RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX		CASE:  PD-2014-02435
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20031031

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (Food Service Specialist) medically separated for left shoulder and left bicep injuries.  These conditions could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS).  He was issued a permanent U3 profile and referred for a Medical Evaluation Board (MEB).  The “fragment injury to left proximal arm and bicep” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded three other conditions (mild to moderate bilateral carpal tunnel syndrome, cervical polyradiculopathy bilaterally, and posttraumatic stress disorder (PTSD)) for PEB adjudication.  The Informal PEB adjudicated “fragment injury left arm proximally and in the biceps area” as unfitting, rated 0% citing application of 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 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 20030708	VA* - (~1 Month Pre-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Fragment Injury Left Arm Proximally and in the Biceps Area	5099-5003	0%	Post-Operative Shrapnel Wound Residuals, Left (Minor) Shoulder	5203	10%	20030925	
Post Traumatic Stress Disorder	Not Unfitting	Post Traumatic Stress Disorder	9411	30%	20030924	
Cervical Polyradiculopathy Bilaterally	Not Unfitting	Intermittent Paracervical Muscle Spasm…	5237-5293	0%	20030925	
Bilateral Carpal Tunnel Syndrome	Not Unfitting	Carpal Tunnel Syndrome, Right…	8715	NSC	20030925	
		Carpal Tunnel Syndrome, Left…	8715	NSC	20030925	
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 7	
RATING:  0%	RATING:  50%	
*Derived from VA Rating Decision (VARD) dated 20031114 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY:   

Left Shoulder/Arm Condition.  The narrative summary (NARSUM) was accomplished in May 2003, approximately 5 months prior to separation.  The NARSUM noted the CI was involved in a training accident in March 2002 when he sustained shrapnel injury to his left bicep.  The CI was transported to a civilian hospital and the shrapnel was removed from his left superior biceps.  He was hospitalized for a few days and sent to physical therapy.  Physical therapy was beneficial; however, he continued to have pain in the left shoulder and upper arm that improved somewhat with Motrin.  Due to his report of numbness and pain in both hands, left greater than right and some swelling in both hands which worsened as the day goes on and significantly greatest in the evening, he was referred for nerve studies.  Results of the electromyogram (EMG) and nerve conduction studies (NCS) demonstrated moderate compressive neuropathy of the median nerve at the wrist bilaterally, right greater than left, and bilateral cervical polyradiculopathy of left greater than right arm.  Having failed conservative management, the CI was referred to the MEB.  An initial NARSUM was conducted in October 2002 and an addendum to that NARSUM was completed in February 2003.  The addendum noted the EMG and NCS had not been performed prior to the writing of the NARSUM.  It was noted that the neurologist had determined at the time of clinical correlation of the nerve studies, that the findings were likely a result of “more of a chronic problem and not as a result of his injury”, and was secondary to “some type of brachial plexus lesion.”  The neurologist also opined that given the extent of left arm nerve damage and the fact that the problem is bilateral, clinical correlation would suggest that “this lesion existed prior to his injury, and the injury “possibly could”, based on records and based on nerve studies, have recurred as a result of the current injury.   Neurological consultation dated 20 March 2003, documented the CI had numbness and tingling in both hands that resolved with a change in position.  He noted symptoms at night which would awaken him and cause him to “shake out his hand”, and this can occur up to 3 times a week.  Physical examination recorded normal muscle bulk and tone except left triceps decreased; however, motor strength was normal (5/5) throughout upper extremities.  At the NARSUM dated 20 May 2003, the CI noted his arm pain continues and is exacerbated by performing his duties as a cook and limits his ability to do physical training.  Numbness and swelling in both hands, left greater than right, interferes with completion of his duties.  Physical examination of the left upper extremity noted mild tenderness to palpation over the anterior lateral portion of the upper arm around the biceps.  He has good contraction of his biceps and strength of 4/5, limited by pain.  Abduction of the shoulder is mildly decreased (due to pain) and range of motion (ROM) recorded shoulder flexion to 130 degrees (180) and abduction “about 110 degrees (180).”  Flexion at the elbow measured 135 degrees with 5 degrees of extension.  Grip strength was mildly decreased bilaterally (4+/5) “with an unexplained etiology for his deficit.”  However, there was no evidence of muscle atrophy, and his hands were not noted to be significantly swollen.  Fingers had normal strength and sensory function. The VA Compensation and Pension (C&P), approximately 5 weeks before separation, recorded physical findings of non-tender surgical scar, and decreased ROM of the left shoulder with flexion and abduction of 110 degrees.  No other abnormalities were recorded for the left shoulder condition.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 0% rating to the condition under the pain policy, coded analogously 5099-5003.  The VA coded the condition 5203 (malunion or nonunion of clavicle or scapula) and granted 10% disability rating.  Applicable diagnostic codes include: 5201 (limitation of arm motion), 5202 and 5203 (impairment of: dislocation of clavicle or scapula, non-union of). The Board noted the 5201 was not applicable in this case since ROM recorded at the NARSUM and C&P exams were not compensable.  Likewise, the 5202 code was not applicable since there were no reports of dislocation or guarding, malunion, or loose movement.  The Board next considered the 5203 code, and members agreed a 10% rating under this code was not supported since there is insufficient evidence of impairment of function of the contiguous joint, or malunion.  The Board next considered the muscle group codes 5301-5304.  A 10% rating under these codes requires evidence of moderate impairment in muscle group function.  The VASRD evaluation of muscle disabilities (§4.56) defines moderate disability as “through and through or deep penetrating wound or short track from a single bullet, small shell or shrapnel fragment…” and complaint of one or more of the cardinal signs and symptoms  of muscle disability (low threshold of fatigue after average use, loss of power, weakness, impairment of coordination and uncertainty of movement), and objective findings of loss of deep fascia or muscle substance or impairment of muscle tonus and loss of power or lowered threshold of fatigue; not supported by the record in evidence.  The Board next considered the applicability of §4.40 or §4.59. The Board members agreed VASRD §4.59, painful motion was applicable in this case and therefore, recommended a disability rating of 10%.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% under 5003 code for the left arm condition.  

