RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2014-00157
BRANCH OF SERVICE:  Army	BOARD DATE:  20141114
SEPARATION DATE:  20060706

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SSG/E-6 (97E30/Human Intelligence Collector) medically separated for chest and wrist pain.  The conditions could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty or satisfy physical fitness standards.  He was issued a permanent P3/L3 profile and referred for a Medical Evaluation Board (MEB).  The chest pain and scaphoid conditions, characterized as “chest pain status post pectus excavatum repair” and “left wrist pain with decreased ROM status post ORIF”, were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other conditions were submitted by the MEB.  The Informal PEB adjudicated “chronic chest pain following surgical correction of pectus excavatum, existed prior to service (EPTS)” and “scaphoid fracture (left) sustained in a fall down stairs, status post open reduction with internal fixation” as unfitting, rated 10% each (combined 20%) with likely application of US Army Physical Disability Agency (USAPDA) pain policy.  The CI made no appeals and was medically separated.

CI CONTENTION:  “I feel the PEB severely undervalued the disability percentage, and did not take into account other permanent disabilities.”  

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 those conditions identified but not determined to be unfitting by the PEB when specifically requested by the CI.  The ratings for the unfitting chest pain and scaphoid conditions are addressed below; no additional conditions are within the DoDI 6040.44 defined purview of the Board.  Any conditions or contention not requested in this application, or otherwise outside the Board’s defined scope of review, remain eligible for future consideration by the Board for Correction of Military Records.  

RATING COMPARISON:  

Service IPEB – Dated 20050605	VA - (4 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Chest Pain following Surgical Correction of Pectus Excavation, Existed Prior to Service (EPTS) 	5009-5003	10%	Chronic Costochondritis, Status Post Repair of Pectus Excavatum	7899-7804	10%	20061030	
Scaphoid Fracture (left) [After fall, ORIF]	5099-5003	10%	Status Post Fracture of Left Scaphoid Bone Fracture	5215	10%	20061113	
Other x 0 (Not in Scope)	Combined:  40%	
Combined/Rating:  20%		
Derived from VA Rating Decision (VARD) dated 20070409 (most proximate to date of separation)

ANALYSIS SUMMARY:  

Chronic Chest Pain following Surgical Correction of Pectus Excavation Condition.  The service treatment record (STR) indicated the presence of pectus excavatum (abnormal development of the rib cage where the breastbone [sternum] caves in, resulting in a sunken chest wall deformity), on the CI’s enlistment physical dated 30 August 1994.  He had complaint of increasing chest pain in 2004 and during a pre-deployment physical evaluation to Korea in November 2004.  The CI had consultation for internal medicine and orthopedics because of the pectus excavatum and underwent corrective surgery with placement of chest strut-bar in March 2005.  Following extended convalescent leave, he was returned to light duty.  In August 2005, the CI after experiencing increasing pain, the chest strut-bar was surgical removal in December 2005 (9 months after placement); however the surgery did not resolve the chest pain.  The CI was informed that further surgeries were not an option and that he would continue to have lifelong pain.  A permanent physical profile (written 3 months prior to separation) was issued for the both pectus excavatum condition and wrist condition, with restrictions to limited walking/ biking/ swimming and lifting less than 10 pounds.  At that time the CI was referred for an MEB.  

Three months prior to separation, the commander noted an increased in the CI’s pain after his second surgery and that the CI was controlling the pain by taking several medications to perform daily activities.  Physical therapy for a separate back condition (following a twisting injury in 1997) had been ongoing, but was on hold due to inability to perform the exercises as a result of the chest.  

In a primary care examination (6 months prior to separation), the CI had normal gait, normal respiratory pattern, marked pectus excavatum of the chest and a large well-healed transverse incision that was tender to palpation (TTP).  In a cardiothoracic consultation (approximately 5 months prior to separation), the CI reported that the pain was throbbing in nature, present all the time and worse with certain postures, movements or sitting straight.  He stated that he only able to sleep 3 hours at time and that his sleep is disturbed by pain, therefore he’s awakening to take his meds and/or to stretch.  The CI was in no apparent distress and the examiner noted a healed incision with tenderness with pressure on the sternum.  The diagnosis was, “chronic post-surgical chest pain, severe, constant.”  In a pain management note (approximately 4 months prior to separation), the CI had normal lumbar range-of-motion (ROM).  At the MEB examination (2 months prior to separation), the examiner noted that the CI had well-healed surgical scars and of the pectus deformity were TTP, chest pain with any arm movement against resistance and minimal loss of ROM.  The DD Form 2808 physical documented normal lung exam.  

