RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01787
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070607

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Unit Supply Specialist, medically separated from the Temporary Disability Retired List (TDRL) for “right (dominant) brachial plexopathy” with a disability rating of 20%.

CI CONTENTION:  The CI requested ratings changes to include limited motion of bilateral temporomandibular articulation.  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 –20070405	VARD - 20061025	
Condition	Code	Rating	Condition	Code	Rating 	Exam	
Right (Dominant) Brachial Plexopathy 	8512	20%	Right Brachial Plexopathy…	8517	20%	20060509	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

Right (Dominant) Brachial Plexopathy.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the right-side dominant CI first presented on 25 March 2005 for right shoulder pain and numbness while running.  He reported an old fracture of the clavicle (collar bone) in 1996.  He was seen in primary care 5 days later and reported that he fell onto a tree branch on a road march.  He endorsed numbness with direct pressure over the shoulder.  Redness of the clavicle was noted.  Both strength and range of motion (ROM) were decreased.  On follow-up on 8 April 2005, he showed tenderness at the acromioclavicular joint (ACJ, the joint between the collar bone and the shoulder).  Motion was painful, but limitations not documented.  Strength was normal.  X-rays showed an old, healed fracture of the mid-clavicle with some deformity.  Possible impingement of the brachial plexus (a nerve bundle near the shoulder than supplies the arm) was thought to be present.  Specific films of the ACJ with and without weight bearing were normal on 12 April 2005.  He was treated in physical therapy for the right shoulder pain, but his symptoms persisted.  On 1 June 2005, he reported right arm numbness while running.  MRIs of the brain and cervical spine were done the next day and were both normal.  Electrodiagnostic testing (EDX) of the upper extremities was suggestive of a mild right brachio-plexopathy of the upper trunk (C5 and C6 nerve roots).  (Signs include weak external rotation, abduction, and elbow flexion.  Reflexes of the biceps and brachioradialis may be diminished.  Sensory loss of digits 1, 2, and 3 can also be found.)  In physical therapy the same day, the CI was noted to have normal sensory and motor function with intact reflexes.  Atrophy was absent.  Marked tenderness over the mid-clavicle was present.  The ROM was full but guarded due to pain.  The CI was issued a U3 profile and referred for an MEB.  

At the MEB examination (recorded on DD Forms 2807 and 2808) dated 30 August 2005, 8 months prior to separation, the CI reported numbness and tingling of the right arm with swelling of the right hand since March 2005.  Movement of the right shoulder was noted to be decreased and strength was reduced in the handwritten comments.  However, the neurological examination was checked “normal.”  The 12 September 2005 orthopedic addendum to the MEB NARSUM, 7 months prior to TDRL placement, the CI reported progression in his symptoms and that he now dropped glasses and had trouble opening door knobs.  On examination, flexion was reduced to 170 degrees (VA normal 180) with normal abduction at 180 degrees.  Atrophy was absent.  Sensation was intact.  The triceps reflex (C7) was absent.  The right triceps was weak (C6-T1) at 4/5.  The hand intrinsic muscles (C5-T1) were also weak at 3/5.  The biceps (C5-7) was intact.  The MEB NARSUM general examination was dated 6 October 2005, 6 months prior to separation.  The CI reported ongoing pain and weakness.  The CI was working in his primary MOS which included moving boxes around.  He reported little effect from the condition while in garrison other than physical fitness training and testing.  No additional physical examination was done for this evaluation.  A VA primary care note dated 8 December 2005 documented that the sensory, motor, and reflex examinations were normal.  The MEB forwarded “right upper extremity brachial plexopathy” for PEB adjudication.  The CI was placed on TDRL effected 2 April 2006.  

The 9 May 2006 VA Compensation and Pension (C&P) general and neurology evaluations were performed 1 month later.  He reported continued pain, numbness, and weakness of the right upper extremity.  He had some difficulty with writing.  He was noted to have a normal gait and no difficulty changing positions getting on and off the examination table or up from a chair.  On examination, the right deltoid was 4+/5.  The right triceps 4+/5.  The right biceps 4+/5.  The grip was 4/5.  The hand intrinsic muscles were 4+/5.  Atrophy of the right deltoid and upper arm was present.  Reflexes were absent for the right triceps and diminished for the right brachioradialis.  Sensation was intact.  The diagnosis of diffuse weakness from brachio-plexopathy was continued.  

The CI underwent the TDRL re-evaluation on 15 March 2007, 11 months after TDRL placement and 3 months prior to TDRL removal.  He reported that his trip strength was stable most of the time and that he could carry two plastic grocery bags up two flights of stairs.  He still had some difficulty turning some doorknobs.  He had less trouble with writing that before.  Repeat EDX studies in January 2007 (not otherwise in evidence) were normal.  It noted that the pain was improved with a medication (Gabapentin) and it was thought that etiology might be from the shoulder.  The cervical spine MRI was repeated and remained normal.  An MRI arthrogram (joint study) of the right shoulder showed a tear of the cartilage lining of the shoulder as well as a rotator cuff injury.  The examining orthopedist opined that the shoulder pathology could be contributing to his symptoms, but it was not clear that this was the primary source.  The orthopedist opined that the CI had not completed an adequate evaluation or treatment yet though.  The CI reported that his strength and numbness were both gradually improving.  On examination, grip strength and forearm rotation (pronation and supination) were both 4-/5.  Triceps function was 4-/5 and biceps 4+/5.  Effort was questionable though as there was jerkiness when the extremities were tested simultaneously; this was consistent with poor effort.  Atrophy was absent.  Reflexes were symmetric.  Sensation was intact.  The ROM of the shoulders had been noted in orthopedics as full.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right major brachio-plexopathy condition 20% at TDRL removal, coded 8512 (paralysis of the lower [cervical] radicular group at the moderate and mild levels).  The VA rated the right major brachio-plexopathy condition at 20%, coded 8517 (neuralgia of the lower [cervical] radicular group at the mild level).  This was based on the C&P examination accomplished one month after TDRL placement.  No additional VA rating or evaluation was in evidence.  The panel considered the evidence.  The CI had findings of weakness and atrophy present on the examination proximate to TDRL entry.  However, he good ROM and adequate function in that he was able to work and use his dominant right upper extremity.  The panel considered the final disability rating.  The EDX studies were now normal.  Atrophy was not present.  The sensory and reflex examinations were normal.  Weakness was observed, but testing was consistent with poor effort.  The evidence does not support a level of impairment higher than the mild severity determined by the PEB.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded that there was insufficient cause to recommend a change in the PEB adjudication for the “right (dominant) brachial plexopathy”.

BOARD FINDINGS:  In the matter of the “right (dominant) brachial plexopathy” condition and IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudication.  There are 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 20150703, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170009073, XXXXXXXXXXXXXXXXXXXXX 

XXXXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXXXX:

	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,					       
						      					
Enclosure