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AF | PDBR | CY2014 | PD-2014-00764
Original file (PD-2014-00764.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXX  CASE: PD-2014-00764
BRANCH OF SERVICE: Army  BOARD DATE: 20141009
SEPARATION DATE: 20050308


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an Active Guard Reserve SGT/E-5 (31U/Signal Support Specialist) medically separated for low back pain (LBP) and left elbow and forearm pain. These conditions could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS). He was issued a permanent U3/L3 profile and referred for a Medical Evaluation Board (MEB). The LBP and left elbow and forearm pain conditions, characterized as “left ulnar neuropathy,” “left SI (sacroiliac) joint dysfunction” and “herniated disc at L5-S1” were the only conditions forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. The Informal PEB adjudicated chronic LBP with SI joint fusion and left elbow and forearm pain as unfitting, rated 10% and 0% respectively, with likely application of the US Army Physical Disability Agency (USAPDA) pain policy for the left elbow and forearm pain. The CI appealed to the Formal PEB (FPEB), which affirmed the PEB findings but increased the left elbow and forearm pain to 10%. The CI was medically separated.


CI CONTENTION: “I had denied a prescription for Vicodin to treat my back pain, and left arm pain. I had become addicted to pain killers after my surgery and struggled to quit them on my own.”


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 degenerative disc disease (DDD) and left elbow and forearm pain conditions are addressed below; and no additional conditions are within the DoDI 6040.44 defined purview of the Board. The Board acknowledges the CI’s assertions that he was denied a prescription for Vicodin. It is noted for the record that the Board has no jurisdiction to investigate or render opinions in reference to such allegations; and, redress in excess of the Board’s scope of recommendations (as noted above) must be addressed by the Board for the Correction of Military Records (BCMR) and/or the United States judiciary system. 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 BCMR.


 RATING COMPARISON :

Service FPEB – Dated 20041014
 VA - (1 yr. Post-Separation)
Condition
 Code Rating Condition Code Rating Exam
Chronic Low Back Pain, … SI Joint Fusion 5236-5243 10% Low Back Strain 5237 10% 20060323
Left Elbow and Forearm Pain 5099-5003 10% Left Ulnar Neuropathy 8615 10% 20060323
Other x 0 (Not in Scope)
 Other x 0
Combined: 20%
 Combined: 20%
Derived from VA Rating Decision (VA RD ) dated 200 60523 ( most proximate to date of separation [ DOS ] ).


ANALYSIS SUMMARY: Both the Service and the VA did not apply any rating deductions for existed prior to service (EPTS) conditions, and the Board likewise makes no EPTS deductions.

Chronic LBP secondary to L5/S1 DDD With SI Joint Fusion. The narrative summary (NARSUM) noted LBP since 2001 with a documented magnetic resonance imaging (MRI) of the herniated disk and DDD. He received an epidural steroid injection in 2002 and underwent SI joint fusion in April 2003. The CI’s lower back and left hip pain continued with daily flare-ups and duty limitations. At the MEB exam, the CI reported continued low back and hip pain. Exam documented pain limited range of motion (ROM), tenderness to palpation (TTP) and normal lower extremity testing of strength, sensation and reflexes.

At the Veterans Affairs (VA) Compensation and Pension (C&P) exam performed a year after separation, the CI reported pain with monthly flare-ups, weakness and stiffness in the low back in addition to instability and lack of endurance. Pain radiated down both legs (left leg worse than right). He missed work 1-2 times per month due to back pain. There were no periods of physician-prescribed bed rest (incapacitation) in the prior 12 months. Exam documented painful limited motion, with additional 10 degree loss on repetition or flare-ups, as charted below. There was no tenderness or spasms. Gait was normal and reflexes were +1 on the left (+2 on the right), with strength 4/5 on the left (5/5 on the right). Lasegue’s sign (testing for nerve entrapment) was negative. The examiner indicated that with repetitive use or flare-ups, there would be a 10-degree loss of ROM due to pain.

At the VA C&P exam performed (May 2008) more than 3 years after separation, the CI’s pain had increased, he was taking narcotic pain medication and ROM had decreased to 50 degrees of forward flexion with normal lower extremity exams for strength, reflexes and sensation.

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.

Lumbosacral ROM
(Degrees)
 MEB ~9 Mo. Pre-Sep VA C&P 1 Yr. Post-Sep
Flexion (90 Normal)
 70 75 (85 -10 DeLuca)
Comment: SI Fusion 200304
 Painful motion; normal lower extremity motor, sensory and reflex exams Painful motion; minus 10 ROM on repetition
§4.71a Rating
 10% 10%

The Board directs attention to its rating recommendation based on the above evidence. Both the FPEB and VA rated the spine and SI joint conditions at 10% using different disability codes under the criteria of the general rating formula for the spine. This formula includes pain (whether or not it radiates), and both the lumbar and SI joint disability are considered under a single thoracolumbar rating IAW VASRD §4.71a. The ratable exams in evidence each warrant a 10% rating and there was insufficient evidence of incapacitating periods (physician-prescribed bed rest), or ROM limitation at or below 60 degrees flexion (or 120 degrees combined) for any higher rating proximate to separation. The remote VA exam from 2008, was adjudged post-separation worsening and not indicative of the CI’s disability level proximate to separation.

