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AF | PDBR | CY2014 | PD-2014-00641
Original file (PD-2014-00641.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXX  CASE: PD-2014-00641
BRANCH OF SERVICE: AIR FORCE     BOARD DATE: 20150407
SEPARATION DATE: 20060508


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (Dental Assistant Journeyman) medically separated for a right wrist condition. The condition could not be adequately rehabilitated to meet the physical requirements of her Air Force Specialty. She was issued a permanent U4 profile and referred for a Medical Evaluation Board (MEB). Chronic right wrist pain and lipoma excision on right lower extremity with surgical reconstruction, were forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123. No other condition was submitted by the MEB. The Informal PEB adjudicated chronic right wrist pain as unfitting, rated 0% with application of the Veterans Affairs Schedule for Rating Disabilities (VASRD). The remaining conditions (seasonal allergic rhinitis, migraine headaches and renal lithiasis) were determined to be C ategory II ( condition can be unfit, but not compensable/ratable) . The CI made no appeals and was medically separated.


CI CONTENTION: “Right hand carpal tunnel surgery seemed affective (sic) until about 1 month after surgery. The hand is weak and I’m barely able to write this sentence. Fine manipulation is shaky and I’m actively trying to improve it. I also believe that I’, experiencing [sic] secondary issues to the surgery. I have burning up my arm and tingling.”


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 when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting. Any conditions outside the Board’s defined scope of review and any contention not requested in this application may remain eligible for future consideration by the Board for Correction of Military/Naval Records. Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate. The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the VASRD standards to the unfitting medical condition at the time of separation. The Board has neither the role nor the authority to compensate for post-separation progression or complications of service-connected conditions. That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws. The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation.


 RATING COMPARISON :
Service IPEB – Dated 20060215
 VA* - (2 Mos. Post-Separation)
Condition
 Code Rating Condition Code Rating Exam
Chronic Right Wrist Pain 8715 0% Right Carpal Tunnel Syndrome 8515 10% 20060707
S/P Surgery Scar, Right Wrist 7805 0% 20060707
Other x 4 (Not in Scope)
 Other x 10
Combined: 0%
 Combined: 60%
*Derived from VA Rating Decision (VARD) dated 20061003 (most proxima te to date of separation (DOS))
ANALYSIS SUMMARY:

