RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2014-02096
BRANCH OF SERVICE:  Army	BOARD DATE:  20150220
SEPARATION DATE:  20050929

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an activated National Guard E-4 (AH-64 Attack Helicopter Repairer) medically separated for left shoulder and chest pain.  The left shoulder and chest pain condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty.  He was issued a permanent U3 profile and referred for a Medical Evaluation Board (MEB).  The left shoulder and chest condition, characterized as “nonspecific left anterior chest and shoulder pain,” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded two other conditions that met retention standards (benign paroxysmal positional vertigo and subjective tinnitus) for PEB adjudication.  The Informal PEB adjudicated “chronic left shoulder and anterior chest pain” as unfitting, rated 0%, referencing the US Army Physical Disability Agency (USAPDA) pain policy.  The remaining conditions were determined to be not unfitting.  The CI made no appeals and was medically separated.

CI CONTENTION:  “Please consider all conditions.”

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 IPEB – Dated 20061219	VA - (7 days Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Left Shoulder and Anterior Chest Pain	5099-5003	0%	Thoracic Outlet Syndrome Involving the Left Arm	8513	30%	20070131	
Benign Paroxysmal Positional Vertigo	Not Unfitting	Vertigo	6204	NSC	STR	
Tinnitus	Not Unfitting	Bilateral Hearing Loss 	6100	NSC	STR	
Other x 0  (Not in Scope)	Other x 6	STR	
Combined:  0%	Combined:  40%	
Derived from VA Rating Decision (VARD) dated 20070402 (most proximate to date of separation [DOS]).
ANALYSIS SUMMARY:

Left Shoulder and Chest Pain Condition.  While performing heavy lifting in September 2005, the right-handed CI injured his left shoulder, which led to complaints of chronic shoulder pain.  Left shoulder arthrography and magnetic resonance imaging (MRI) of the left shoulder were normal.  A neurologic physical examination in January 2006 reported findings suggestive of thoracic outlet syndrome (upper extremity symptoms from neurovascular compression due to an abnormally narrowed chest outlet).  Electrodiagnostic testing of the left arm and left neck muscles was normal.  A VA Compensation and Pension (C&P) evaluation on 23 January 2006 (12 months prior to separation) reported that the pain was in the anterior shoulder, was mostly related to activity and caused him to avoid heavy lifting or overhead work.  Because the CI reported loss of feeling in the fingers of the left hand during abduction of the shoulder, the examiner rendered a diagnosis of thoracic outlet syndrome.

A vascular surgery evaluation on 20 June 2006 (7 months prior to separation) reported the pain was constant, but worsened if the shoulder was in certain positions.  The CI also complained of numbness and a heavy sensation in the left hand, which was constant and worsened with an overhead position.  Physical examination noted pain with rotation of the left shoulder.  However, examination maneuvers were not consistent with a diagnosis of thoracic outlet syndrome, and the examiner concluded that “The (CI) does not have Thoracic Outlet Syndrome.”

An orthopedic evaluation on 21 June 2006 (7 months prior to separation) confirmed that left shoulder and chest pain persisted since the initial date of injury, and that episodic hand numbness and tingling occurred.  Physical examination noted no shoulder tenderness and no sign of shoulder instability or rotator cuff impingement.  “Cogwheel weakness” of the left upper extremity was reported, but muscle strength appeared to be normal.  Left shoulder range-of-motion (ROM) was considered to be “full” compared to the other side.  The examiner’s diagnosis was “nonspecific left anterior chest and shoulder pain, not orthopedic in nature.”  At the MEB exam on 22 August 2006, the CI reported pain in the shoulder, arm and hand; and numbness and tingling in the hand and fingers 3-4 times per day.

At a physical medicine evaluation on 26 September 2006 (4 months prior to separation) the CI complained of left shoulder pain radiating to the arm, strength loss, numbness and “discoloration at times.”  Physical exam noted mild weakness of left hand grip strength and wrist extension.  Sensation was intact except for mild impairment in fingertips.  Electrodiagnostic testing was suspicious for a minor left C6-7 radiculopathy, but an MRI the following day found no evidence of C6-7 nerve root impingement.

A physical therapy (PT) evaluation on 27 September 2006 observed limitation of active ROM (see chart below).  When asked why he could not fully flex or abduct the shoulder, the CI indicated that the shoulder “won’t go any higher.” However, the examination reported normal passive ROM and normal active rotation.  The examiner concluded that the ROM limitations did not appear to be due to pain or mechanical factors.

At the narrative summary (NARSUM) evaluation on 28 September 2006 the CI reported frequent, intermittent, sharp episodes of left shoulder and upper left anterior chest wall pain that radiated down the left upper extremity to the fingers.  Aggravating factors included sit-ups, push-ups, repetitive use of left arm, overhead weight bearing, or lifting greater than 10 pounds.  The examiner rendered a diagnosis of non-specific left anterior chest and shoulder pain.