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 low back and SI joint fusion condition.

Left Elbow and Forearm Pain. The NARSUM noted the CI was right-handed (confirmed by the Military Entrance Processing Station entry physical). The CI had a left elbow fracture (supracondylar fracture) in 1984 (as a child). During training in 1997 he had an overuse injury of the left elbow. He was noted to have deformity of the left forearm and complained of chronic left elbow and hand pain. Symptoms and abnormal electrodiagnostic testing (NCV) of the ulnar nerve in the left arm indicated an ulnar neuropathy. The CI underwent surgery in December 2000 for decompressing the ulnar nerve at the elbow, without complete relief. At the MEB exam, the CI reported increased pain in his left elbow with numbness, progressing down his forearm to his left 4th and 5th digits and pain to 6/10. The MEB physical exam noted a well-healed 6-cm scar at the elbow with visible deformity and decreased sensation to light touch over the 4th and 5th digits (ring and little fingers). Elbow ROM was 0-130 degrees (0-145 degrees normal) and supination and pronation (turning the forearm with hand palm-up to palm down) limited to 70 degrees each (normal supination 85 degrees; pronation 80 degrees). X-ray of the elbow was normal. At the VA C&P exam performed a year after separation, the CI reported numbness and tingling pain that radiated from the left elbow to the 4th and 5th digits, with weakness, stiffness and swelling. He also reported instability, locking and lack of endurance with precipitating factors including repetitive motions, lifting the arm above the head or lifting more than 20 pounds. Exam documented pain along the elbow with tenderness to palpation and ROM of 5-120 degrees (0-145 degrees normal) with full supination and pronation. The examiner stated, “Neurovascular is intact to the fingertips. No estimated loss of motion with repetitive use or flare ups.” The diagnosis was left ulnar neuropathy and there was no later VA exam in evidence.

The Board directs attention to its rating recommendation based on the above evidence. Both the FPEB and VA rated the left elbow and ulnar nerve condition at 10% using different disability codes. The FPEB coding of 5099-5003 was analogous to arthritis or using the Army pain policy, but could also apply to painful motion (“rated for tenderness”) of the elbow joint. Initial VA coding of 8615 was for mild neuritis of the median nerve and was noted as changed to 8616 mild neuritis of the ulnar nerve by VASRD in 2013.

The left upper extremity pain was diagnosed as left ulnar neuropathy by both the Service and VA, and there was insufficient evidence of elbow joint pathology or objective painful motion of the elbow joint for separate joint coding. Ideal coding of the CI’s left upper extremity disability would be IAW VASRD §4.124a—Schedule of Ratings–neurological conditions and convulsive disorders. Code 8616, neuritis of the ulnar nerve aligns with the CI’s diagnosis and disability picture. There was no objective motor weakness of the ulnar distribution (for rating directly as paralysis), and there were no organic changes noted in the ulnar nerve distribution. T herefore , IAW VASRD §4.123, the highest peripheral nerve (neuritis) rating is limited to “ moderate. ” The Board deliberated if the disability picture at the time of separation more nearly approximated the “moderate” 20% rating level (minor side as CI was right-handed) or the “mild” 10% rating level.

There was no objective motor weakness of the ulnar nerve distribution. The sensory deficit noted at the Service exam (the 4th and 5th digits) was to light touch only and, and no ulnar nerve deficits were noted at the post-separation VA exam. The Board majority adjudged that the CI’s disability picture proximate to separation was closest to the 10% disability level and found no path to any rating higher than 10%. Although coding analogous to 5003 is not ideal, it is still within the musculoskeletal system and no coding change (to neurologic system) would provide any benefit to the CI. 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 left elbow pain and ulnar neuropathy 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. As discussed above, PEB reliance on the USAPDA pain policy for rating the left elbow pain and ulnar neuropathy condition was operant in this case and the condition was adjudicated independently of that policy by the Board. In the matter of the low back pain and SI joint fusion condition, and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication. In the matter of the left elbow pain and ulnar neuropathy condition, and IAW VASRD §4.71a and §4.124a, the Board majority recommends no change in the PEB adjudication. The dissenting voter chose not to submit a minority opinion. There were no other conditions within the Board’s scope of review for consideration.


RECOMMENDATION: The Board, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination.


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20140207, 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 , AR20150006642 (PD201400764)

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 and hereby deny the individual’s application.
This decision is final. The individual concerned, counsel (if any), and any Members of Congress who have shown interest in this application have been notified of this decision by mail.

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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