RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2013-01929
BRANCH OF SERVICE:  AIR FORCE 	BOARD DATE:  20150430
SEPARATION DATE:  20051213

SUMMARY OF CASE:   Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (Personnel Craftsman) medically separated for moderate weakness left upper extremity.  The condition could not be adequately rehabilitated to meet the physical requirements of her Air Force Specialty (AFS).  She was issued a permanent P4 profile and referred for a Medical Evaluation Board (MEB).  The “neuropathy and weakness, left upper extremity,” “mild depression with anxiety secondary to multiple trauma and witnessing death of a friend,” “chronic neck pain,” and “bilateral upper extremity pain secondary to bilateral clavicular fracture,” were forwarded to the Physical Evaluation Board (PEB) IAW AFI 48-123.  The Informal PEB (IPEB) adjudicated “moderate weakness left upper extremity, status post motor vehicle accident with bilateral clavicle fractures (healed) and vascular injury (healed)” as unfitting, rated 10% in accordance with Veterans Affairs Schedule for Rating Disabilities (VASRD).  The remaining conditions; mild neck pain and mild gastroesophageal reflux disease were determined to be Category II can be unfit, but are not currently compensable or ratable.  The CI made no appeals and was medically separated.  

CI CONTENTION:  The CI elaborated no specific contention in her application.  

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:  

Recon IPEB – Dated 20051101	VA* - (~2 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Moderate Weakness Left Upper Extremity, Status Post Vehicle Accident with Bilateral Clavicle Fractures (Healed) and Vascular Injury (Healed)	5399-5304	10%	Residual Weakness and Limited Motion, Left Clavicle Fracture	5299-5201	20%	20060127	
			Residual Limited Motion, Right Clavical Fracture	5299-5201	20%	20060127	
			Residual Scar, Subclavian Artery Repair	7804	10%	20060127	
Other MEB/PEB Conditions x 0 (Not in Scope)	Other x 4	
RATING:  10%	RATING:  70%	
*Derived from VA Rating Decision (VARD) dated 20060410 (most proximate to date of separation (DOS)) and VARD dated 20090203.

ANALYSIS SUMMARY:  

Moderate Weakness Left Upper Extremity with Bilateral Clavicle Fractures (Healed) and Vascular Injury (Healed).  On 5 February 2004, the CI was in a motor vehicle accident while in Qatar.  She was ejected from a vehicle after being hit from behind by a high speed vehicle.  Upon arrival to Hamad General Hospital, she had a large blood clot (hematoma) on the left shoulder and no palpable pulses of the left upper extremity (LUE).  Evaluations there documented bilateral clavicle fractures, bilateral pneumothoraxes and lung contusions, left sided hemothorax, an arterial (left subclavian) laceration with LUE ischemia (loss of blood and oxygen supply to the LUE), and a mandibular fracture, all surgically repaired (immediate left subclavian artery exploration with vein patch, bilateral chest tubes, and subsequent open reduction internal fixation of the mandible.  She was hospitalized for 10 days in their intensive care unit.  On arrival to Al Udeid Airbase, Qatar, on 16 February 2004, the CI reported occasional LUE paresthesias.  The admitting physician documented palpable pulses in the LUE, inability of the CI to abduct the LUE above shoulder level, and RUE abduction above shoulder level.  Radiographs demonstrated bilateral displaced mid clavicular fractures, bilateral upper rib fractures, no residual pneumothorax, possible bilateral scapulothoracic dissociation and “trauma to proximal roots of both upper extremities.”  The physician requested an orthopedic evaluation of the LUE for possible occult nerve injury.  The orthopedic surgeon found no evidence of motor/sensory neurological dysfunction, no evidence of deep vein thrombosis on ultrasound, and opined that the range-of-motion (ROM) limitations were likely related to the musculoskeletal injuries.  An orthopedic evaluation dated 24 February 2004 at Landstuhl Regional Medical Center documented an intact neurovascular system with tender nodules on the middle shaft of the bilateral clavicles.  The left clavicular nodule was noted to tent the skin and the right clavicular nodule was large and tender.  Radiographs documented bilateral displaced clavicle fractures with an approximate 2 centimeter shortening of the left clavicle.  

