RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03415
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20060915

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an activated National Guard E-4, Cannon Crewmember, medically separated for a chronic left upper extremity pain condition, rated at 10%.  

CI CONTENTION:  The CI request consideration of all of his conditions.  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:  

IPEB – Dated 20060809	VA* - (~4 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Left (Non-Dominant) Upper Extremity Pain	5099-5003	10%	Ulnar Nerve Neuropathy, Left Arm	8516	10%	20070201	
			Retained Shrapnel, Left Shoulder	5203-5203	10%	20070116	
Posttraumatic Stress Disorder	Not Unfitting	Post-Traumatic Stress Disorder	9411	10%	20070129	
Hypertension	Not Unfitting	Hypertension	7101	10%	20070116	
Bilateral Hearing Loss and Tinnitus	Not Unfitting	Tinnitus	6260	10%	20070116	
		Left Ear Hearing Loss	6100	0%	20070116	
		Right Ear Hearing Loss	6100	NSC	20070116	
Allergic Rhinitis	Not Unfitting	Allergic Rhinitis	6522	NSC	20070201	
Hyperlipidemia	Not Unfitting	No VA Placement	
Left Rib Contusion	Not Unfitting	No VA Placement	
Other x 0 (Not In Scope)	Other x 1 	
RATING:  10%	RATING:  40%	
*Derived from VA Rating Decision (VARD) dated 20070329 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY:  

Chronic Left (Non-Dominant) Upper Extremity Pain Condition.  The narrative summary (NARSUM) noted the CI sustained injury to his left arm in August 2005 after being exposed to improvised explosive device.  He was taken to the aid station where an x-ray demonstrated the presence of shrapnel fragments within the soft tissues of the left arm diagnosed as a soft tissue injury.  His arm was wrapped and he returned to his unit.  His condition was treated supportively with Motrin, and he remained with his unit until they redeployed to U.S. The CI was evaluated by neurology in January 2006 for the report of experiencing left arm pain when attempting to fully abduct the upper extremity.  He also had some swelling, and sharp pains in the fingers without associated weakness or numbness.  Sensory examination around the sites of the shrapnel fragments in his left arm and axilla region was normal.  Nerve conduction studies of the left extremity demonstrated evidence of mild, left distal ulnar neuropathy, and no other significant finding.  The CI continued to report sensitivity in the left axilla, left shoulder and radicular hand pain which was treated with medication and occupational therapy.  The NARSUM dated 10 July 2006 documented the CI underwent consultation with general surgery who advised that removing the shrapnel would cause more harm than good.  It was noted that the mild left distal ulnar neuropathy “appears to be an incidental finding” not related to his complaint.  Despite multiple conservative management approaches to address his pain, the CI continued to have pain in the left upper extremity axilla region and was unable to fire a weapon, or wear his gear.  The CI noted his pain was intermittent and presented throughout the day.  It was worse at night, interfering with his ability to sleep.  He could not lift greater than 5 pounds with his left arm, and he was unable to play sports with his son.  Physical examination documented normal range of motion (ROM) in both shoulders and no tenderness to palpation.  Muscle strength was normal.  Radiographs conducted in January 2006 demonstrated several tiny irregular metallic densities imbedded in the superficial soft tissues and no evidence of fracture or dislocation.  The physician opined that he had frequent pain that was slight in severity.  

 The VA Compensation and Pension (C&P) examination was accomplished on the same day of the NARSUM.  That examination documented the report of daily left arm pain that is relieved with medication and rest.  ROM measurements recorded flexion of 180 (180) in both shoulders, and abduction of 180 (180) both shoulders.  Muscle strength was normal, neurological examination was normal, and tenderness to palpation of the shoulders was absent.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB chose to rate the condition analogous to 5003 (degenerative arthritis) and under the pain policy, granted 10% for the non-dominant left shoulder pain.  The VA rated ulnar nerve neuropathy coded 8516 (ulnar nerve, incomplete paralysis) and assigned a disability rating of 10%, and granted a 0% rating for retained shrapnel.  The Board considered the 5202 (humerus, other impairment); however, Board members agreed this code was not applicable.  The Board noted the absence of a history of shoulder dislocation in the 24 months prior to separation, and the record do not support any ratable impairment of the scapula or scapulohumeral joint. Likewise, VARSD code 5201 (arm, limitation of motion) was not applicable since the ROM measurements were normal and not compensable.  There was no evidence of shoulder instability, thus, code 5203 is not applicable.  The Board also considered the 8516 code; however, found no evidence to support the use of this code since sensory and motor examinations were normal at both VA and NARSUM examination, and there was no evidence that any sensory or motor deficit had resulted in any impairment.  Reports of inability to flex, abduct, or adduct the hand, fingers, or wrist, were absent, and there was no report of hand weakness.  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 adjudication for the left shoulder condition.  

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the contended PTSD, allergic rhinitis, hypertension, hyperlipidemia, bilateral hearing loss, and left rib contusion conditions were not unfitting.  

PTSD.  The service treatment record documented the CI’s report of problems with sleep, and some depression and anxiety suggestive of PTSD.  His initial diagnosis was acute stress disorder and he was prescribed medication for sleep and depression, and he also participated in counseling.  His diagnosis was later changed to PTSD and he continued in treatment with medication and counseling.  The treatment records demonstrated absence of suicidal or homicidal ideation, absence of visits to the emergency room for psychological concerns, and no history of psychiatric hospitalization.  

Allergic rhinitis, hypertension, hyperlipidemia, bilateral hearing loss, and left rib contusion.  The Board next reviewed the remaining conditions and noted the CI was prescribed medication for his high blood pressure, allergic rhinitis, and hyperlipidemia.  Although the record documented frequent elevation of his blood pressure, the record was silent for emergency room visits related to his blood pressure.  The Board also noted the left rib contusion had likely resolved since the NARSUM did not record chest pain or chest discomfort, or any pulmonary symptoms.  

The Board noted that none of the contended conditions were profiled or implicated in the commander’s statement and none were 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 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 the PTSD, allergic rhinitis, hypertension, hyperlipidemia, bilateral hearing loss, and left rib contusion conditions and so no additional disability ratings are recommended. 

BOARD FINDINGS:  In the matter of the chronic left upper extremity pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended PTSD, allergic rhinitis, hypertension, hyperlipidemia, bilateral hearing loss, and left rib contusion 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.  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 20140629, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB

XXXXXXXXXXXXXXXXXXXXXXXXX

MEMORANDUM FOR Commander, US Army Physical Disability Agency
(AH RC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation
for XXXXXXXXXXXXXXXXXXXX, AR20160008013 (PD201403415)

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