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AF | PDBR | CY2014 | PD-2014-01240
Original file (PD-2014-01240.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXX    CASE: PD-2014-01240
BRANCH OF SERVICE: Army  BOARD DATE: 20150305
SEPARATION DATE: 20080701


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was a National Guard E-4 (Infantryman) medically separated for a left wrist condition. This condition could not be adequately rehabilitated to meet the requirements of his Military Occupational Specialty, but he could take an alternate physical fitness test. He was issued a permanent U3 profile and referred for a Medical Evaluation Board (MEB). The wrist condition, characterized as “left wrist and forearm pain status-post open reduction/internal fixation,” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501; no other conditions were submitted by the MEB. The PEB adjudicated “limitation of pronation left (non-dominant) wrist following ORIF…” as unfitting, rated 0%, referencing the US Army Physical Disability Agency (USAPDA) pain policy. It also noted that the condition existed prior to service (EPTS), but was permanently service aggravated. The CI appealed to the Formal PEB, but an Informal Reconsideration PEB adjudicated a 20% disability rating and removed the reference to the USAPDA pain policy. The CI concurred with this PEB adjudication and was medically separated.


CI CONTENTION: “Left arm fx”


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 Veterans Affairs Schedule for Rating Disabilities (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 Recon PEB – Dated 20080207
 VA - (~5 years Pre-Separation)
Condition
 Code Rating Condition Code Rating Exam
Limitation of pronation left (non-dominant) wrist 5213 20% Residuals, Left Wrist Navicular Bone Fracture 5215 10%* 20031007
No Additional MEB/PEB Entries in Scope
Combined: 20%
 Combined: 10%
* Derived from VA Supplemental Statement of Case (SSoC) dated 200 90910 . Later increased to 30% effective on 23 Oct 2008 .

ANALYSIS SUMMARY:

Left Wrist Condition. The right dominant CI was first seen for left arm pain on 17 March 2002. He reported that it had started the previous night and he did not know how he injured it. The wrist was swollen and painful; gout was suspected. No evidence of trauma was noted such as bruising, redness, or abrasions. He was referred for further evaluation. These records are not in evidence, but it is clear that additional treatment and evaluation was received from the documentation in evidence. A line of duty determination (LOD) the next day noted that the CI had no trauma, but that this had happened once before. On 23 April 2002, an X-ray showed a chronic fracture of the scaphoid (one of the wrist bones next to thumb) with evidence of advanced degenerative changes. The wrist was immobilized and the CI was referred to orthopedics. The CI stated on 10 June 2002 that he had injured his left wrist by hitting it against a tree while on patrol (training). A statement by the First Sergeant the next day documented that the CI had reported to him that his forearm had swollen before, but recorded the date evaluated as 12 March 2002 on a hand written note, but on 17 March 2002 on the typed note. The CI noted on 20 July 2002 that he had jumped behind a tree during an attack on 12 March 2002. A statement recorded by another senior NCO on 28 August 2002 documented that the CI initially stated that he did not know the cause of his pain, but that it had occurred a year previously. Subsequently, the CI reported that he had injured his wrist in training when he struck a tree. A LOD investigation on 8 October 2002 noted that the CI had sustained an injury on his job on 22 April 2002. An additional note on 10 October 2002 documented that the CI had sustained a FOOSH injury (fall onto outstretched hand) at work on 22 April 2002 while cutting tree branches. At subsequent administrative review, the LOD was changed to EPTS with service aggravation. At the orthopedic evaluation on 4 October 2002, the CI reported that he was running with his rifle and fell in March 2002 with immediate left wrist pain. He stated that he reported this to his superiors, but did not receive specific treatment. He also reported that prior to this he had no problems with his wrist. He was noted to have a non-union of a scaphoid fracture and operative repair was recommended. The initial surgery was on 21 February 2003, but was not successful as documented on a CT scan on 10 October 2003. A VA Compensation and Pension (C&P) examination 3 days earlier had recorded range-of-motion (ROM) value. However, a second procedure was performed on 22 January 2004, rendering these values as non-probative to rating. An orthopedic note dated 24 November 2004 by the treating orthopedist indicated a successful outcome. However, a Social Security disability assessment dated 7 February 2005 indicated that an X-ray in April 2004 showed non-union. The Board notes that this X-ray most likely predated the X-ray which the orthopedist reviewed. A letter by the orthopedist dated 21 April 2006 documented that while the CI continued to have reduced ROM and pain of the left wrist, the fracture had healed. In 2006, while not in a duty status, a box fell on the CI resulting in a fall onto his left wrist with re-injury (as noted in the 10 September 2009 VA appeals review). Subsequently, he had an operative fusion, but the date of this is not clear from the record. Physical therapy (PT) ROM measurements on 25 March 2007 and 25 September 2007 are charted below. The narrative summary was dated 15 October 2007 and based on an examination dated 14 December 2006. The CI reported that he fell down in the summer of 2002 and injured his left wrist and forearm with immediate pain, swelling, and limited ROM to both. The Board noted that this is not consistent with contemporaneous records. The CI also reported reduced ROM and pain with daily activities. On examination, the ROM values from the PT evaluation on 25 September 2007 were cited. At the VA C&P examination performed on 23 October 2008, 3 months after separation, the CI reported that it was painful to grab objects with his left hand secondary to the wrist condition. On examination, there were 0 degrees of flexion, extension, and radial/ulnar deviation. It was swollen with severe tenderness; and based on accepted medical principles; this is consistent with a recent injury. An X-ray noted degenerative changes, but did not document fusion. A 20 December 2011 orthopedic assessment noted that the CI was last seen by him on 7 March 2008 at which time he had a healed navicular (scaphoid) fracture with post-traumatic arthritis. Subsequently, the CI had a fusion (of the wrist) under Workman’s Compensation; the date is not in the records in evidence. 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.

