RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-04025
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20030725

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an, E4, Medical Laboratory Specialist, medically separated for “long thoracic nerve palsy, right (major)…” with a disability rating of 20%.

CI CONTENTION:  The CI requested consideration of all conditions. The CI’s 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 - 20030623	VARD - 20041018	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Long Thoracic Nerve Palsy, Right (Major)	8519	20%	Long Thoracic Dysfunction with Associated Right Scapular Winging and Right Upper Extremity Dysesthesias	5201-8519	20%	20040826	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Long Thoracic Nerve Palsy, Right (Major).  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s right shoulder pain and weakness condition began insidiously in approximately May 2002 without any obvious trauma.  X-rays on 20 June 2002, ordered for a 3-week history of right shoulder pain after playing basketball, demonstrated “no acute bony abnormality with bony prominence of the posterior rim of the right glenoid.”  Orthopedic and physical therapy evaluations were consistent with long thoracic nerve palsy of the right shoulder.  Scapular stabilizing and other exercises to increase serratus anterior muscle strength were instituted; however, there was continued shoulder pain with the exercises and physical therapy was discontinued.  Electrodiagnostic tests of the right upper extremity were normal; however, it was noted that the “serratus anterior muscle is difficult to examine in cases of long standing long thoracic nerve palsy.” 

At the MEB examination (recorded on DD Forms 2807 and 2808) dated 10 April 2003, 3 months prior to separation, the CI reported  right shoulder pain with popping and rubbing, which caused numbness and tingling, and his right shoulder fell lower than the left shoulder.  The examiner noted a decreased range of motion (ROM) of the right arm/shoulder secondary to long thoracic nerve impairment. Abduction was to 90 degrees and external rotation was decreased.  At the NARSUM examination of the CI’s right shoulder dated 15 May 2003 active ROM measurements were forward flexion 90 degrees, abduction 90 degrees, external rotation 40 degrees, and internal rotation to L5.  With forward flexion there was obvious winging of the scapula and when the CI pushed up again the wall there was moderate to severe scapula winging on the right side.  Tests for subacromial impingement (Hawkin’s and Neer’s) and biceps tendon pathology (Speed’s and Yergason’s) were negative as were the apprehension test (to check for a possible torn labrum or anterior instability) and sulcus sign (to test for inferior instability of the shoulder/glenohumeral joint).  There were no surgical indications and due to the injury he had significant limitation of active motion.

At the VA Compensation and Pension (C&P) examination on 26 August 2003, performed 1 month after separation, the CI reported chronic pain, constant in nature, in his right shoulder that he graded as 7/10 (10 being the worst pain) and noted any movement at all made the pain worse.  Celebrex [celecoxib, a nonsteroidal anti-inflammatory drug (NSAID)] did not relieve the pain completely.  The right-hand dominant CI complained of paresthesias and he intermittently lost control of his coffee cup.  Electrodiagnostic testing was within normal limits.  Physical examination showed right shoulder abduction and flexion 0-120 degrees with mild tenderness to palpation at the right acromial process and marked winging with forward leaning.  With his arms abducted at 90 degrees, he was able to perform 0-90 degree internal rotation bilaterally and 0-20 degrees external rotation on the right side.  Grip strength was decreased on the right side compared to the left; however, he was able to get on and off the examination table without difficulty and was able to disrobe for his upper extremity examination.     

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 20% rating using code 8519 (long thoracic nerve paralysis-incomplete:  severe) for a long thoracic nerve palsy, right (major).  The VA assigned a 20% rating using code 5201-8519 (arm limitation of motion-long thoracic nerve paralysis) for long thoracic dysfunction with associated right scapular winging and right upper extremity dysesthesia (includes claim for right arm deformity).  Board members discussed alternative rating options and noted that VASRD §4.71a code 5201 (arm, limitation of motion) offers higher ratings for midway between the side and shoulder level or 25 degrees from the side, neither of which were applicable in this case.  Furthermore, in the absence of ankylosis of the shoulder (code 5200) or humerus impairment (code 5202), a rating higher rating than 20% is not obtainable.  However, Board members extensively discussed the concept of complete of paralysis of the long thoracic nerve, which warrants a 30% rating and was supported by a winged scapula deformity of the dominant arm warrants and at the NARSUM examination both flexion and abduction were at 90 degrees; however, at the VA examination flexion and abduction were to 120 degrees.  Board members then discussed the variance in the NARSUM and VA examinations and felt the 120 degrees represented arm limitation of motion was more proximate to the shoulder level compared to full flexion and abduction of 180 degrees.  Since the CI demonstrated winging of the scapula when leaning forward at both the NARSUM and VA examinations, a 30% rating is, therefore, not unreasonable.  Additionally, the Board members discussed the use of a muscle code 5301 (Group I. Function: Upward rotation of scapula; elevation of arm above shoulder level. Extrinsic muscles of shoulder girdle: (1) Trapezius; (2) levator scapulae; (3) serratus magnus).  However, IAW VASRD §4.56 evaluation of muscle disabilities, the cardinal signs and symptoms of muscle disability are loss of power, weakness, lowered threshold of fatigue, fatigue-pain, impairment of coordination and uncertainty of movement.  By assigning a 20% rating using code 8519 the PEB determined the CI’s the disability was severe, which using code 5301 warrants a 40% rating for the dominant arm.  However, a severe or even a moderately severe disability of the muscles includes a through and through or deep penetrating wound or bone damage and hospitalization for a prolonged period as well as objective findings showing loss of muscle substance and severe impairment of function, none of which was in evidence; however there was positive evidence of impairment of serratus anterior muscle resulting in winging of the scapula.  Therefore, an analogous code 5399-5301 for a moderately severe muscle injury with a 30% rating is not unreasonable.  However, since the VASRD specifically listed the long thoracic nerve, Board members felt it was more accurate to use the 8519 code rather than the analogous 5399-5301 code.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 30% for the long thoracic nerve palsy, right (major) condition, coded 8519.  

BOARD FINDINGS:  In the matter of the long thoracic nerve palsy, right (major) condition, the Board unanimously recommends a disability rating of 30%, coded 8519 IAW VASRD §4.124a.  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	
Long Thoracic Nerve Palsy, Right (Major)	8519   	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated, 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, AR20160017805   (PD201404025)

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 re-characterize the individual’s separation as a permanent disability retirement with the combined disability rating of 30% 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 30% 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