RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01551
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20090226 

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Infantryman) medically separated for “muscle injury, Group II, left (non-dominant) pectoralis muscle,” rated 20%.  

CI CONTENTION:  The applicant makes no specific contention in his application.  His complete submission is at Exhibit A.

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 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 20081119	VA* - (~1 Mos. Pre-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Muscle Injury, Group II, Left (non-dominant) Pectoralis Muscle	5302	20%	Avulsion of the Left Pectoralis Major Muscle	5302	20%	20090213	
Other MEB/PEB Conditions x 1 (Not in Scope)	Other x 0 	
RATING:  20%	RATING:  20%	
*Derived from VA Rating Decision (VARD) dated 20090417 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY:  

Muscle Injury, Group II, Left (Non-Dominant) Pectoralis Muscle Condition.  The CI was right handed.  According to service treatment records and the MEB narrative summary (NARSUM), the CI’s left pectoralis muscle condition began in July 2005 when he tore his left pectoralis muscle doing weight lifting.  The CI had a prolonged and incomplete course of healing with chronic residuals that increased following deployment in 2006-7 and interfered with duty.  Radiographs in September 2008 documented a partial thickness pectoralis muscle tear which was clinically confirmed by orthopedic specialist evaluation.  The CI was not a surgical candidate.  

The MEB NARSUM exam on 21 October 2008 (4 months prior to separation) noted complaints of left chest muscle and shoulder pain.  The CI was generally pain free except for unpredictable flares with activity that occurred on average twice a day.  He reported lack of functional strength especially with pushing and overhead work.  

At the VA Compensation and Pension (C&P) exam on 13 February 2009 (less than a month before separation), the CI reported pain, decreased coordination, increased fatigability, weakness and uncertainty of movement.  The CI described that he could not use his left arm for lifting or some activities such as exercising or swimming.  The examiner confirmed that the CI was right handed.  Exam documented injury to Group 2 [Pectoralis Major (costosternal origin)] and Group 3 [Pectoralis Major (clavicular head)] muscles.  There was complete muscle herniation, with the left pectoralis muscle unattached at the tail, with muscle scarring and with contraction against strong resistance it formed “a bulky and ineffective muscle mass.”  There was no limitation of joint motion by muscle disease or injury.  

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB assigned a 20% rating under the 5302 code (muscle injury, Group 2), citing muscle atrophy and weakness and rated as moderate for two cardinal signs.  The VA also assigned a 20% rating using 5302 code, citing moderate muscle disability criteria.  The Board evaluated the CI’s muscle injuries IAW VASRD §4.55 (principles of combined ratings for muscle injuries) and §4.56 (evaluation of muscle disabilities) and considered that the VA-noted Group 2 and Group 3 muscle group injuries were in the same anatomic region and acted on the same joint.  Since the CI was right hand dominant, the muscle injury would have to reach the “severe” level, as a “moderately severe” rating would remain at the 20% rating level for the non-dominant side.  

There was not sufficient evidence to warrant a “moderately severe” (30%) IAW VASRD §4.56(d)(4) as there was no penetrating wound, extensive debridement, shattering of bone, prolonged hospitalization, radiographic evidence of retained fragments or explosive effect, or other §4.56 criteria supported.  

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 (non-dominate) pectoralis muscle injury 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.  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 (non-dominate) pectoralis muscle injury condition and IAW VASRD §4.73, the Board unanimously recommends no change in the PEB adjudication.  There were no other conditions within the Board’s scope of review for consideration.  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 20140312, 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 XXXXXXXXXXXXXXXXXX, AR20160003147 (PD201401551)

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:

Enclosure

CF: 
(  ) DoD PDBR
(  ) DVA