strength and sensation with mild hypersensitivity over the incision line. However, orthopedic examination indicated the ulnar nerve was still in the tunnel. Repeat electro-diagnostic studies 4 months post-operatively were consistent with a chronic/resolving ulnar neuropathy at the left elbow. X-rays of the left hand performed 11 months post-operatively were unremarkable.

The commander’s statement dated 7 April 2004 indicated the CI was physically incapable of performing his duties including operating, driving, loading, and climbing in and out of a variety of military vehicles due to numbness and ulnar nerve damage in his left hand. The MEB narrative summary, dated 12 April 2004, approximately 3 months prior to separation, noted the CI still had pain, weakness and numbness in his left hand with considerable disability and “profound numbness in his finger.” He lacked 15 degrees of full extension of the elbow with full flexion. He was unable to feel deep pain, but could feel light touch, which was not normal. Hypothenar atrophy with intrinsic weakness was present. Tinel’s sign was positive overlying the cubital tunnel. The CI noted he dropped trays, had pain on lifting, and was unable to change truck tires. It appeared that the ulnar nerve was still present in the ulnar tunnel post-operatively, rather than transposed (moved). The pain rating was mild with occasional moderate pain. At the MEB examination dated 12 April 2004, the CI reported numbness of the left hand and elbow with pins and a staple in the left wrist, while the MEB medical exam (DD Form 2808) on 20 April 2004 noted a scar on the left elbow. A permanent U3 profile was issued on 15 April 2004 for the ulnar nerve transposition with limitations of no push-ups, carrying more than 30 pounds, or constructing an individual fighting position.

At the VA Compensation and Pension (C&P) examination dated 21 December 2004, performed approximately 5 months after separation, the CI reported he injured his left elbow and wrist in 1991 during physical training and underwent surgery in 1991 and had transposition of the ulnar nerve of the left elbow in 2004. He had pain 4-5/10, weakness, stiffness, and a coordination deficit. He had recurrent flare-ups, two or three times per week at which time pain increased to 7/10. Examination of the elbow revealed scar tissue about 12 cm with sensitivity and pain with palpation and the ROMs were: flexion 145 degrees (normal 145) and extension 0 degrees (normal 0). Pronation and supination were good as was strength in the biceps, triceps, and deltoid muscles. Sensation was intact in the area of the arm and forearm except in the distribution of the ulnar nerve where it was decreased. A 3 cm healed scar was present on the ulnar side of the wrist and ROMs were: extension 50 degrees (normal 70), flexion 65 degrees (normal 80), ulnar deviation 30 degrees (normal 45), and radial deviation 15 degrees (normal 20). Approximately 10 to 15 degrees was lost after 5 repetitions. There was decreased sensation in the ulnar nerve distribution. The Froment test (ulnar nerve palsy of the thumb) was positive. Mild atrophy of the first interosseous muscle with weakness of the hand muscles innervated by the ulnar nerve was present. The temporally remote (51 months post-separation) VA C&P examination offered additional probative evidence of significant value confirming that CI was ambidextrous, although he wrote with his right hand.

The Board direct ed its attenti on to its rating recommendation based on the above evidence . The PEB assigned a 20% rating using code 8516 ( incomplete moderate ulnar nerve paralysis ) for left - sided cubital tunnel syndrome status post ulnar nerve transposition with residuals of chronic pain, numbness and weakness in the wrist and hand. The VA assigned a 10% rating using code 8515 (median nerve paralysis ) but should have been code 8516 (ulnar nerve ) ; a 10% rating using code 7804 (scar(s), unstable or painful); and a 10% rating using code 5211 (ulna impairment) for fracture s , left distal radius and ulnar styloid ( initiated and continued since 1993). Therefore, t he Board recommends code 8516 (ulnar nerve) , as utilized by the PEB, that address es cubital tunnel syndrome due to the CI’s mild left ulnar neuropathy, post major release .

 The Board sought a route for a higher rating. T he Board first reviewed the entire STR as well as post-separation documents. The STR indicate s the CI initially entered the service in 1985 as left - hand domina n t , subsequent entries referred to his being right hand dominant, left hand dominant, left arm dominant, left wrist dominant, and ambidextrous. The Board noted that the CI had fractured bones of the left wrist requiring surgery on or about 199 3 , which may account for the report of his writing with his right hand. Based on the STR and VA evidence the Board determined the CI did not experience an injury that affected the functionality of his right hand. The PEB assignment of a 20% rating r eflect ed the CI’s non-dominant left hand. However, the Board considered a 30% rating based on the CI’s left hand being dominant as more appropriate since the STR addressed the CI’s dominant hand as left, right and ambidextrous. According to VASRD §4.69 ( d ominant hand ) the “ Handedness for the purpose of a dominant rating will be determined by the evidence of record, or by testing on VA examination. Only one hand shall be considered dominant. The injured hand, or the most severely injured hand, of an ambidextrous individual will be considered the dominant hand for rating purposes. ” Bearing that in mind , the Board agreed the CI injured his left wrist and then left elbow on two separate and distinct occasions requiring surgery that affected his left hand functionality and that a 30% rating is appropriate IAW VASRD §4.3 ( r esolution of reasonable doubt), which states: “ …to administer the law under a broad interpretation, consistent, however, with the facts shown in every case , ” and VASRD §4.6 ( e valuation of evidence), which states: “ … Every element in any way affecting the probative value to be assigned to the evidence in each individual claim must be thoroughly and conscientiously studied by each member of the rating board … that decisions will be equitable and just as contemplated by the requirements of the law.”

Alternatively, the Board also considered a 30% rating for a severe incomplete paralysis of the ulnar nerve , if the left hand were not the dominant hand , to be not unreasonable since the CI had a moderate to severe entrapment of the ulnar nerve with atrophy of the muscles of his left hand preoperatively. However, in spite of the left ulnar transposition surgery, the nerve was noted to be in the cubital tunnel; atrophy of the intrinsic muscles was still present; the CI dropped things and could not do his job; and the pain was still present. Conversely, repeat electro-diagnostic studies of the left ulnar nerve 4 months post-operatively showed a chronic resolving neuropathy suggesting improvement was proceeding, and the neuropathy did not rise to the severe level (30% for left hand dominant ), but is more consistent with a moderate partial paralysis (20% for left hand non- dominant). The operative scar of the left elbow was not in scope, did not impede flexion of the elbow, and the pain associated with it was a component of the neuropathy. The wrist fractures were fully healed on X-ray studies prior to separation in 2004; and the limited loss of motion of the wrist is insufficient to warrant an additional rating using the VASRD. 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 left hand dominant) for the left ulnar nerve injury 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. 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 ulnar nerve injury condition, the Board unanimously recommends a disability rating of 30%, coded 8516 IAW VASRD §4.124a. 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; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective as of the date of his prior medical separation:

CONDITION
 VASRD CODE RATING
Left Ulnar Nerve Injury 8516 30%
COMBINED
 30%


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20140104, 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 , AR20150007061 (PD201400492)
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 30% 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 30% 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                                                  XXXXXXXXXXXXXXXXX
                                                      Deputy Assistant Secretary of the Army
                                                      (Review Boards)
                                                     
CF:
( ) DoD PDBR
( ) DVA

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