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the conditions of PTSD, bilateral carpal tunnel syndrome, and cervical polyradiculopathy bilateral, were not unfitting.  The Board’s threshold for countering fitness determinations requires a preponderance of evidence, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  The Board first considered the condition of PTSD.  The MEB NARSUM noted the CI had not been in MH treatment since January 2001, and the mental status examination for the addendum was conducted on the day of his last MH visit, 21 January 2002.  At the time the CI reported difficulty falling asleep, nightmares, startled response, increased irritability and anger.  The addendum noted that he participated in group therapy, and had a reduction in his symptoms, notably, his sleep improved and he had less intrusive recall of his accident.  He continued to have mild difficulty with “expressing irritability and anger”.  The psychologist opined that his symptoms improved to the point that his condition is not a significant issue in terms of his daily functioning.  The diagnosis of PTSD was recorded, and the examiner documented impairment for military duty: None, for social/industrial adaptability: None to Mild.  A global assessment of functioning (GAF) score of 75 (if symptoms are present, they are transient and expectable reactions to psychosocial stressors).  The examiner opined the condition of PTSD is medically acceptable.  The Board next reviewed the records related to the bilateral carpal tunnel condition.  As noted above, the CI reported that he underwent EMG and nerve conduction studies at a community hospital which showed that he had mild to moderate compressive neuropathy of his median nerve at the wrist.  Neurology evaluation noted the CI has symptoms suggestive of mild carpal tunnel syndrome that should improve with conservative measures.  Examination of the bilateral hands at the NARSUM documented deficient grip strength bilaterally; however, no evidence of muscle wasting, or significant hand swelling.  He had full strength in both hands, and normal hand and wrist motion, and normal sensation.  The condition of cervical polyradiculopathy was considered by the Board.  MRI showed a subtle central disc protrusion at C3-C4 without compression, and mild cervical spondylosis at C6-C7.  The CI reported he has mild to moderate symptoms that occurs intermittently, 2-3 days a week.  Neurological evaluation recorded no clinical evidence of a brachial plexus injury or cervical radiculopathy by MRI, examination or history.  The neurologist opined that “previously reported electrodiagnostic (EMG, NCS) results are not definitive for any of the above diagnoses” (bilateral carpal tunnel syndrome and cervical polyradiculopathy).  The Board noted that although the carpal tunnel syndrome was profiled, and documented in the commander’s statement, there was no performance based evidence from the record that this condition significantly interfered with satisfactory duty performance.  His profile had no restrictions to reflect limitations specific to this condition.  Although the CS mentioned this condition, there was no mention of how this condition interfered with performance of duty.  The PTSD and cervical polyradiculopathy conditions were not profiled or implicated in the commander’s statement and were not judged to fail retention standards.  All were reviewed and considered by the Board.   There was no performance based evidence from the record that any of the contended 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.  As discussed above, PEB reliance on the USAPDA pain policy AR 635-40 DoDI 1332.39 for rating left arm was operant in this case and the condition was adjudicated independently of that policy/ instruction by this Board.  In the matter of the fragment injury left arm condition, the Board unanimously recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.59 and §4.71a.  In the matter of the contended PTSD, bilateral carpal tunnel syndrome, and cervical polyradiculopathy bilateral 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:  

CONDITION	VASRD CODE	RATING	
Fragment Injury Left Arm 	5099-5003	10%	
COMBINED	10%	

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

MEMORANDUM FOR Commander

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation
for XXXXXXXXXXXXXXXXXXXX, AR20160004499 (PD201402435)

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,
accept the Board's recommendation to modify the individual's disability rating to 10%
without re-characterization 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:

CF:
( ) DoD PDBR
( ) DVA