RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00017
BRANCH OF SERVICE:  AIR FORCE	BOARD DATE:  20150127
SEPARATION DATE:  20060606

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an Air National Guard E-5 (Air Transportation Journeyman) medically separated for right shoulder pain and a right upper arm nerve injury.  The condition could not be adequately rehabilitated to meet the requirements of his Air Force Specialty or physical fitness standards, so he was issued a temporary U4 profile and referred for a Medical Evaluation Board (MEB).  The shoulder and nerve conditions, characterized as “right shoulder pain; shoulder sprain superior glenoid, labrum lesion,” “right rotator cuff status-post surgical repair and revision,” and “musculocutaneous nerve palsy,” were forwarded to the Physical Evaluation Board (PEB) AFI 48-123.  No other conditions were submitted by the MEB.  The Informal PEB adjudicated “right shoulder pain” and “right musculocutaneous nerve injury” as unfitting, rated 10% and 10%, referencing the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The CI made no appeals and was medically separated.

CI CONTENTION:  “Deteriation [sic] of affeted [sic] areas and expansion of nerve palsey [sic] as rated by VA increased disability rating (by VA Drs) to 60% application filed thru VA office for disability rating increase to 100%.”

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 20060425	VA - (8 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Shoulder Pain	5399-5304	10%	Degenerative Joint Disease of the Right Shoulder	5304-5203	10%	20070205	
Right Musculocutaneous Nerve Injury	8722	10%	Right Musculocutaneous Neuropathy	8722	10%	20070205	
No Additional Conditions in Scope	No Other VA Conditions in Scope	
Combined:  20%	Combined:  20%	
Derived from VA Rating Decision (VARD) dated 20070526.

ANALYSIS SUMMARY:  The right shoulder and right upper extremity nerve condition were evaluated at the same exams and are discussed together below, with separate discussions for rating.  The right shoulder pain condition included the MEB diagnoses of shoulder sprain superior glenoid, labrum lesion and right rotator cuff status-post surgical repair and revision.

Right Shoulder Pain Condition.  The CI was right handed.  The narrative summary (NARSUM) noted the CI injured his right shoulder in July 2004.  Conservative therapy for shoulder pain failed, and in December 2004 he underwent right shoulder surgery (arthroscopy and acromioplasty) with a second operation in March 2005 to repair a labral tear, resect the distal clavicle and repair the rotator cuff.  Evaluation in June 2005 documented forward flexion of 0 degrees-90 degrees (normal 180 degrees) and abduction of 0 degrees-80 degrees (normal 180 degrees) with internal and external rotations of 45 degrees.  The CI had continued complaints of “musculocutaneous nerve distribution pain along the biceps region.”  Evaluation in August 2005 by Pain Management Consultant noted complaints of shoulder pain radiating down towards the elbow and “… In the past he has had symptoms into the hand including numbness and weakness but those are not currently major complaints.”  History indicated cortisone injections provided only temporary relief.  Exam documented allodynia (pain from usually non-painful stimuli - usually light touch) with evidence for nerve pain (sympatherically maintained component to pain).  The specialist performed two nerve blocks (stellate ganglion sympathetic blockade in August and on 7 September 2005) providing temporary relief.  NARSUM and exam on 25 September 2005 demonstrated shoulder forward flexion 0 degrees-150 degrees (normal 180 degrees) and abduction 0 degrees-120 degrees (normal 180 degrees) with weakness (4/5).  The NARSUM dated 25 February 2005 (4 months prior to separation) by the same physician, indicated a history of shoulder range-of-motion (ROM) “improved to forward flexion 90, abduction 80, internal rotation 45, external rotation 45.”  Physical exam specified “Limited range of motion in the upper extremities” with no measurements listed.  Diagnoses were as listed on the MEB as stated above.

At the VA Compensation and Pension exam performed 8 months after separation, the CI reported problems with the right shoulder, arm and hand including right arm numbness.  He reported missing work as a driver over 3-4 days a week due to pain in his right arm and an inability to drive big trucks.  He reported getting tremors of his right arm and hand since surgery, had weakness, stiffness and occasional hand swelling.  He complained of a snapping noise at the shoulder, but no locking.  He described fatigability and lack of endurance, with 2-4 flare-ups a week.  Exam documented right shoulder flexion limited to 100 degrees and abduction to 60 degrees (normal 180 degrees) with pain.  The examiner stated “actually it was all passive; he was using other arm to raise it. … Repetitive use was not tried because the veteran was in extreme pain to start with.  Actually he also had weakness, so repetitive use was not tried.”  He had problems making a grip and writing and problems with dexterity because of the right hand.  Right upper extremity strength “was about 3 to 4/5, and it is mostly because of pain and weakness of the arm that his muscle strength is decreased.  I do not think it is a neurological problem.”  Reflexes were 1+ on the right 2+ on the left upper extremity.  The examiner indicated the CI “seemed to have loss of sensation in the musculocutaneous nerve distribution.  … EMG shows evidence of right sided musculocutaneous neuropathy.”  VA exam in April 2008 documented increased neurologic symptoms, similar ROMs and a new finding of deltoid muscle atrophy.  The VA increased their shoulder and nerve ratings to 20% each (5201 at 20%; 8517 at 20%), effective January 2008 based on this exam.  More remote VA exams in 2010 and 2013 led to an increase in 5201 (shoulder) rating to 30% as well as addition of other right upper extremity ratings.