The CI arrived at Wright Patterson AFB on 27 February 2004 for continued evaluation and monitoring.  Physician notes dated 1 March 2004 documented the CI report of LUE pain rated as 3/10, stiffness and difficulty with movement above her head, cold sensitivity and weakness.  The examiner documented mid clavicular tenderness bilaterally, forward flexion to 70 degrees bilaterally (normal 180 degrees), external rotation of 40 degrees bilaterally (normal 60-70 degrees), internal rotation “to the belt line bilaterally,” and intact sensation to light touch.  The right ulnar artery pulse was patent (palpable), but left radial pulse was described as “very sluggish” with a capillary refill of less than 6 seconds and equivocal Allen test secondary to a cold [left] extremity.  The motor strength of the deltoid (upper shoulder) muscles was 5/5 (normal) while the motor strength of wrist, triceps, and biceps was 4/5.  Reflexes of the LUE were 1-2+/4, as compared to the right upper extremity (RUE) with reflexes of 2+/4.  Radiographs documented similar findings from prior, with bilateral clavicle and upper rib fractures indicative of high energy trauma.  The examiner requested referrals to an orthopedic trauma and vascular surgeon for a second opinion regarding a left brachial plexopathy and possible need for clavicular fixation.  A vascular surgery note dated 5 March 2004 documented fair right arm use and mobility with poor left arm use and mobility, no LUE distal pulses, and diagnosed significant disability of the LUE with lesser RUE disability.  The examiner requested spine films (normal), angiography (to determine blood flow) and electrophysiologic studies to evaluate for a left brachial plexus injury.  An orthopedic note dated 17 March 2004 documented that the civilian trauma specialist recommended waiting an additional 6-8 weeks for bony bridging across the clavicle fractures.  

At a physical medicine and rehabilitation visit dated 18 March 2004, the CI reported left shoulder pain requiring narcotics.  Left shoulder ROM for forward flexion was 140 degrees (normal 180 degrees), abduction of 85 degrees, with pain noted at the clavicle with all motions; muscular strength was 3-4/5 (normal 5/5) throughout; and scapular winging was noted.  The right shoulder had full ROM; pain with elevation and abduction at the right clavicular fracture point; muscular strength was 4-5/5 throughout.  The clavicles were tender to palpation bilaterally and with right and left rotation of the cervical spine.  The examiner diagnosed bilateral shoulder muscle weakness and “rule out brachial plexus injury.”  Electrophysiologic studies performed on 24 March 2004 demonstrated abnormalities consistent with left brachial plexopathy with a good prognosis.  Radiographic evaluation of the left subclavian dated 25 March 2004 artery was normal.  

At a functional capacity evaluation dated 22 March 2005, the CI reported an aching, dull pain (4-5/10) that was worse as night and discontinued functional capacity testing due to complaints of “right shoulder burning and hand weak[ness],”and the “left shoulder and whole left arm and fingers having a tough time turning pegs.”  The examiner documented no visible edema of the bilateral hands, inconsistent bilateral hand localization to light touch, limited endurance and limited tolerance (due to weakness, pain and tingling sensation) with repetitive tasks, left hand greater than right, and a below average grip on the right.  The examiner opined that the CI had below average pinch bilaterally, and sensation deficits in all nerve distributions of the bilateral hands.  The examiner further noted dyskinesia (fragmented or jerky motion) of the scapulothoracic region (lower and mid trapezius, rhomboids, and serratus anterior bilaterally) with questionable integrity of clavicular stability and support bilaterally; and was concerned about potential impingement from the significantly internally rotated resting posture of the bilateral shoulders.  The examiner further documented the bilateral shoulder joints to have 3+/5 to 4/5 strength.  He noted downward rotation and winging of the inferior angles of the bilateral scapula with flexion and abduction and when performing weight bearing tasks with her upper extremities.  The examiner opined that the bilateral shoulders had a ROM within functional limits for overhead reach activities, although the resting posture of the bilateral shoulders for internal rotation gave rise to “questionable scapuloclavicular stability bilaterally.”  The examiner concluded that the CI was unable to perform frequent or constant material handling from shoulder to overhead levels and recommended formal therapy and additional medical evaluation for persistent bilateral upper extremity sensory alteration and bilateral shoulder girdle dyskinesia.  