Left Wrist ROM
(Degrees)
 MEB ~18 Mo. Pre-Sep PT ~16 Mo. Pre-Sep PT ~11 Mo. Pre-Sep VA C&P ~ 3.5 Mo. Post-Sep
Dorsiflexion (70 Normal)
 20 20 20 0
Palmar Flexion (80)
 20 30 20 0
Ulnar Deviation (45)
 18 22 18 0
Radial Deviation (20)
 11 15 11 0
Forearm Supination (0-85)
 35 40 35 ---
Forearm Pronation (0-80)
 35 34 35 ---
Comment
 P ain and possible mechanical limitation Limited by pain Wrist swollen on examination
§4.71a Rating
 20% 20% 20% 30%

The Board directed attention to its rating recommendation based on the above evidence. The history provided was inconsistent between examinations. However, the record does support a significant injury in April 2002 after release from orders and again in 2006 and possibly 2008. The ROM in evidence prior to separation supports a 20% rating and is not consistent with the ankylosis documented by the VA examiner 3 months after separation. The X-rays taken that day do not show that the CI had undergone fusion. At the 7 March 2008 orthopedic evaluation, the scaphoid was noted to have healed. Based on the evidence, it is more likely than not the CI injured his left wrist at least twice after release from his activation in March 2002. The ankylosis documented by the VA C&P examiner is not consistent with the ROM obtained which was obtained less than a year earlier and stable. It is not explained in the report and not consistent with the X-ray findings. The MEB ROM values are therefore assigned higher probative value and used for rating the left wrist. 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 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 surmised from the record in this case that no prerogatives outside the VASRD were exercised by the reconsideration PEB. In the matter of the left wrist condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication. There were no other conditions within the Board’s scope of review for consideration.


RECOMMENDATION: The Board, therefore, recommends no re-characterization of the disability and separation determination.
The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20140310, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans Affairs Treatment Record






XXXXXXXXXXXXXXX
President
DoD 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 XXXXXXXXXXXXXXX, AR20150013365 (PD201401240)


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              XXXXXXXXXXXXXXX                   
                           Deputy Assistant Secretary of the Army
                           (Review Boards)
                                                     
CF:
( ) DoD PDBR
( ) DVA

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