RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2013-01928
BRANCH OF SERVICE:  AIR FORCE	BOARD DATE:  20150310
SEPARATION DATE:  20051206

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (Aircraft Electrician) medically separated for bilateral upper extremity tingling and pain.  The bilateral upper extremity condition 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).  The “bilateral upper extremity tingling and pain,” was forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123.  No other condition was submitted by the MEB.  The Informal PEB adjudicated “bilateral upper extremity tingling and pain (Category I)” as unfitting, rated 20%, citing application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The CI made no appeals and was medically separated.

CI CONTENTION:  “Diagnoses has worsened.  I am now experiencing a high difficulty with sleep.  My condition makes it necessary to try and sleep on back only.  Any other position results in severe numbness to the point that I wake up 6-7 times per night.  I also am now experiencing pain in my neck area, frequently.  I associate this pain with the condition I was medically discharged with.”

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:

IPEB – Dated 20051006	VA* - (~6 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Upper Extremity Tingling and Pain
(Right 10% + Left 10%)	8799-8712	20%	Left Brachial Plexus Neuropathy (Claimed as Upper Body and Arm Condition), Non-Dominant	8599-8519	10%	20060609	
			Right Brachial Plexus Neuropathy (Claimed as Upper Body and Arm Condition), Dominant	8599-8519	10%	20060609	
Other x 0 (Not In Scope)	Other x 4	
RATING:  20%	RATING:  20%	
*Derived from VA Rating Decision (VARD) dated 20060801 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Bilateral Upper Extremity Condition.  According to an orthopedic clinic evaluation on 27 March 2003, the CI developed symptoms of numbness and tingling of both arms around January 2003.  Extensive work-up failed to delineate a specific diagnosis for his symptoms.  X-rays of the neck in February 2003 showed bilateral C7 cervical ribs with relative neuroforaminal (nerve outlet) narrowing at several levels (between C4 and C6).  Magnetic resonance imaging (MRI) of the cervical spine showed mild narrowing of the right neural foramina (nerve outlets) at C3-4 and C4-5 levels without evidence of nerve compression.  An MRI of the brachial plexus (network of nerves from the spinal cord, located in the neck and axilla) showed some possible lymphadenopathy, however another MRI did not show the lymphadenopathy.  Nerve studies (electromyelogram and nerve conduction) on 30 April 2003 were normal:  “There is no evidence via electrodiagnostic parameters to suggest cervical radiculopathy, brachial plexopathy, thoracic outlet syndrome, ulnar neuropathy or median neuropathy.”  On 24 May 2004, a neurologist reported that, “According to the patient, if he lifts his arms above his head or uses his arms, he will experience pain in his neck followed by numbness and tingling in his arms and sometimes weakness in his arms.”  Examination demonstrated tenderness to palpation over the muscles in the right posterior lower neck next to the spine; with normal strength and reflexes.  There was no report of sensory deficits.  The impression was, “neck pain associated with bilateral arm numbness, tingling, and weakness with activity.”  On 10 June 2004 he saw a hematologist/oncologist (presumably for the questionable lymphadenopathy near the brachial plexus); her diagnosis (given before the completion of her intended work-up) was “numbness and tingling in the upper extremities, exacerbated by physical activity.”  She recommended no push-ups, heavy lifting, or any activity requiring arms to be lifted above the shoulders.  He was seen by pain management in August 2004 and had steroid injections into the area for a possible brachial plexopathy (nerve impingement), which helped temporarily.  A duty restricting profile, on 7 June 2005, recommended no lifting over five pounds and no lifting overhead.  An examination by a thoracic surgeon on 28 July 2005 (5 months prior to separation) showed tenderness over the latissimus dorsi muscle (lower, lateral back) all over on the left side; full range of movement with the shoulder; no neurological problems; and no clinical evidence of thoracic outlet syndrome.  The thoracic outlet is the space at the top of the thoracic (chest) cavity, formed by several bones, though which several important structures pass (including nerves and blood vessels).  Impingement of these structures as they pass through the thoracic outlet causes the symptoms of thoracic outlet syndrome.  The surgeon determined that surgery would not be helpful.  The MEB narrative summary on 7 September 2005, reported the CI had tingling of the fingertips, loss of strength in the hands, and dropping wrenches at work.  On 22 September 2005, the commander noted the CI was restricted from lifting more than 10 pounds or anything above his head, and was therefore not performing aircraft electrical maintenance duties on the flightline and could not deploy.  A VA mental health clinic note, on 3 March 2006, 3 months after separation, noted the CI was employed by a defense contractor as a helicopter mechanic.  

