RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01814
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070214

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Petroleum Supply Specialist, medically separated for “chronic pain, status post closed fracture of right 4th - 6th ribs…,” with a disability rating of 10%.

CI CONTENTION:  The CI did not submit a contention in the application.  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 - 20070118	VARD - 20070720	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Pain, S/P Closed Fracture of Right 4th - 6th Ribs…	5099-5003	10%	Residuals… Chest & Lung Injury	6843	0%	20070620	
			Scars from Punctured Lung	7804	10%	20070620	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Chronic Pain, Status Post Closed Fracture of Right 4th - 6th Ribs.  According to service treatment record and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s chronic pain, status post closed fracture of the right 4th to 6th ribs began in October 2005 after an all-terrain vehicle (ATV) accident.  In the emergency room on 29 October 2005, a chest tube was placed based on examination, chest X-rays that showed a right-side pneumothorax (collapsed lung) with multiple right rib fractures, and the CI’s difficulty breathing.  Additionally, a right-sided chest tube was put in place.  
Computed tomography (CT) scan on 25 August 2006, 6 months prior to separation, demonstrated a streaky density posterior to the major fissure in the right lower lobe, which may have represented scar in the area of prior trauma and chest tube placement.  Old rib fractures with some overlap and slight foreshortening of alignment of the ribs were also noted.  Pulmonary function tests (PFT) on 6 September 2006 (5 months prior to separation) revealed an FVC (forced vital capacity) of 79% predicted consistent with a mild restrictive ventilatory defect, an FEV1 (forced expiratory volume at 1 second) 94% predicted, and an FEV1/FVC 119% predicted.
  
During the 20 December 2006 MEB examination (recorded on DD Forms 2807-1 and 2808), 3 months prior to separation, the CI reported frequent shortness of breath and constant pain in the chest.  Physical examination revealed pain with deep inspiration and palpation of the right rib cage.  The 21 December 2006 MEB NARSUM examination, 3 months prior to separation, noted complaints of pain, rated 6/10 in severity, going to 8/10 with exertion and shortness of breath.  Physical examination showed the CI’s lungs were clear, but he had pain with deep inspiration and pain to palpation of the ribs on the right.  The examiner noted that while the CI still worked within his military specialty, there was a significant portion of his duties that he could not complete secondary to pain.

At the 21 March 2007 VA Compensation and Pension (C&P) evaluation, performed a month after separation, the CI reported right chest wall pain.  Examination revealed a 3.0 cm x 0.5 cm surgical scar, on the right side of the chest at the level of the seventh rib in the mammary line, a 2.5 cm x 10 cm surgical scar a little bit prominent (keloid-like) in the anterior axillary line at the level of the seventh rib, and a 2.5 cm x 0.6 cm surgical scar in the mid-axillary line at the level of the seventh rib.  All scars were tender, hyperpigmented and non-adherent to the subcutaneous tissue.  The CI was seen in April 2007, 2 months after separation, and his condition was assessed as right chest pain, chronic following traumatic injury, likely neuropathic/chronic inflammatory.     PFTs were FVC 82% predicted and FEV1/FVC 104% predicted, which were interpreted as normal results.  A CT scan on 23 April 2007 demonstrated remote healed rib fractures of the right fourth, fifth, and sixth ribs and no pneumothorax was present.  At the 20 June 2007 VA C&P respiratory evaluation, performed 4 months after separation, the CI reported almost constant shortness of breath and chest pain in the front of the right lung area that was penetrating to the rear aspect of that lung.  Physical examination of the lungs revealed breath sounds equal and the same bilaterally, and front and back.  On the right chest wall were two 1 1/4 inch scars from the chest tubes and a 1 inch scar from the chest tube.  Chest X-rays demonstrated old rib fractures and scarring of the bases.  PFTs revealed no obstruction, no restriction, and no significant change in air flow after an inhaler bronchodilator.  Spirometry was normal with the FEV1/FVC 88% predicted pre-bronchodilator and 94% predicted post-bronchodilator.  The examiner noted the CI had recently completed law enforcement training and was able to participate in physical training (2 mile runs).  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic pain, status post closed fracture of right 4th – 6th ribs condition 10%, coded analogously as 5099-5003 (arthritis, degenerative), citing the US Army Physical Disability Agency pain policy.   The VA rated the right ribs pain condition 0% coded 6843 (traumatic chest wall defect, pneumothorax, hernia, etc.), based on the VA C&P examination 4 months after separation, citing normal PFT and no medication or treatment for the condition.  The VA additionally rated the scars on the right chest 10%, coded 7804 (scar(s), unstable or painful).  Because there were no evidence of occasional incapacitating exacerbations despite X-ray evidence of involvement of two or more major joints or two or more minor joint groups, a 20% rating using analogous code 5099-5003 is not warranted.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel majority concluded there was insufficient cause to recommend a change in the PEB adjudication for the chronic pain, status post closed fracture of right 4th - 6th ribs.  
BOARD FINDINGS:  In the matter of the chronic pain, status post closed fracture of right 4th - 6th ribs condition and IAW VASRD §4.118, the panel majority recommends no change in the PEB adjudication.  The single voter for dissent submitted the appended minority opinion.  There were no other conditions within the panel’s scope of review for consideration.  The panel majority, 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 20150630, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