Chronic Right Wrist Pain. On 22 December 2004 the CI complained of right wrist pain, especially at work as a dental technician, where repetitive movements when “cleaning teeth” exacerbated the pain. She also had tingling and numbness in the middle fingers. Examination revealed a full range-of-motion (ROM) of the right wrist with a positive Phalen’s test (a provocative test used in the diagnosis of carpal tunnel syndrome [CTS] ) and a positive Tinel’s test (to detect an irritated nerve by tapping). Treatment consisted of a splint , ice, rest, and Motrin , a nonsteroidal anti-inflammatory medication. Pain persisted and increased over the next 3 weeks ; and she was advised to continue the treatment protocol and a temporary profile precluding fine motor work was issued. In follow-up on 11 February 2005 , the CI reported a cortisone injection did not provide relief. There was edema of the wrist and decreased muscle and grip strength. Orthopedic evaluation was carried out on 2 5 February 2005 at which time the CI complained of right hand numbness when awake and when asleep, tingling, loss of grip, and a lump on the volar aspect of the wrist and weakness. The wrist and hand were normal to inspection. There was tenderness to the volar aspect of the right wrist and no intrinsic atrophy or thenar muscular atrophy . The ROM was excellent and both Phalen’s and Tinel’s tests were positive. Electrodiagnostic studies were requested and the electromyographic (EMG) nerve stimulation study (to test muscle function) of the right upper limb was normal. Because she noted dysesthesia (abnormal sensation) around the ulnar side of the forearm going into the hand with relative weakness in that area, she was referred to a hand and upper extremity surgical service specialist . On 20 June 2005, she was evaluated for a mass of the right wrist and indicated she occasionally dropped objects, had no symptoms on the left side, and had no numbness or tingling at night. On 1 August 2005, a magnetic resonance imaging was interpreted as a demonstrating a cystic lesion adjacent to the median nerve at the wrist level, which was observable when the CI moved her fingers. A carpal tunne l release with exploration and synovial biopsy was performed on 2 August 2005 . Apparently an anatomical variant of the origin of the lumbrical muscles (intrinsic muscles of the hand) was probably the source of the bulge with flexion and when making a fist. Two weeks post - operatively movement gradually improved, but pain persisted and she was referred to physical therapy. On 19 August 2005, there was moderate swelling and ROM was restricted to 30 degrees (Normal 80 degrees) of flexion and 40 degrees (Normal 7 0 degrees) of extension with grip strength 3/5, wrist strength 3/5, and fingers within functional limits. At 5 weeks post - operatively the operative site was completely healed ; and she had no tenderness at the scar , was able to elevate the thumb, made a fist quite well, and had a full ROM of the wrist. Grip testing from position I-IV was between zero and one kilogram, while the left hand was between twenty and 30 kilograms. The surgeon noted the CI had a very weak grip, almost not recording on the scale, which was difficult to explain. The CI requested another opinion because of continued pain and paresthesias (tingling) in the wrist with a severity of 5/10 and difficulty with grip strength of the right hand. Examination revealed t he operative site was well-healed at the distal flexion crease. Phalen’s and Tinel’s tests were negative , although there was some discomfort at the site of palpation. Sensation and two point discrimination were intact as w ere vascularity and anterior interosseous and ulnar nerve motor function, although posterior interosseous (involving extension of the wrist and some of the fingers) motor function was 4/5. However, t he etiology of the pain was unclear. On 9 November 2005, the CI noted increased swelling and numbness of her finger s after picking up a large bag of dog food. Tenderness to palpation of the wrist and decreased motor function were noted. A brace and profile for lifting no more than five pounds were issued. On 19 December 2005 , e lectrodiagnostic studies revealed no electrical evidence of peripheral neuropathy, entrapment neuropathy, radiculopathy, or other lower motor neuron disease of the right arm, while physical examination of the right arm revealed a full ROM throughout with normal strength, sensation, and reflexe s .

At the MEB narrative summary examination dated 30 December 2005, approximately 4 months prior to separation, the CI reported right wrist pain for 1 to 1.5 years. She was initially treated conservatively with bracing, ice, and nonsteroidal anti-inflammatory medication. Steroid injections were not efficacious. An initial EMG was not diagnostic. She was evaluated multiple times thereafter and underwent a carpal tunnel release in August 2005. However, wrist pain persisted postoperatively, and it limited her ability to perform her duties as a dental technician. She stated she had an inability to perform fine motor movements with her right hand, had decreased grip strength, numbness, and tingling, especially to the medial and ulnar components of her wrist and hand as well as pain with flexion and extension of the wrist. She had a post-operative second opinion, although there was a clear carpal tunnel without impingement postoperatively. Examination revealed a right hand dominant dental hygienist with a well-healed surgical incision. She had full ROM with flexion, extension and rotation of her wrist. She had positive Phalen’s and positive Tinel’s signs. Neurovascularly, her radial pulses were two plus bilaterally; and neurologic examination was grossly intact with some minimally decreased sensation to her ring and middle finger. A revised temporary U4 profile was issued on 11 January 2006 indicated the CI was not fitness test qualified for push-ups, but allowed to run, lift, carry, push/pull up to 10 pounds (previously was 5 pounds) with the caveat of no fine manipulation/grasping with the right hand. The commander’s statement dated 15 January 2006 indicated the CI was performing light duty and the medical condition did impact her ability to meet the duty requirements of her position and she was non-deployable.

