RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-04214
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20030218

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Security Forces Journeyman, medically separated for “left brachial plexopathy,” with a disability rating of 20%.

CI CONTENTION:  The CI requests 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 based upon a 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 - 20021122	VARD - 20030625	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Brachial Plexopathy	8710	20%	Cervical Spine Lesion with Left Brachial Neuroplexopathy	5010-8510	20%	20030426	
			Hypertrophic Changes, Left Acromioclavicular Joint	5010	0%	20030426	
Tobacco Abuse	Cat III	No VA Placement	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Left Brachial Plexopathy.  According to service treatment records (STRs) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s left shoulder pain condition, which also included twitching of the second and third digits of the left hand, began in June 2000 after he had carried furniture as part of a work detail.  Treatment consisted of toradol (ketorolac, a nonsteroidal anti-inflammatory drug (NSAID) and Motrin (ibuprofen, an NSAID).  In October 2000 he was diagnosed with left shoulder muscle strain and treated with ibuprofen.  X-rays of the shoulder showed no fracture or dislocation.  During deployment in 2001 he was diagnosed with cubital tunnel syndrome based on numbness and tingling of the left lateral three fingers and at follow-up visit he was diagnosed as likely having a brachial plexopathy (a form of peripheral neuropathy of the nerves of the brachial plexus).  Electrodiagnostic studies demonstrated evidence of a left cervical plexopathy involving the upper C5, 6, and 7 segments.  Magnetic resonance imaging (MRI) demonstrated mild hypertrophic changes in the left acromioclavicular (AC) joint.  A neurologist in November 2001 felt the CI’s pain was likely secondary to a plexus or stretch injury and prescribed gabapentin (for nerve pain).  An MRI of the cervical spine in December 2001 demonstrated small posterior osteophytes at the C3-4 level without a significant degree of spinal or foraminal stenosis.  Computed tomography (CT scan) of the lower cervical spine was normal.  A neurosurgeon’s impression was cervical pain with radiation to the left upper extremity, left cervical plexopathy and r/o neurofibromatosis (benign neural tumors), but he noted he was unable to make a definitive diagnosis.  Another neurologist diagnosed cervical radiculopathy, probably C7-8 by examination, and axonal neuropathy at the level of the forearm in the ulnar nerve and recommended increasing the gabapentin dosage and adding Ultracet (tramadol, an opioid-like drug and acetaminophen, a pain reliever).  Pain related insomnia was treated with Ambien (zolpidem, a sedative), which caused hallucinations; and it was discontinued.  Additional opinions in June 2002 included probable left brachial plexus lower cord injury and left C3-4 foraminal stenosis with range of motion (ROM) of the neck normal, slightly decreased grip strength and decreased deep tendon reflexes of the left biceps, brachioradialis, and triceps muscles.  No trophic changes of the hand associated with reflex sympathetic dystrophy were noted.  Somatosensory evoked potentials (SSEPs) of the median nerve bilaterally were normal.  A cervical spine series was technically incomplete without RAO (right anterior oblique) views, but was otherwise normal.  ROM measurements of the left shoulder were flexion to 150 degrees and abduction to 150 degrees, both with severe pain in August 2002.  An orthopedic surgeon noted forward flexion 180 degrees and abduction 170 degrees with spasms/twitching of the left ring and middle fingers, which were interrupted with motor distraction on the right.  The CI’s condition was assessed as “left upper quadrant symptoms of unclear etiology, confusing picture; no evidence of glenohumeral/subacromial/acromioclavicular etiology.”  Differential diagnosis included thoracic outlet syndrome, cubital tunnel syndrome (unlikely) or cervical radiculopathy (not entirely consistent) with some elements of complex region pain syndrome or RSD (reflex sympathetic dystrophy).  The examiner “suspect[ed] some element of underlying pathophysiology but with some magnification of symptoms/behavioral overlay.”  Physical therapy was recommended.   

At the NARSUM examination in October 2002, 4 months prior to separation, the CI’s extremities had full ROMs and strength, except the left arm, which was held splinted next to his side and was limited by pain. Additionally, he had an intermittent resting tremor of the middle fingers.  The examiner’s diagnosis was left upper extremity brachial plexopathy, chronic.  He opined that “the unclear presentations and difficulties in defining a clear diagnostic picture even after multiple imaging and ancillary studies and seven specialty consultants suggested a behavioral overlay, but no psychological diagnosis was specified.”  However, “[w]ith or without a behavioral component, the chronicity, restrictions, and lack of improvement of his condition is not consistent with continued military service.”  

