RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01588
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20091220

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E3, Health Care Specialist Trainee, medically separated for “all radicular groups injury, right (dominant)” with a disability rating of 20%.

CI CONTENTION:  He was given a higher rating for his condition by the VA.  His complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44.  It is limited to those conditions determined by the Physical Evaluation Board (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 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 PEB - 20091106	VARD - 20131028	
Condition	Code	Rating	Condition	Code	Rating	Exam	
All Radicular Groups Injury, Right (Dominant)	8513	20%	Spinal Root Nerve Brachial Plexus Injury with Right Hand Numbness (Dominant)	8513	40%	20130913	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

All Radicular Groups Injury, Right (Dominant).  

The service treatment record and Medical Evaluation Board (MEB) narrative summary (NARSUM) documented a “ruck sack” injury of the right shoulder in March 2009 (1 month after entry) that resulted in decreased movement of his right arm.  At an orthopedic consultation in March 2009 (9 months pre-separation), the examiner documented inability to initiate or maintain shoulder abduction, forward flexion, and external rotation.  There was weakness (4/5) of the posterior shoulder (subscapularis m.) without winging.  There was 5/5 motor strength of the upper arm (biceps, triceps), wrist, hand and finger muscles.  There was normal, full passive range of motion (ROM) of the shoulder.  There was normal and symmetric sensation of the arm and hands (axillary, radial, ulnar and median nerve distributions, and in the C5-C8 dermatomes).  The examiner diagnosed a focal motor paralysis of the shoulder muscles (deltoid, infraspinatus, and supraspinatus).  Electro-physiologic studies performed a week later documented no evidence of cervical radiculopathy (pain with loss of sensation).  However, there was evidence of a right median neuropathy (affecting C5-T1); and evidence of “amyotrophy” that resulted in shoulder muscle weakness and wasting (by affecting C5-C6 of the brachial plexus, with active denervation in the deltoid, supraspinatus, and flexor policis longus [without] re-innervation).  Electro-physiologic studies in August 2009 (4 months pre-separation) documented “slight interval improvement.”  There was persistent evidence of right neuralgic amyotrophy (muscle weakness and wasting) with improved innervation and an unchanged median neuropathy [C5-T1].  At a physical therapy visit in August 2009 (4 months pre-separation), the examiner documented forward flexion to 170 degrees (normal 180) and abduction to 155 degrees (normal 180).  On the MEB DD Form 2697, Report of Medical Assessment, dated 22 September 2009 (3 months pre-separation), the CI reported trouble lifting, performing pushups and carrying a ruck sack due to his brachial plexus injury.  

The MEB NARSUM examination was performed on 29 September 2009 (3 months pre-separation).  The CI reported constant dull neck and shoulder pain that occasionally radiated to the 4th and 5th digits.  Flare-ups occurred five to six times per day, and lasted only seconds.  There was arm weakness with inability to lift any weight more than 90 degrees.  He reported that the fingers were usually held in a curled position, he had difficulty cleaning and reaching, and that numbness caused difficulty with fine or coordinated movements of the hand such as typing.  The examiner documented pain with shoulder abduction, forward flexion and lifting above 90 degrees, with no tenderness or muscle spasms.  The CI was able to perform abduction to 120 degrees, forward flexion to 135 degrees, internal and external rotation to 85 degrees each (compared to 90 degrees on the normal left side).  On the MEB DD Form 2808, Report of Medical Examination, the examiner documented decreased active ROM, with full passive ROM of the right shoulder, pain when lifting greater than 90 degrees, and decreased sensation to light touch in the 4th and 5th fingers.  On the MEB DD Form 2807-1, Report of Medical History, dated 7 October 2009 (2 months pre-separation), the CI reported shoulder and neck pain, right hand paresthesia and numbness, and impairment of the right arm.  

