RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	      CASE:  PD-2015-00453
BRANCH OF SERVICE:  Army	Separation DATE:  20051031

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E6, Fire Support Specialist, medically separated for “chronic chest wall pain,” with a disability rating of 20%.

CI CONTENTION:  The CI’s condition continues to worsen and negatively affect daily activities.  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 – 20050826	VARD - 20071114	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Chest Wall Pain Left Side	5099-5003	20%	Painful Scars on Chest	7804	10%	20060623	
			Partial Left Pneumonectomy	6844	Deferred	20080123	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Chronic Chest Wall Pain, Left Side.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI experienced a spontaneous left pneumothorax (presence of gas between chest wall and lungs causing lung collapse) approximately 15 months prior to referral for MEB.  He was initially treated with a tube thoracotomy (pleural cavity chest tube to drain air or fluids) for 1 week.  A pneumothorax recurred 3 days after discharge, and the CI was readmitted for definitive treatment.  He CI underwent a thoracotomy (chest wall surgical incision), partial pneumonectomy (lung tissue excision), and pleural (membranes lining thorax and enveloping lungs) sclerosis (chemical induced serositis and subsequent fibrosis of the pleura).  
At the MEB examination on 12 April 2005, 6 months prior to separation, the CI complained of left chest numbness and paresthesia (abnormal sensation, tingling, burning, prickling) following surgery to treat recurrent pneumothoraces.  He complained of constant left chest pain with intermittent sharp pains of the entire side with deep breathing or sneezing.  The CI reported being unable to wear uniforms because of the pain caused by tight clothing.  The physical examination revealed decreased sensation of the left anterior chest to light touch with hyperesthesia (abnormal increased sensitivity to stimulation) on deep pressure.  The diagnosis listed left chest neuropathic pain (sensory nerve injury pain) with allodynia (pain from stimuli which are not normally painful) status post thoracotomy.  At a 5 May 2005 Physical Medicine and Rehabilitation (PM&R) evaluation, the CI complained of left anterior chest numbness and pain status post surgery for pneumothorax.  The constant, 5/10 pain was exacerbated by hot weather and relieved with topical Lidocaine and Motrin.  The physical examination revealed no tenderness along the left intercostal (between ribs) region.  There was full chest expansion without pain and the neurological examination was normal.  The impression listed intercostal neuralgia (dull and intermittent pain involving characteristic nerve distribution) secondary to surgery for pneumothorax.  

The 30 June 2005 NARSUM, 4 months before separation, recounted the history and interventions.  The CI complained of chronic chest wall pain since the thoracotomy.  Pain was exacerbated by exertion, physical training, wearing the prescribed uniform, and any close fitting clothing.  He experience only temporary relief with medications (Gabapentin, topical Lidocaine and Ibuprofen) prescribed by pain management.  The CI declined a nerve block procedure because of concerns for another pneumothorax.  Under physical examination, the author documented “Please refer to his physical examination (SF 2807/2808) Dated 20050412 for further details.”  The diagnosis listed chronic chest wall pain.  The 23 June 2006 general Compensation and Pension (C&P) examination, 8 months after separation, recounted the history and interventions.  The CI complained of 2 of 4 surgical scars being frequently painful.  Pain was exacerbated by any form of impact and was significantly reduced by occasional use of Lidocaine gel.  The pain did not interfere with normal activities.  The chest examination revealed four small scars (approximately 1 inch each) which were slightly darker than surrounding skin.  One scar was slightly indented and two were tender.  Lung sound were normal without rales (abnormal respiratory sounds from fluid accumulation), rhonchi (abnormal respiratory sounds from airway secretions), or wheezes.  The impression listed prior left-sided pneumothorax surgically repaired with residual scars, two of which are occasionally painful.  A 26 June 2006 chest X-ray was normal, except for a small lateral right lung calcified granuloma (nodular mass of chronically inflamed tissue).  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 20% rating under an analogous 5003 code (arthritis, degenerative) citing chronic left chest wall pain, with pain considered marked and constant.  The VA assigned a 10% rating under the 7804 code (scar[s], unstable or painful) based on the VA C&P examination 8 months after separation, citing residuals of left pneumonectomy.  While the PM&R evaluation listed intercostal neuralgia, there is no specific code to address intercostal nerves under §4.124 (neuralgia, cranial or peripheral).  The VA C&P examination findings of two painful scars was consistent with the 10% rating under 7804.  Atypical chest pain analogizes to 5321 (muscle group XXI: muscles of respiration: thoracic muscles) per Analogous Codes from Medical EPSS and it may be reasonable to analogize costochondritis (inflammation of costal cartilage where ribs connect to sternum) to this code.  Board members agreed that the disability more closely approximated the moderate (10%) than the slight (0%) rating under 5321 (muscle group XXI).  The Board agreed a 10% rating was supported based on VASRD §4.40 (functional loss) or §4.59 (painful motion).  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 chest wall condition.  

BOARD FINDINGS:  In the matter of the chest wall condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  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 20150530, with attachments
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 
XXXXXXXXXXXXXXXXXX, AR20170000107 (P201500453)

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