A VA PT note on 21 November 2006 (2 months prior to separation) reported that the CI was complaining of chest, left shoulder and left neck pain.  Simple activities such as driving or folding laundry caused severe pain.  Examination showed the left arm to be held in a dependent position, with guarding and avoiding movement.  Active elevation of the shoulder of approximately 80 degrees was attained.  Moderate atrophy of the left upper trapezius muscle was noted, along with weakness and winging of the scapula (abnormal protrusion of the shoulder blade due to nerve injury).

At the VA C&P exam performed on 31 January 2007 (a week after separation), the CI reported that pain involved the entire left upper extremity, shoulder girdle and area of the head and neck behind the ear.  He complained of worsening left upper extremity pain as well as numbness from the elbow to the fingers.  Flare-ups of pain could occur spontaneously or in association with activity and arm movement.  Pain severity was described as 7/10 at baseline which would increase to 10/10, 2-5 times per day lasting up to 20 minutes.  Rest or change in positions could alleviate pain.  He reported being unemployable due to his left shoulder pain.  The examiner cited an electrodiagnostic study done in April 2006 that showed evidence of left spinal accessory nerve (cranial nerve XI) dysfunction (palsy) “with ongoing incomplete recovery.”  Examination showed marked guarding of the left shoulder girdle.  There was no muscle atrophy, but shoulder muscles were tender diffusely.  The clavicle (collarbone) was extremely tender, but specific shoulder joints were not.  Painful motion was noted at extremes of motion during abduction and flexion.  Repetitive motion did not result in additional limitation.  Shoulder laxity was absent.  Winging of the left scapula was noted.  Muscle strength and sensory examinations were not reported.  The examiner rendered a diagnosis of thoracic outlet syndrome.

At a VA outpatient clinic evaluation on 1 February 2007, the CI reported that the pain in the left upper chest and shoulder was worsening, and he was concerned because “he feels unemployable.”  He reported that the pain was “spontaneous” and was not exacerbated by any particular factors.  ROM was “markedly decreased” to less than 90 degrees.  A rotator cuff impingement sign was positive.  A VA examination on 11 June 2007 observed an inability to actively abduct or flex the left shoulder above shoulder level.  Passive ROM was normal.

A VA C&P evaluation on 1 August 2007 (6 months after separation) cited repeat electrodiagnostic studies in March 2007 which showed only abnormalities of the spinal accessory nerve.  Although muscle strength of the shoulder girdle was noted to be significantly reduced on physical examination, muscle atrophy was absent, and muscle tone and bulk were normal.  Joint function was not considered to be affected by a nerve disorder.  There were no objective neurologic abnormalities reported of the left arm, forearm or hand.  At a mental health evaluation on 9 August 2007, the CI reported that he recently completed schooling and passed an examination for a trucking license.  He stated that his shoulder did not interfere with his ability to drive a truck.

A VA physiatry follow-up evaluation on 9 November 2007 (10 months after separation) confirmed a previous diagnosis of cranial nerve XI injury.  This led to shoulder drooping that was presumed to cause secondary thoracic outlet symptoms manifested by episodic radiating pain to the arm and hand.  Repeat electrodiagnostic studies of the left upper extremity in December 2007 were normal; minor abnormalities of the spinal accessory nerve were present.  The goniometric ROM evaluations in evidence, which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.

Left Shoulder ROM
(Degrees)	VA C&P 12 Mos. Pre-Sep	MEB PT 4 Mos. Pre-Sep	VA C&P 7 Days Post-Sep	VA C&P 6 Mos. Post-Sep	
Flexion (180 Normal)	125	108, 107, 108	90	180	
Abduction (180)	105	134, 133, 135	90	170	
Comments	+Painful motion		+Guarding, painful motion	Painless ROM	
§4.71a Rating	10%	10%*	20%	0%	
	       *Conceding §4.40 (functional loss) or §4.59 (painful motion)

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 0% rating under an analogous 5003 code (degenerative arthritis) with application of the USAPDA pain policy.  The VA initially assigned a 20% rating prior to final separation under the 8513 code (all radicular groups) for a diagnosis of thoracic outlet syndrome.  The VA increased this rating to 30% effective near to the time of separation.  The Board agreed that a 10% rating was reasonably conceded IAW §4.40 (functional loss) or §4.59 (painful motion), but considered if there was evidence of limitation of motion to warrant a higher rating.  The VASRD §4.71a threshold for a 20% rating of the non-dominant arm is ROM limited to “at shoulder level”, i.e., 90 degrees.  The Board agreed that while the VA C&P exam a week after separation supported a 20% rating on the basis of limitation of shoulder motion, the other ROM measurements in evidence depicted ROM above the 90 degree level.  The Board therefore concluded that a rating higher than 10% was not justified on the basis of limitation of motion.  It was also agreed that the PEB appropriately subsumed chest pain under the shoulder pain condition.