At the VA Compensation and Pension (C&P) examination dated 7 July 2006, approximately 2 months after separation, the CI reported numbness of the right palm and all five fingers. Physical examination revealed mild tenderness of the right wrist and full ROM of the wrist. She had what was diagnosed as right CTS marked by pain and paresthesias with decreased manual dexterity along with problems of lifting and carrying, lack of stamina, and decreased strength. At the time of the VA examination, she was not employed. Temporally remote (more than 7 years and 9 years after separation) VA C&P examinations were reviewed; however, they offered very limited or no probative after separation evidence of significant value, but did note the CI reported residual numbness and pain and examiners noted the right wrist ROM was normal, but the CI had an impaired ability to execute skilled movements smoothly and a decreased grip strength.

The 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)
 PT
~9 Mo. Pre-Sep
 Ortho
~8 Mo. Pre-Sep
 NARSUM
~4 Mo. Pre-Sep
 VA C&P
~2 Mo. Post-Sep
Dorsiflexion (70 Normal)
 40 60 FROM FROM
Palmar Flexion (80)
 30 80 “
Ulnar Deviation (45)
 -- -- “
Radial Deviation (20)
 -- -- “
Comment
 Grip strength 3/5; wrist strength 3/5 ; moderate swelling Right grip test 0 and 1 kg; left grip test 20-30 kg Positive Phalen’s and Tinel’s tests; minimal decreased sensation right middle and ring finger DeLuca negative
§4.71a Rating
 0 % 0 % 0 % 10 %

The Board directed attention to its rating recommendation based on the above evidence. The PEB assigned a 0% rating using code 8715 (median nerve neuralgia) for chronic right wrist pain. The VA assigned a 10% rating using code 8515 (median nerve incomplete paralysis-mild) for right CTS (also claimed as right wrist pain). The VA additionally assigned a rating of 0% for status post surgery scar, right wrist. The Board sought a route for a higher rating and noted at minimum the CI’s condition at the time of separation was at least consistent with a mild neuralgia warranting a 10% rating. However, the CI was a right hand dominant dental technician, who worked on patient’s teeth in various positions for many years. Not only did she have pain, numbness, and paresthesias, but she also reportedly dropped objects occasionally and had diminished grip strength thereby limiting her from working in that specialty or other areas where dexterity and tactile skills are required. Therefore, a 30% rating is a reasonable consideration for the dominant hand using code 8715 rather than 8515 since post-operatively electrodiagnostic testing was normal. However, if the tests revealed any abnormal findings, that might have provided additional supportive evidence for the CI’s diminished grip strength and her subjective, but nevertheless constant and consistent, symptoms. Use of a wrist code could not provide a route to a higher rating since her wrist ROM post operatively was normal on at least two independent examinations. The surgical scar was not in scope and it was reported to be well-healed and non-tender except when tapped during Tinel’s test. 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 right wrist 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 right wrist condition, the Board unanimously recommends a disability rating of 10% coded 8715 IAW VASRD §4.124a. There were no other conditions within the Board’s scope of review for consideration.


The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of her is prior medical separation:

CONDITION
 VASRD CODE RATING
Chronic Right Wrist Pain 8715 10%
RATING
 10%


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20140127, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans Affairs Treatment Record








XXXXXXXXXXXXXXXXX
President
Physical Disability Board of Review


 SAF/MRB
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD 20762

 XXXXXXXXXXXXXXXXX

Dear XXXXXXX:

 Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2014-00641 .
         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 not appropriate under the guidelines of the Veterans Affairs Schedule for Rating Disabilities. Accordingly, the Board recommended modification of your assigned disability rating without re-characterization of your separation with severance pay.

         I have carefully reviewed the evidence of record and the recommendation of the Board. I concur with that finding, accept their recommendation and direct that your records be corrected as set forth in the attached copy of a Memorandum for the Chief of Staff, United States Air Force. The office responsible for making the correction will inform you when your records have been changed.

 Sincerely,





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

cc:
SAF/MRBR

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