RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2014-00105
BRANCH OF SERVICE:  Army	BOARD DATE:  20141230
SEPARATION DATE:  20060716

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an activated Reserve E-6 (Petroleum Supply Specialist) medically separated for lymphedema, left upper extremity.  The condition could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty (MOS).  She was issued a permanent P3/U3 profile and referred for a Medical Evaluation Board (MEB).  The lymphedema condition, characterized as “lymphedema upper extremity” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded five other conditions for PEB adjudication.  The Informal PEB adjudicated “lymphedema left upper extremity” as unfitting, rated 20% with likely application of the VA Schedule for Rating Disabilities (VASRD), quoting the 8-year rule.  The remaining conditions were determined to be not unfitting.  The CI made no appeals and was medically separated.

CI CONTENTION:  “1.) Lymphedema, left arm – 20% 2.) Patellofemoral syndrome, Right knee Patellofemoral syndrome, Left knee – 10%/10% w degenerative changes – 10% 3.) Chronic patellofemoral syndrome, bilateral – 0% Tinea Pedis – 0% Sinusitis – 0% Endometriosis – 0% The evidence does not show a current diagnosed disability.  Vein that’s not completely open in neck – open July 18, 2012 Breast cancer (mascectomy).”

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 Admin Correction PEB – Dated 20060613	VA - (4 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Lymphedema Left Upper Extremity	7199-7120	20%	Lymphedema, Left Arm S/P Mastectomy w/ Lymph Node Dissection	7199-7121	20%	20061107	
Breast Cancer	Not Unfitting	Cancer of Breast, S/P Left Mastectomy	7627	NSC	19940808	
Patellofemoral Syndrome	Not Unfitting	Chronic Patellofemoral Syndrome, Bilateral*	5257	0%	20061107	
		Chronic Patellofemoral Syndrome, Right Knee	5260	0%	20061107	
Hypertension	Not Unfitting	Hypertension	7101	NSC	20061107	
Tinnitus w/ High Frequency Hearing Loss	Not Unfitting	Bilateral Tinnitus	6260	NSC	20061114	
		Bilateral Hearing Loss	6100	NSC	20061114	
Bilateral Knee Osteoarthritis	Not Unfitting	Patellofemoral Syndrome, Left Knee with Degenerative Changes (Claimed as Osteoarthritis/Degenerative Arthritis)	5260-5010	10%	20061107	
Other x 0  (Not in Scope)	Other x 3 	20061107	
Combined:  20%	Combined:  40%	
Derived from VA Rating Decision (VARD) dated 20070327 (most proximate to date of separation [DOS]).   
* Chronic Patellofemoral Syndrome, Bilateral granted 0% from 1994.  Discontinued by the VA when CI went back to an active duty status.

ANALYSIS SUMMARY:

Lymphedema Left Upper Extremity:  Treatment records recorded the CI reported persistent swelling of the left arm following surgery for breast cancer in 2001.  The condition was diagnosed as lymphedema and treated with a compression sleeve.  Treatment records were scare; however, available records noted the CI reported pain and swelling that increased in frequency over time, without evidence of decrease in range-of-motion (ROM) or motor strength.  The CI had reported numbness and tingling of the left extremity which led to further investigation.  She underwent motor and sensory nerve conduction studies which were normal.  Treatment entry dated 21 January 2005 recorded the CI reported increased flare-ups over the past month with episodes of intense pain described as 9/10.  Examination of the left arm noted mild diffuse swelling, full ROM, and normal muscle strength.  At the lymphedema evaluation on 7 November 2005, the CI noted a 10-year past history of breast cancer and absence of lymphedema treatment.  She indicated during her deployment to Iraq, her duties included lifting hoses to refuel aircraft, and carrying a pack and weapon.  These activities caused pain and swelling of the left upper extremity.  The examiner noted mild fibrosis of left upper extremity, and noted she had good rehabilitation potential provided she was compliant with the proposed treatment plan.  At the MEB/narrative summary evaluation on 23 March 2006, 4 months prior to separation, the CI reported she began having problems with her left arm and swelling with pain about 3 months into her tour.  She noted increased swelling that had not resolved with rest and the associated pain had persisted.  She was unable to meet the requirements of her MOS and was placed on a profile that limited lifting; however, she was able to complete her deployment.  Physical examination of the upper left extremity recorded the presence of edema from the axilla to the hand.  The CI wore a compression garment on the left arm.  The physician noted the CI had received treatment with the lymphedema clinic and her condition limited lifting, and required the use of compression garments and daily pain medication.  Her prognosis was recorded as good. At the VA Compensation and Pension examination dated 7 November 2006, 4 months after separation, the CI noted pain level of 7/10 and the pain was constant.  She received some benefit from the use of the arm sleeve.  Physical examination recorded mildly swollen left arm in a diffuse distribution.  There was no evidence of inflammation or infection.
The Board directed attention to its rating recommendation based on the above evidence.  The PEB and VA both rated the condition 20% using similar codes.  The PEB coded the condition analogously to 7120. The higher rating of 40% requires persistent edema and stasis pigmentation or eczema, with or without intermittent ulceration.  The Board adjudged that the record sufficiently documented clear evidence for the rating of 20%; however, the Board was unable to find documentation of changes in skin coloration or eczematous changes in the record in evidence to support the higher rating of 40%.  The Board was unable to find a pathway to a higher rating using any other applicable VASRD code.  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 upper extremity condition.

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the breast cancer, bilateral patellofemoral syndrome, hypertension, tinnitus and right high frequency hearing loss, and bilateral knee osteoarthritis conditions were not unfitting.  The Board’s threshold for countering fitness determinations is higher than the VASRD §4.3 (reasonable doubt) standard used for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  The above recorded conditions were not profiled; however, the Board acknowledged the P2 profile for knee pain that restricted running, jumping and marching.  There was not a preponderance of evidence to support that the knee condition was unfitting.   None of the above contended conditions were implicated in the commander’s statement or were judged to fail retention standards.  All were reviewed by the action officer and considered by the Board.  There was no performance based evidence from the record that any of these conditions significantly interfered with satisfactory duty performance.  After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the any of the contended conditions 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 lymphedema left upper extremity condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended breast cancer, bilateral patellofemoral syndrome, hypertension, tinnitus and right high frequency hearing loss, and bilateral knee osteoarthritis conditions, the Board unanimously recommends no change from the PEB determinations as not unfitting.  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 20131226, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

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, AR20150007640 (PD201400105)

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			    
						         
CF: 
(  ) DoD PDBR
(  ) DVA