A chiropractic summary dated 23 June 2005 stated that the CI was referred on 2 December 2004 for “chronic neck [and] back pain, left army tingling with weakness and burning between the shoulder blades…worsening and interfering with ADL’s, sleep patterns and physical therapy demands.”  At the time of the initial evaluation, the examiner documented weakness of the left upper extremity compared to the right with diminished sensation reported.”  The CI reported improvement in activities of daily living and sleep patterns after chiropractic spinal manipulation, but less improvement in the LUE issues.  The examiner recommended continued sessions.  
At an orthopedic visit dated 25 June 2004, the CI reported improved but continued pain of the shoulders, neck and back, decreased ROM of the LUE, with the ability to work full days.  The examiner documented palpable left radial pulse and slightly decreased active ROM, and recommended a 90-day extension of her profile with continuance of physical therapy.  A chiropractic consultation was ordered on 22 November 2004 for persistent neck and back pain and failure to progress during physical therapy.  

The initial narrative summary (NARSUM) dated 7 April 2005 referenced the multiple injuries and a left brachial plexus injury.  She attended physical therapy and chiropractic treatments, but continued to have upper back and neck pain.  The examiner opined that the CI was able to perform her current duties, but would not likely tolerate the physical demands of a deployment, and that only modest improvement was expected.  The initial IPEB dated 6 June 2005 upheld the MEB recommendation dated 5 May 2005 that found the CI to be fit for duty.  A memorandum of support dated 24 June 2005 was written in response to the Fit for Duty IPEB decision.  The commander stated that the CI continued to have a cold left hand and her shoulders were still not healed properly resulting in severe chronic pain which affected her daily performance.  The commander requested reconsideration for a medical retirement.  The MEB process was repeated.  

Radiographic studies dated 3 August 2005 demonstrated overlapping clavicular fracture fragments with remodeling, with the union being better on the right than on the left.  Electrophysiologic studies were repeated on 9 August 2005 and documented a normal study with no evidence of brachial plexopathy or neuropathy of either extremity.  A chiropractic summary dated 17 August 2005; documented the examiner’s opinion that the incomplete union of the clavicles could lead to residual weakness/poor stability of the LUE and shoulder girdle.  He further stated that there was evidence of decreased grip strength of the non-dominant (left) hand of 15 kg compared to the expected average for individuals of 22 kg for age, gender, and occupation.  

The second NARSUM dated 18 August 2005 stated that despite completing all treatment and therapy requested, the CI continued to have decreased left upper arm strength, numbness in the left upper extremity, and chronic pain.  The CI reported that any amount of lifting over 10 pounds, overhead motion, pressure/ weight on her shoulder, or prolonged sitting caused pain in the neck and shoulders.  She managed it well with frequent position changes and limiting lifting/ activities and had not required narcotics.  The examiner documented symmetric reflexes, strength of 4/5, decreased ROM of the upper extremities (approximately 90 degrees without pain, cannot extend to 180 degrees, winging of scapula), and that she appeared to be in mild discomfort.  

At the VA Compensation and Pension (C&P) exam dated 27 January 2006, performed a month after separation, the CI reported constant burning pain in her mid-back and both shoulders (left greater than right) and rated 3-4/10.  The pain was sharp and could increase to a 7/10 and was mildly relieved by Motrin or Tylenol.  She also reported weakness and easy fatigability of the LUE greater than the right, and numbness and tingling in the fingers of her left hand but was able to perform her activities of daily living without much difficulty and maintain gainful employment.  The examiner documented hyperesthesia (sensitive/painful to touch) of an 8 cm left sided anterior chest scar, mild decrease in fine touch sensation of the left hand, symmetric peripheral pulses, and notable LUE weakness (4/5) compared to the RUE (5/5) on resistance testing.  There was also decreased ROM of the shoulders secondary to pain, particularly with abduction; abduction to 170 degrees limited by pain, forward flexion to 180 degrees with pain; after repetition, there was decreased ROM and internal rotation of the LUE to 50 degrees and external rotation to 90 degrees with pain.  There was also fatigue, weakness and lack of endurance with repetition on the left and notable scapular winging of both scapulae.  The RUE had full ROM with abduction to 180 degrees and forward flexion to 180 degree and internal/ external rotation with lesser pain than on the left; and no fatigue, weakness, or lack of endurance on the right.  The examiner documented right hand dominance with decreased strength in her left hand in comparison to her right; a right hand grip strength of 45 pounds and left hand grip strength of 30 pounds; and further stated that her grip was “good, but … seemed to be slightly stronger on the right side than the left side.”  There was radiographic evidence, dated 27 January 2006, that documented bilateral mid-clavicular deformities remotely healed with slight overriding.  