The Board directed attention to its rating recommendation based on the above evidence.  Regarding the shoulder condition – The PEB coded the shoulder condition analogous to muscle code 5304 at 10% (Group IV as moderate) and the VA 10% rating was coded 5304 analogous to 5203 (Clavicle or scapula, impairment of:  Malunion or Nonunion Without loose movement).  (NOTE:  Later VARDs used code 5201).  The shoulder injury to the rotator cuff and acromioclavicular joint did not lend itself to rating under §4.73 (Schedule of Ratings–Muscle Injuries) as there was no specific injury to the muscles and little alignment to the criteria of VASRD §4.55 (Principles of combined ratings for muscle injuries) or §4.56 (Evaluation of muscle disabilities).  The two shoulder surgeries and resultant pain limited motion was best aligned with coding under VASRD §4.71a (Schedule of ratings–musculoskeletal system) that includes joints, bones, tendons and connecting tissues.  The Board considered if rating above 10% were justified under alternative coding of 5203 (similar to the VA), 5024 (tenosynovitis), or 5201 (Arm, limitation of motion).  There was no loose movement of the shoulder for higher rating under 5203.  However, the right arm had limitation of abduction to no higher than shoulder level (90 degrees) on the June 2005 NARSUM, possibly at the February 2006 NARSUM (dates unclear), and at the initial VA exam.  The initial VA exam also documented that ROMs were passive as the CI used his opposite arm to assist ROM to 60 degrees of abduction with weakness noted.  Weakness and limitations in lifting and use of the arm overhead was also considered in rating the shoulder IAW VASRD §4.40 (functional loss).  The remote VA exams documenting deltoid muscle atrophy was considered post-separation worsening.

Considering the totality of the record and right (dominate) arm limitations, the CI’s disability picture was closest to that of code 5201 at 20% for limitation at shoulder level.  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 5203-5201) for the right shoulder condition.

Right Musculocutaneous Nerve Injury of the Right Arm.  Both the PEB and VA rated the peripheral nerve condition using code 8722 at 10% (Neuralgia of the musculocutaneous nerve; “moderate”).  However, VASRD code 8722 refers to the “musculocutaneous nerve (superficial peroneal)” in the lower leg rather than the musculocutaneous nerve in the upper extremity – code 8717.  Later VA ratings corrected the nerve code to 8517 for partial paralysis of the musculocutaneous nerve in the upper extremity.  Rating under a more central nerve (radiculal groups – 8710, 8711, or 8713) was considered; however, the nerve was identified as the musculocutaneous nerve by providers and objective testing (EMG).

IAW §4.124a (Schedule of Ratings–Neurological Conditions) and §4.124 (Neuralgia) or §4.123 (Neuritis – without organic changes) the maximum rating is equal to moderate incomplete paralysis.  That would remain at no higher than 10% coded under either 8617 (Neuritis) or 8717 (Neuralgia).  There was no evidence of organic changes proximal to separation for a higher neuritis rating.  The Board next considered if there was sufficient evidence of weakness for analogous coding to incomplete or partial paralysis of the right upper extremity musculocutaneous nerve.  Weakness (for rating paralysis) was attributed by examiners as predominately due to pain rather than partial paralysis.  At the time of separation, there was insufficient evidence of a “severe” peripheral nerve deficit or weakness to support a rating higher than 10%.
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 10% adjudication for the right musculocutaneous nerve injury condition, but that coding should be corrected to 8717 for the correct nerve.

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 shoulder condition, the Board unanimously recommends a disability rating of 20%, coded 5203-5201 IAW VASRD §4.71a.  In the matter of the right musculocutaneous nerve condition and IAW VASRD §4.124a, the Board unanimously recommends no change in the PEB 10% adjudication, but a change of coding to 8717.  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 his prior medical separation:

UNFITTING CONDITION	VASRD CODE	RATING	
Right Shoulder Pain	5203-5201	20%	
Right Musculocutaneous Nerve Injury	8717	10%	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20131213, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

		
XXXXXXXXXXXXXXXXXXXX
President
DoD Physical Disability Board of Review

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

Dear XXXXXXXXXXXXXXXXXXXX:

	Reference your application submitted under the provisions of DoDI 6040.44 (Title 10 U.S.C. § 1554a), PDBR Case Number PD-2014-00017.

	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.  

							Sincerely,

XXXXXXXXXXXXXXXXXXXX
Director
Air Force Review Boards Agency

Attachment:
Record of Proceedings

cc:
SAF/MRBR