RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00968
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20040407

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Heavy Wheeled Vehicle Mechanic, medically separated for “chronic chest wall pain,” with a disability rating of 10%.

CI CONTENTION:  “I was not medically retired from the military but received a 70% disability from the VA right at separation.”  The complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The panel’s scope of review is defined in DoDI 6040.44.  It is limited to review of disability ratings assigned 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 or non-compensable.  Any conditions outside the panel’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 panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The panel’s assessment of the PEB rating determination is based on 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(s) at the time of separation.  The panel 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 panel 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 - 20040114	VARD - 20050119	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chest Wall Pain	5099-5003	10%	Anterior Chest Wall Pain	6699-7804	0%	20040218	
Osteoarthritis, R Knee	Not Unfitting 	Residuals of ACL Repair, R Knee with DJD and Scar	5010-5257	10%	20040218	
Osteoarthritis, L Knee	Not Unfitting	Retropatellar Pain Syndrome, L Knee with DJD	5010-5014	10%	20040218	
Low Back Pain	Not Unfitting	DDD, Lumbosacral Spine	5010-5243	40%	20040218	
Right Shoulder Pain S/P Rotator Cuff Repair	Not Unfitting	Residuals, Right Shoulder Rotator Cuff Repair	5010-5201	30%	20040218	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  70%	

ANALYSIS SUMMARY:  

Chest Wall Pain.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s chest pain condition began in May 2002 after he developed a right lower lobe pneumonia with complications that included an empyema (a walled off collection of infectious fluid) requiring drainage with a chest tube.  In June of 2002 the CI was seen in pulmonary clinic for follow-up.  He reported anterior chest wall pain at the site of the chest tube scar.  Chest X-rays showed residual scarring at the site of the right lower lobe pneumonia without other complications.  The CI was evaluated 8 weeks later and noted he was able to be very active and was running several miles per day, but he still reported chest wall pain with any pressure over the site of the scar.  Repeat chest X-rays and a computed tomography scan in November 2002 were normal, except for the previously noted scarring.  The CI was evaluated by a cardiothoracic surgeon and the assessment was intercostal nerve related pain and a referral to pain clinic was recommended.  The MEB NARSUM examination on 13 August 2003, 8 months prior to separation, noted complaints of chronic chest wall pain.  Physical examination showed a normal exam of the heart and lungs.  The chest wall incision was well healed.  The MEB NARSUM examiner indicated that the chest wall pain impaired the CI’s ability to perform exertional activities and wear a rucksack or other equipment.  

At the 18 February 2004 VA Compensation and Pension (C&P) evaluation, performed 2 months before separation, the CI reported anterior chest wall pain with use of anti-inflammatory medication and occasional pain medication.  Physical exam showed two scars from the chest tube that were not raised, depressed, adherent and there was no loss of tissue.  The scars and surrounding area were tender to palpation (TTP).  There was TTP that extended to the right anterior flank.  

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the chest wall pain 10%, coded 5099-5003 (analogous to arthritis, degenerative), citing application of the US Army Physical Disability Agency (USAPDA) pain policy, slight/constant.  The VA also rated the chest wall pain condition 10%, but coded 6699-7804 (scars, superficial painful on examination), based on the VA C&P examination 2 months before separation, citing painful scars on examination.  

There was evidence of persistent anterior chest wall pain thought to be related to an intercostal nerve neuropathy due to damage or scarring from the chest tube placement (intercostal nerves travel from the thoracic spine anterior, just under the ribs).   The panel noted there was not a VASRD code for incomplete paralysis of the intercostal nerve and deliberated which nerve code was the best analogous code for the anterior chest pain.  The anterior branches of the upper thoracic intercostal nerves supply sensation to the anterior chest skin and breasts.  The most similar nerve code in function and symptomology the panel noted was 8529 (external cutaneous nerve of the thigh), which supplies sensation to the upper outer thigh; compression/irritation of the nerve causes localized thigh pain.  The rating criteria of 8529 provide 0% for “mild” or “moderate” incomplete paralysis, and 10% for “severe.”  The panel agreed that the incomplete paralysis, which was wholly sensory could not achieve higher than a 0% rating with this code because according to the VASRD when the “involvement is wholly sensory the rating should be for the mild, or at most, the moderate degree.”  Members looked to see if any other §4.124a code provided a higher evaluation, but found none that were closely similar in anatomic location, function and symptomology to the CI’s disability IAW §4.20 (Analogous ratings).  There was no pathology of the lungs that contributed to the ongoing pain identified for rating IAW VASRD 4.97 (respiratory system).  Following resolution of acute pneumonia, ratings are based on residuals related to either pulmonary function abnormalities, decreased exercise capacity, or cardiac or pulmonary complications, none of which were present in this case.  The CI was noted to be able to run several miles without difficulty despite the chest pain, which was mainly aggravated by direct pressure externally.  A 10% rating was supported coded as 7802 and there was no higher rating warranted under any other VASRD scar coding.  There was no higher rating available than the 10% provided by the PEB under any applicable VASRD code and the PEB’s reliance on the USAPDA pain policy for rating was not detrimental to arriving at the highest rating.  Therefore, no change to the code is recommended.  After due deliberation in consideration of the preponderance of the evidence, the panel concluded that there was insufficient cause to recommend a change in the PEB adjudication for the chronic anterior chest wall pain condition.  