VA Compensation and Pension (C&P) exams performed (4 months after separation), documented the CI’s history similar to the service history.  The CI’s complaints were chronic chest discomfort especially with turning and occasional abdominal discomfort.  Exam documented chest scars that were without tenderness, skin breakdown, inflammation, or underlying tissue loss.  Back exam noted normal gait with a slight hump in the mid-back area (rigid kyphosis).  Lung exam was normal and the diagnosis was “post repair of pectus excavatum… Currently he has chronic costochondritis”.

The Board directs attention to its rating recommendation based on the above evidence.  The CI was consistently described as having severe pain, although the exam showed only tenderness to palpation.  There was no significant respiratory or pulmonary deficit documented.  The PEB rated the condition at 10% with an orthopedic code (5099-5003) while the VA rated it at 10% using a code for scars (7899-7804).  The PEB disability description stated “rated for pain, slight/constant,” indicating likely use of the USAPDA pain policy.  Both 10% ratings appeared to be correct for the codes used.  The Board considered whether a more appropriate code, allowing for a higher rating IAW VASRD §4.7 would be 5321 (Muscle Group XXI, Muscles of Respiration:  Thoracic Muscle Group).  The CI’s pain appeared to be more widespread and more severe than that generally attributed to a simple scar and muscle coding might better reflect the entire scope of the CI’s disability.  The rating criteria for muscle disabilities is detailed under §4.56, evaluation of muscle disabilities.  Rating the condition as “moderate” would result in a 10% rating, no different from the ratings posted by the PEB and VA, so the Board considered whether the condition could be rated as “moderately severe” at 20%.  

Muscle ratings rely on the type of injury; history and complaint and objective findings.  The only muscle injury was the surgical wound, there was no prolonged hospitalization or debridement, and there was no documented intermuscular scarring.  History and complaint focused on pain relief and profile restriction that may have indicated inability to keep up with work requirements.  The objective findings were tenderness, a well healed tender scar and complaint of increased chest pain with arm movement against resistance.  There was no documented respiratory impairment from the chest condition.  

The Board therefore adjudged that the muscle disability was best described as “moderate” at 10%.  Although muscle coding would be an optional alternative coding, the PEB coding of 5099 5003 (as analogous to painful motion in the sternum to rib joints) or the VA coding for painful scar (with costochondritis) likewise warranted a 10% rating IAW VASRD-only criteria.  There was therefore no benefit to the CI for changing the rating coding.  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 chest condition.  

Left Wrist Condition.  The CI was right hand dominant.  The STR noted that the CI fell down a flight of stairs in September 1999, sustaining a fracture of the left wrist (scaphoid).  He underwent surgery (ORIF and bone graft).  He had persistent decreased ROM despite therapy and two additional surgeries (debridement in September 2001 and hardware removal in 2002).  During the 5 years prior to separation, the CI noted increasing pain, stiffness, decreased ROM and increasing difficulty performing required duties.  At the MEB examination (2 months prior to separation), the CI had active dorsiflexion 35 degrees (normal 70 degrees) and palmar flexion 40 degrees (normal 80 degrees) with pronation and supination each to 90 degrees (above normal VASRD limits).  Passive ROMs were greater than active ROMs.  The NARSUM summarized prior orthopedic exams which indicated a positive carpal compression test (for possible nerve impingement) and painful motion.  Radiographs showed no acute bony abnormality, with “ulnar position of the carpus with respect to the distal forearm may be secondary to surgical removal of the more distal and radial portion of the scaphoid”.

At the VA C&P exam (performed 4 months post-separation), the history included intermittent use of a wrist brace, pain and vague dysthesias (unusual sensations) of the hand with stiffness and weakness.  Exam documented dorsiflexion to 35 degrees (normal 70 degrees), palmar flexion to 40 degrees (normal 80 degrees), radial deviation to 15 degrees (normal 20 degrees), and ulnar deviation to 40 degrees (normal 45 degrees), without any additional limitation with repetitive use.  Motor exam documented dorsiflexion and (palmar) flexion as 4+ out of 5 (indicating slight weakness).  The VARD assigned an evaluation of 10% “for chronic pain, decreased range of motion, decreased strength and compromised hand function with evidence of degenerative changes”.  

The Board directs attention to its rating recommendation based on the above evidence.  The PEB rated the wrist condition at 10% as scaphoid fracture (left) (code 5099-5003), analogous to degenerative arthritis with some loss of joint motion.  The VA rated the condition at 10% with code 5215 (wrist, limitation of motion of).  Although the PEB and VA used different codes, they described similar levels of disability and the disability rating cannot be increased without evidence of further loss of motion or ankylosis (no movement) of the joint (codes 5213, 5214, or 5215).  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.  As discussed above, PEB reliance on the USAPDA pain policy for rating the chest condition was operant in this case and the condition was adjudicated independently of that policy by the Board.  In the matter of the chest condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the 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 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 20131230, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

		
XXXXXXXXXXXXXXX
President
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, AR20150003758 (PD201400157)

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