The Board directed its attention to its rating recommendation based on the above evidence.  The IPEB adjudicated “moderate weakness left upper extremity, status post motor vehicle accident with bilateral clavicle fractures (healed) and vascular injury (healed)” as unfitting, rated at 10% in accordance with VASRD and coded analogously as 5399- 5304 (muscle group IV [rotator cuff muscles]).  The VA rated 20 % for “residual weakness and limited motion, left clavicle fracture (claimed as clavicle fracture, left shoulder, and left arm condition)” coded analogously as 5299-5201 (arm, limitation of motion).  

The PEB combined “moderate weakness left upper extremity, status post motor vehicle accident with bilateral clavicle fractures (healed) and vascular injury (healed)” conditions under a single disability rating, coded analogously to 5399-5304.  Although VASRD §4.71a permits combined ratings of two or more joints, it allows separate ratings for separately compensable joints.  The Board must follow suit (IAW DoDI 6040.44) if the PEB combined adjudication is not compliant with the latter stipulation, provided that each “unbundled” condition can be reasonably justified as separately unfitting in order to remain eligible for rating.  If the members judge that separately ratable conditions are justified by performance based fitness criteria and indicated IAW VASRD §4.7 (higher of two evaluations), separate ratings are recommended; with the stipulation that the result may not be lower than the overall combined rating from the PEB.  The Board’s initial charge in this case was therefore directed at determining if the PEB’s combined adjudication was justified in lieu of separate ratings.  To that end, the evidence for the “moderate weakness left upper extremity, status post motor vehicle accident with bilateral clavicle fractures (healed) and vascular injury (healed)” conditions are presented separately; with attendant recommendations regarding separate unfitness, and separate rating if indicated.  

Left Upper Extremity Weakness, Left Clavicle Fracture.  The Board first considered if the left upper extremity weakness, left clavicle fracture and vascular injury, having been de-coupled from the combined PEB adjudication, was reasonably justified as separately unfitting.  The left upper extremity condition was profiled, implicated in the NARSUM and commander’s statement, and designated as failing to meet retention standards.  Members agreed that the functional limitations in evidence justified the conclusion that the condition was integral to the CI’s inability to perform her AFS and could be reasonably justified as separately unfitting and a separate rating is recommended.  

The Board then considered the rating recommendation.  Under the VASRD §4.56 (evaluation of muscle disabilities) the cardinal signs and symptoms of muscle disability are loss of power, weakness, lowered threshold of fatigue, fatigue-pain, impairment of coordination and uncertainty of movement.  There was service treatment record (STR) documentation of high energy trauma of scapulothoracic dissociation, bilateral clavicular fracture, and ischemic injury to the non-dominant LUE requiring intensive care hospitalization for a prolonged period.  The functional capacity evaluation documented objective findings of weakness, decreased grip strength, limited endurance and tolerance, and dyskinesia of the scapulothoracic region resulting in scapuloclavicular instability and a moderate level of functional impairment.  The commander’s statement, dated 25 August 2005, documented performance based functional impairment as a direct result of her injuries.  The chiropractic summaries documented residual weakness and poor stability of the LUE and shoulder girdle.  Both the NARSUM and the VA C&P documented decreased strength, painful motion and decreased ROM of the LUE.  The VA C&P examination documented notable LUE weakness and decreased ROM to the shoulder level as well as fatigue, weakness and lack of endurance with repetition.  The Board deliberated whether the positive evidence of impairment of strength and endurance and inability to keep up with work requirements supported a 20% rating under the VASRD muscle codes.  There was also documentation of decreased ROM to 90 degrees of flexion with pain to warrant a 20% rating coded as 5201 (arm limitation of motion, at shoulder level).  There was no path to a higher rating of the non-dominant LUE.  There was no evidence of additional functional limitation secondary to nerve involvement for additional rating under the VASRD nerve codes.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 20% coded analogously as 5399-5304 (Group IV, shoulder stabilization) for moderately severe disability.  