	
Minority Opinion.

The panel minority voter noted that scarring was presumably contributory to both the chest pain and shortness of breath.  The CT scan on 25 August 2006 demonstrated a streaky density posterior to the major fissure in the right lower lobe, which may have represented a scar in the area of prior trauma and chest tube placement.  Additionally, VA examinations within 12 months of separation noted three separate scars on the chest, all of which were tender.  Therefore, a 20% rating using code 7804 (three or four scars that are unstable or painful) is reasonable; however, there was no evidence that the scars were unstable, which would warrant an additional rating IAW code 7804 Note (2) (“If one or more scars are both unstable and painful, add 10 percent to the evaluation that is based on the total number of unstable or painful scars”). Nevertheless, despite the trauma and residual malalignment of the fractured ribs and the scars both on the skin and within the lung, pulmonary function studies both prior to and post-separation were within normal limits precluding a rating using code 6843, which requires decreased pulmonary function tests (FEV-1 of 71- to 80-percent predicted, or; FEV-1/FVC of 71 to 80 percent, or; DLCO (SB) 66- to 80-percent predicted) to warrant even a 10% rating.  While there were rib fractures, code 5297 requires removal of ribs in order to warrant a rating, which was not the case for the CI.

The majority raised the question whether coding and rating for the scars was actually consistent with the scope of review that was predicated on the PEB’s adjudication of “Chronic Pain, Status Post Closed Fracture of Right 4th - 6th Ribs.”  The minority voter’s view is a resounding yes since there was pain with deep inspiration and palpation of the right rib cage between the axillary line and mid clavicular [area] as well as worse pain with exertion.  Furthermore, the CI reported almost constant shortness of breath and chest pain in the anterior aspect of the right lung area that was penetrating to the posterior aspect of that lung.  Those findings all unequivocally support a role for the scarring in the genesis of the CI’s pain whether it was on the surface or deep within the lung.  The scarring, therefore, did not represent a new condition brought in to generate an additional rating, but was a source of pain, which was the not only his chief complaint but was congruent with the PEB’s disability description of the unfitting condition and occurred as a direct result of the trauma, tube placement and removal, and healing processes as well as by movement of the ribs and right lung interactions with the scars, which were stretched and pulled while breathing, and even more so during exertion.

Considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel minority recommends a disability rating of 20% for the chronic pain, status post closed fracture of right 4th - 6th ribs condition, coded 7804 IAW VASRD §4.118.    

AR20170007432, 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