At the VA Compensation and Pension (C&P) examination on 26 April 2003, performed 2 months after separation, the right-hand dominant CI reported steady, persistent, non-changing left arm pain, which was related to the amount of activities done, and weakness with difficulty lifting his arm; however, he was on no medications for the pain.  Examination of the shoulder revealed a full ROM with very mild tenderness over the AC joint.  On examination there was no effusion or any other evidence of subluxation or laxity in the shoulder.  Motor examination of the left arm was markedly abnormal.  He had severe atrophy of the rhomboid muscles along the medial side of the scapula, which winged out when he tried to bring his elbow posteriorly and the muscle mass was markedly decreased.  The supraspinatus and deltoid muscles were also weak and slightly atrophic.  The biceps and triceps muscles and the muscles of wrist flexion, extension, and intrinics of the hand were normal in the left arm.  Sensory examination was essential normal except there was a slight decrease in the third and fifth fingers of the left hand.  Reflexes of the biceps and triceps were 2+ and Tinel’s sign (to determine nerve irritation) was negative in the cubital tunnel.  The examiner opined based on his examination of the anatomical findings and neuroanatomy of the muscles involved, the CI had multiple cervical radiculopathies or cervical radicular/plexopathy of which the etiology was not entirely clear and noted the CI’s shoulder had only mild pain probably associated with some very mild arthritis of the AC joint.  

The Board directed attention to its rating recommendation based on the above evidence.   The PEB assigned a 20% rating under the 8710 code (upper radicular group (fifth and sixth cervicals)-mild), citing left brachial plexopathy.  The VA also assigned a 20% rating using an analogous 5010-8510 code (arthritis, due to trauma, substantiated by X-ray findings-upper radicular group (fifth and sixth cervicals) incomplete paralysis-mild) based on the VA C&P examination 2 months after separation, citing cervical spine lesion with left brachial neuroplexopathy.  The VA also assigned a 0% rating using code 5010 for hypertrophic changes, left acromioclavicular joint, which was not explicitly in the scope of review.

Board members noted that there were differences of opinion among the many examiners in regard to the etiology of the CI’s condition as well as clinical manifestations and limitations due to the brachial plexopathy, which was confirmed by electrodiagnostic studies with involvement of C5, C6, and C7 segments.  Muscle and grip strength of the left upper extremity were noted to be slightly diminished, but at the VA examination rhomboid musculature (of the mid/upper back) was noted to be markedly diminished; reflexes of the left upper extremity were slightly decreased; and winging of the scapula was present when the CI tried to bring his elbow posteriorly.  Additionally he had difficulty performing overhead work or lifting and noted painful motion, although his ROMs were within normal limits.  Furthermore, while he was prescribed several medications on active duty, at the VA examination, he reported no medication use.  Board members discussed whether the CI’s condition did rise to the level of a rating of 30%, which although not unreasonable for a moderate brachial plexopathy using code 5010-8510 (or 5010-8710), which captures MRI arthritic changes in the cervical spine and the left shoulder as well as the several clinical neurologic and muscular findings of the brachial plexopathy; nevertheless, the etiology remained elusive even with the CI having been evaluated by multiple specialists.  Therefore, because of the equivocal and at times disparate findings, Board members felt that a rating higher than 20% would be speculative in the absence of more definitive, objective and credible medical evidence.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the left brachial plexopathy condition.  

Contended PEB Conditions:  Tobacco Abuse.  The Board’s main charge is to assess the fairness of the PEB’s determination that the contended condition was not unfitting.  The contended condition is not considered a physical disability and is therefore not ratable or compensable.  After due deliberation, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the contended condition and so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the left brachial plexopathy condition and IAW VASRD §4.124a, the Board unanimously or majority recommends no change in the PEB adjudication.  In the matter of the contended tobacco abuse condition, the Board unanimously recommends no change from the PEB determination 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 20140123, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAF/MR
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD  20762

Dear XXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2014-04214.

After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was appropriate.  Accordingly, the Board recommended no re-characterization or modification of your separation.

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding and their conclusion that re-characterization of your separation is not warranted.  Accordingly, I accept their recommendation that your application be denied.

Sincerely,

Attachment:
Record of Proceedings