Right Clavicle Fracture.  The Board next considered if the right clavicle fracture, having been de-coupled from the combined PEB adjudication, was reasonably justified as separately unfitting.  Bilateral upper extremity pain secondary to bilateral clavicular fractures were identified and forwarded by the MEB.  The IPEB found the bilateral clavicular fractures as unfitting.  Although the initial profile was written for the left upper extremity, all profiles included no weapons bearing, lifting, carrying, climbing, push-ups, and reaching overhead and could have hidden limitations for the right upper extremity as well.  Both upper extremity conditions were implicated in the NARSUM and commander’s statement and designated as failing to meet retention standards.  Members agreed that the functional limitations in evidence justified the conclusion that the condition was integral to the CI’s inability to perform her AFS and could be reasonably justified as separately unfitting and a separate rating is recommended.  

The Board then considered the rating recommendation.  Throughout the STR there was documentation of chronic pain and inability to abduct and internally rotate the right shoulder due to shoulder pain.  The functional capacity evaluation noted bilateral shoulder dyskinesia and clavicular instability causing an internally rotated posture bilaterally; and the examiner concluded inability for the CI to perform frequent overhead shoulder maneuvers from bilateral shoulder girdle.  The VA C&P examinations documented painful shoulder motion bilaterally with abduction and radiographic evidence of bilateral mid-clavicular deformities.  The Board determined that there was sufficient evidence of clavicular instability and impairment from the fracture dislocation to warrant a 20% rating coded as 5203 (clavicle, impairment of: dislocation).  There was no evidence of addition functional limitation secondary to nerve involvement for additional rating under the VASRD nerve codes.  There was no evidence of limitation of motion of the arm for a higher rating under the 5201 code.  There was no evidence of severe muscle impairment of the dominant arm for a higher rating under the VASRD muscle codes.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 20% for the right clavicle condition.  

Vascular Injury.  The Board next considered if the vascular injury was by the preponderance of the evidence separately unfitting.  All evidence was reviewed and considered by the Board.  It was not judged to fail retention standards by the MEB and not implicated in the commander’s statement.  It was included in the PEB findings and designated as “healed.”  There was no performance based evidence from the record that the condition significantly interfered with satisfactory duty performance.  After due deliberation, in consideration of the preponderance of the evidence, the Board determined that the vascular injury could not be reasonably justified as separately unfitting and so no additional disability ratings are recommended.  

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 upper extremity condition, the Board unanimously agrees that it was unfitting and recommends a disability rating of 20%, coded 5399-5304 (Group IV, shoulder stabilization) IAW VASRD §4.56.  In the matter of the right clavicle condition the Board unanimously agrees that it was unfitting and recommends a disability rating of 20%, coded as 5203 (clavicle, impairment of: dislocation) IAW VASRD §4.71a.  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 her prior medical separation:  

CONDITION	VASRD CODE	RATING	
Left Upper Extremity Weakness, Left Clavicle Fracture Residuals	5399-5304	20%	
Right Clavicle Fracture Residuals	5203	20%	
COMBINED w/BLF	 40%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20131124, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

		
Dear XXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2013-01929.

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 your separation be re-characterized to reflect disability retirement, rather than 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 determined that your records should be corrected accordingly.  The office responsible for making the correction will inform you when your records have been changed.

As a result of the aforementioned correction, you are entitled by law to elect coverage under the Survivor Benefit Plan (SBP).  Upon receipt of this letter, you must contact the Air Force Personnel Center at (210) 565-2273 to make arrangements to obtain an SBP briefing prior to rendering an election.  If a valid election is not received within 30 days from the date of this letter, you will not be enrolled in the SBP program unless at the time of your separation, you were married or had an eligible dependent child, in such a case, failure to render an election will result in automatic enrollment.

Attachment:
Record of Proceedings 

cc:
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