At the VA Compensation and Pension (C&P) exam on 8 June 2006, 6 months after separation, the CI reported that he was right hand dominant and that his symptomatology was isolated to the left arm, but that he had pain in both shoulders that radiated down the arm (left greater than right).  He had difficulty with dropping objects, lifting, and overhead activities.  The examiner noted various possible diagnoses previously considered for his symptoms had included thoracic outlet syndrome and brachial plexus neuropathy.  On examination he had painful motion of the right and left shoulders.  The examiner stated, “The numbness is bilaterally in the ulnar nerve distribution predominantly forearm and hands and there is no muscular atrophy, the reflexes are equal.”  The CI had normal gait and no muscle spasms or atrophy; there was no report of muscle weakness.  The diagnosis was, “Upper body shoulder condition and bilateral arm condition is diagnosed as bilateral brachial plexus neuropathy, and although significant involvement on the left side than on the right side.”  A VA C&P examination on 8 April 2014 noted that the CI continued to work for the same defense contractor since separation from service as an aircraft electrician (performing modifications to helicopters).

The Board directed attention to its rating recommendation based on the above evidence.  The PEB’s diagnosis was “bilateral upper extremity tingling and pain” and rated each arm separately at 10% (under analogous code 8712 [peripheral nerves, neuralgia of the lower cervical radicular group]) with application of the bilateral factor for its combined rating of 20%.  The VA rated each arm separately under analogous code 8519 (peripheral nerves, incomplete paralysis of the long thoracic nerve) at 10% (moderate).  Although the CI had symptoms of the upper extremities that affected his ability to accomplish his duties, extensive evaluation failed to show a specific underlying diagnosis, although the latest examination (VA C&P exam on 9 June 2006) listed bilateral brachial plexus neuropathy.  Neurology and neurosurgery evaluations both noted no specific neurologic abnormalities, although there was tenderness in the posterior muscles of the lower neck.  The VA exam noted pain and painful motion in both arms, left greater than right, predominantly concentrated in the left anterior and lateral shoulder, which did not correspond to a specific underlying pathologic process.  The decreased sensation in the bilateral ulnar nerve distribution did not appear to be specifically unfitting for duty, and that finding was not congruent with the CI’s other symptoms or his nerve studies.  Since there was no specific pathology, there was no definitive corresponding VASRD code, and the Board was faced with choosing the “best” analogous code.  When there is no specific compensable disability, VA guidelines allow a 10% evaluation for limited or painful motion of a major joint, which appeared to correspond to the CI’s primary disability (movement of and lifting with the shoulders).  Since there was no described joint pathology and the duty-limiting symptoms were largely associated with the shoulders, the Board concluded that the best appropriate analogous code was 8519 (long thoracic nerve), which is associated with inability to raise the arm above shoulder level.  In view of the significant symptoms but minimal findings on physical examination (including no loss of strength) and negative nerve studies, the Board determined that the condition was best described as “moderate,” which corresponded to a 10% rating for each arm.  

The Board discussed whether a higher rating was supported; however, the evidence after separation reflected the CI was performing work in aircraft electrical maintenance shortly after separation and continuing for several years.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded the rating was better described as 10% rating for each upper extremity analogously coded 8599-8519 similar to the VA however the Board concluded there was insufficient cause to recommend a change in the combined rating.

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.  In the matter of the right upper extremity condition, the Board unanimously recommends a disability rating of 10%, coded 8599-8519 IAW VASRD §4.71a, §4.124a, and §4.40.  In the matter of the left upper extremity condition, the Board unanimously recommends a disability rating of 10%, coded 8599-8519 IAW VASRD §4.124a and §4.40.  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, effective as of the date of his prior medical separation:

CONDITION	VASRD CODE	RATING	
Right Upper Extremity Tingling and Pain	8599-8519	10%	
Left Upper Extremity Tingling and Pain	8599-8519	10%	
COMBINED (w/ BLF)	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20131021, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAF/MRB

Dear XXXXXXXXXXXXXXXXXXXX:

	Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2013-01928.

	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.

Attachments:
1.  Directive
2.  Record of Proceedings

cc:
SAF/MRBR