Contended PEB Conditions.  The panel’s main charge is to assess the fairness of the PEB’s determination that the right knee osteoarthritis, left knee osteoarthritis, low back pain, and right shoulder pain conditions were not unfitting.  

Right and Left Knee Osteoarthritis.  The CI had right knee anterior cruciate ligament reconstruction following an injury in 1996 and also had a history of left knee pain, less than the right, without specific injury.  In June 2002 the CI was given a permanent L2 profile for bilateral knee pain.  This L2 profile prohibited running or walking for conditioning and indicated no push-ups, but allowed alternate aerobic events of swimming or bicycling and push-ups to satisfy Army physical fitness testing (APFT) requirements.  A pulmonary clinic visit on 24 September 2003 noted that the CI was “running several miles” daily without problems.  The commander’s statement dated 30 September 2003 implicated the knees, but comments about profile limitations appeared to be referencing a temporary profile stating “if the profile is determined to be permanent he will have difficulty performing his mission.”  The Ortho MEB examiner indicated the CI failed retention standards for the right and left knees, but he recommended profile limitations which mirrored the permanent L2 profile in record.  Neither knee condition was listed on the permanent profile dated June 2003.  The PEB discontinued the PEB proceedings and specifically asked the MEB to clarify profile requirements for this condition in October 2003 and there was no evidence in record that the MEB provided an updated profile.  The record indicated the CI had intermittent flare-ups of knee symptoms through the years but there was no evidence in record of a new injury or significant change in either knee condition proximate to separation.  Per the Commander’s statement the CI was an instructor for the Drivers Training Program and his performance was “excellent.”  The panel noted as well that the permanent P3 profile for the chronic chest wall pain condition issued in June 2003 was more restrictive (prohibited all APFT) than the physical limitations recommended by the MEB orthopedic evaluation in September 2003.  Therefore, the panel concluded that there was not a preponderance of evidence in record to overcome the PEB’s fitness determination.  

Low Back Pain.  There were temporary profiles for the low back condition in record 27 March 2003 and 21 May 2003.  The physical therapy visit on 21 May 2003 noted that there had been improvement in the “lumbar derangement” with improved right great toe strength.  The profile was lightened and noted the CI could lift up to 40 pounds and could run and walk at his own pace, march up to 5 miles at his own pace, but no physical fitness testing or rucksack for 30 days.  The back condition was not permanently profiled.  The Orthopedic (Ortho) MEB addendum 4 September 2003 noted that the CI had been helped “a fair amount” by physical therapy for his back and no further intervention was recommended at the time.  The Ortho MEB addendum indicated the CI failed to meet retention standards for the back condition, but also noted that the CI’s knees were his most limiting orthopedic condition.  Ortho recommended that the CI would need the profile limitations noted above, which were the same as for the L2 profile for the knees.  As noted above, the PEB specifically requested additional information about profile requirements for this condition in October 2003 and there was no evidence in record that the MEB provided an updated profile and the commander’s statement dated 30 September 2003 did not implicate the back condition.  

Right shoulder.  The CI underwent a right rotator cuff repair in 1996.  In 2001 the CI completed a physical fitness test scoring the maximum 100 points for push-ups.  At the Orthopedic MEB addendum the CI reported persistent symptoms of the right shoulder, but there were no treatment visits for the shoulder in record more recent than December 1996.  The right shoulder condition was not permanently profiled or implicated in the commander’s statement.  The Ortho MEB examiner indicated the CI failed retention standards for the shoulder, but recommended physical limitations that mirrored the permanent L2 profile in record as elaborated on previously, which included no push-ups, although it appeared push-ups for APFT testing were permitted.  The PEB specifically asked the MEB about profile requirements for this condition in October 2003 and there was no evidence in record that the MEB provided an updated profile.  There was no evidence that the right shoulder significantly interfered with the CI’s ability to adequately perform his duties proximate to separation.  

After due deliberation, the panel concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the right knee, left knee, low back or right shoulder conditions.

BOARD FINDINGS:  In the matter of the chronic chest wall pain condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the contended right knee osteoarthritis, left knee osteoarthritis, low back pain and right shoulder pain conditions, the panel unanimously recommends no change from the PEB determinations as not unfitting.  There were no other conditions within the panel’s scope of review for consideration.  The panel, 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 20150609, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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Dear XXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found your separation disability rating and your separation from the Army for disability with severance pay to be accurate.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed), and I accept its recommendation.  I regret to inform you that your application to the DoD PDBR is denied.  

	This decision is final.  Recourse within the Department of Defense or the Department of the Army is exhausted; however, you have the option to seek relief by filing suit in a court of appropriate jurisdiction.

Sincerely,