There were no VA Compensation and Pension (C&P) examinations in evidence before 2013.  At the VA C&P examination performed on 13 September 2013 (4 years post-separation), the CI reported numbness of the right hand, limited mobility, and weakness that caused him to drop objects.  The CI reported flares that occurred 20-30 times per year (that lasted weeks to months) and caused inability to type, use the hand, or move the fingers due to swelling.  The examiner documented decreased 4/5 strength of elbow and wrist flexion and extension, grip, and pinch; and no muscle atrophy.  Right shoulder flexion and abduction were to 120 degrees each with pain; and were unable to be repeated due to numbness and tingling.  Reflexes of the right upper extremity were decreased compared to the left.  Sensation in the C5-C8 distribution was normal.  The examiner diagnosed a moderate, incomplete paralysis of the entire arm (radial, median, ulnar, musculocutaneous, circumflex, and long thoracic nerves, and upper, middle and lower radicular groups).  

The Board directed attention to the rating recommendation based on the above evidence.  The PEB rated the “all radicular groups injury, right (dominant)” at 20%, coded 8513 (all radicular groups) citing “essentially intact sensation” except in the 4th and 5th digits and 4/5 weakness of the triceps and biceps only.  A disability claim was made 4 years later, at which time the VA coded similarly and rated 40% citing moderate incomplete paralysis of the major extremity, based on the VA C&P examination dated 13 September 2013.  

IAW VASRD §4.124a, Diseases Of The Peripheral Nerves, the term “incomplete paralysis” with this and other peripheral nerve injuries indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve.   It further states that “when the involvement is wholly sensory, the rating should be for mild, or at most, the moderate degree.”  A “moderate” degree of impairment for the dominant major extremity would confer a 40% rating, while “mild” would be rated 20%.  Member consensus was that a fair threshold for the ‘moderate’ rating should entail functionally significant motor and/or sensory impairment encroaching on some occupational tasks.  

Upon initial evaluation, the CI could not initiate or maintain any shoulder movements, with normal movement at the elbow, lower arm, wrist, hand, and fingers with normal sensation throughout.  At the time of the second electro-physiologic study, there was still evidence of brachial plexus injury and amyotrophy (muscle weakness).  Physical therapy ROMs at 4 months pre-separation, were documented to be near normal for flexion and abduction.  At the time of the NARSUM, 3 months pre-separation, the examiner had documented decreased active ROM (indicative of muscle weakness) with greater decreases in ROMs compared to the prior physical therapy examination but still in the functional range.  

Although the VA C&P examination was 4 years after separation, there was documentation of similar examination and ROM findings with weakness and inability to perform repetitive motions that resulted in a “moderate, incomplete paralysis” description and a 40% rating from the VA.  In consideration of these factors and the severity of symptoms and disability in evidence, members agreed that the “incomplete moderate” 40% rating for the dominant extremity offered by 8513 (all radicular groups) code should be recommended.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 40% for the radicular nerve condition, coded 8513.    

BOARD FINDINGS:  In the matter of the radicular nerve condition, condition, the Board majority recommends a disability rating of 40%, coded 8513 IAW VASRD §4.124a.  The single voter for dissent recommended no change and did not elect to submit a minority opinion.  There were no other conditions within the Board’s scope of review for consideration.  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 the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
All Radicular Groups Injury, Right (Dominant)	8513	40%	
COMBINED	40%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140309, 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

17 AUG 2016

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation
for XXXXXXXXXXXXXXXXXX, AR20160007460 (PD201401588)

1. Under the authority of Title 10, United States Code, section 1554(a), I approve the enclosed recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) pertaining to the individual named in the subject line above to recharacterize the individual’s separation as a permanent disability retirement with the combined disability rating of 40% effective the date of the individual’s original medical separation for disability with severance pay.

2. I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum: 

a. Providing a correction to the individual’s separation document showing that the individual was separated by reason of permanent disability retirement effective the date of the original medical separation for disability with severance pay.

b. Providing orders showing that the individual was retired with permanent disability effective the date of the original medical separation for disability with severance pay.

c. Adjusting pay and allowances accordingly. Pay and allowance adjustment will account for recoupment of severance pay, and payment of permanent retired pay at 40% effective the date of the original medical separation for disability with severance pay.

d. Affording the individual the opportunity to elect Survivor Benefit Plan (SBP) and medical TRICARE retiree options.

3. I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures.

BY ORDER OF THE SECRETARY OF THE ARMY:
Enclosure
CF:
( ) DoD PDBR
( ) DVA