The Board considered other coding options, and noted in this case that a diagnosis of spinal accessory nerve palsy was confirmed by electrodiagnostic testing in April 2006.  The severity of the left shoulder pain, limitation of shoulder ROM, trapezius muscle atrophy, winged scapula and shoulder drooping were consistent with this diagnosis, which was not considered in the Disability Evaluation System process or the VARD.  Under the 8211 code (eleventh cranial, or spinal accessory, nerve), a 10% rating is described by “incomplete, moderate” paralysis, a 20% rating is warranted for “incomplete, severe” paralysis, and the highest 30% rating requires “complete” paralysis.  The rating criteria also stipulate “Dependent upon loss of motor function of sternomastoid and trapezius muscle.”  Since there was no evidence of sternomastoid muscle impairment in this case, and follow-up exams soon after separation reflected nerve recovery as manifested by substantially improved shoulder abduction, the Board agreed that the 30% rating was not supported.  The Board majority concluded that “incomplete, severe” was the most accurate descriptor at the time of separation, and a 20% rating was justified on this basis.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board majority recommends a disability rating of 20% for the chronic left shoulder and anterior chest pain condition, coded 8211 IAW VASRD §4.124a. The Board also noted that chest pain was appropriately subsumed under this coding pathway.

Finally, the Board deliberated a rating under the peripheral nerve code adopted by the VA for a diagnosis of thoracic outlet syndrome.  The available record provided conflicting opinions regarding the etiology of the CI’s unfitting shoulder and chest pain.  A neurologic basis for pain was first considered by a neurologist in January 2006, who reported physical examination findings consistent with a diagnosis of thoracic outlet syndrome.  However, a vascular surgery evaluation in June 2006 firmly concluded that thoracic outlet syndrome was not present.  The physiatrist who detected the presence of cranial nerve XI dysfunction by electrodiagnostic testing later opined that the resulting trapezius muscle dysfunction led to left shoulder drooping with consequent episodic thoracic outlet-like symptoms.  Although the shoulder pain, with subsumed chest pain, is most appropriately rated as above under the 8211 code, Board members debated if additional rating was warranted on the basis of secondary left upper extremity nerve impairment.  The presence of functional impairment with a direct impact on fitness and duty performance is the key determinant in the Board’s decision to recommend any condition for rating as additionally unfitting.  Repeated left upper extremity electrodiagnostic studies failed to show any nerve dysfunction that could explain symptoms from peripheral nerve pathology.  Additionally, the Board noted that symptoms were intermittent and involved no documented persistent motor weakness.  Therefore, any manifestation of such nerve impairment, if present, could only have been intermittent and could not involve neurologic weakness.  There is no evidence in this case of functional impairment attributable to peripheral neuropathy other than the spinal accessory nerve palsy.  The Board therefore concluded that additional disability was not justified on this basis.

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that benign paroxysmal positional vertigo and subjective tinnitus (ringing in ears) 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.

At an otolaryngology evaluation in September 2006 the CI reported a 10-year history of intermittent tinnitus, and of episodic vertigo lasting 1-10 minutes, 2-3 times per week.  Except for an evaluation performed by an audiologist the day before, the CI had never been seen or treated for these conditions.  The examiner could not reproduce vertigo symptoms with a provocative maneuver.  The NARSUM examiner stated that vertigo and tinnitus met retention standards, and the commander’s statement only mentioned the shoulder condition.

The vertigo and tinnitus conditions were not profiled or implicated in the commander’s statement and were not judged to fail retention standards.  Both were reviewed by the action officer and considered by the Board.  There was no performance based evidence from the record that either 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 either 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.  As discussed above, PEB reliance on the USAPDA pain policy for rating chronic left shoulder and chest pain was operant in this case and the condition was adjudicated independently of that policy by the Board.  In the matter of the chronic left shoulder and anterior chest pain condition, the Board, by a majority vote recommends a disability rating of 20%, coded 8211 IAW VASRD 4.124a.  In the matter of the contended benign paroxysmal vertigo and subjective tinnitus 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 recommends that the CI’s prior determination be modified as follows, effective as of the date of his prior medical separation:
 
UNFITTING CONDITION	VASRD CODE	RATING	
Chronic Left Shoulder and Anterior Chest Pain	8211	20%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140508, 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, AR20150010472 (PD201402096)

1.  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 to modify the individual’s disability rating to 20% without recharacterization of the individual’s separation.  This decision is final.  

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.   

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:

Encl		     XXXXXXXXXXXXXXX
			     Deputy Assistant Secretary of the Army
			         (Review Boards)

CF: 
(  ) DoD PDBR
(  ) DVA