RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02406
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20030501

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reserve O4, Engineer Officer, medically separated for “thoracic outlet syndrome” with a disability rating of 0%.

CI CONTENTION:  “I was separated for thoracic outlet syndrome in 2003.  I continue to have persistent pain and numbness in my left arm which limits my ability to use that arm.  Request reconsideration as this is a chronic condition.”  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 progression or complications of service-connected conditions after separation.  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 - 20030318	VARD - 20040518	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Thoracic Outlet Syndrome	8599-8513	0%	Thoracic Outlet Syndrome	8510	NSC	20040223	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  Primary source documents including radiographic (X-rays), electromyography (EMG) study results, and vascular studies as well as consultant reports performed prior to the CI’s mobilization were not available in evidence before the panel.  Although the missing documents may contain relevant evidence, members agreed that the available service treatment record (STR) and VA evidence is sufficiently probative to render a fair assessment of the presence or absence of applicable VASRD rating criteria and functional limitations.  Thus, it is believed that the missing evidence did not materially affect the panel’s recommendations.

Thoracic Outlet Syndrome.  According to STR and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI was evaluated in January 2003 for persistent symptoms indicative of early thoracic outlet syndrome, which caused pain in the left shoulder and left hand due to compression of structures.  While still undergoing testing, the CI was mobilized for active duty effective on 18 February 2003.  

During the 21 February 2003 MEB examination (recorded on DD Forms 2807-1 and 2808), 2 months prior to separation, the CI reported having the thoracic outlet syndrome.  The examiner only recorded “LT” for clinical evaluation of the upper extremities and noted the CI had documented thoracic outlet syndrome with symptoms involving overhead work and any significant compression over the shoulder.  A P3 profile was issued on 26 February 2003 with restrictions of no lifting, wearing a backpack, carrying a rifle, or participating in physical training except for walking or running at his own pace.  

The 25 February 2003 MEB NARSUM examination, 2 months prior to separation, noted complaints of increasing symptoms over the prior 4 months with paresthesias and numbness into his hands much worse on the left than the right, which was not in the scope of review.  Weakness was minimal and moving his arms about improved symptoms briefly.  He did not wake up with symptoms and denied leg difficulties, gait problems, or obvious cranial nerve changes.  The neurologist, who authored the NARSUM noted that the CI had an EMG in January 2003, prior to his mobilization, which did not reveal any significant pathology, and X-rays of the spine that did not demonstrate cervical ribs; however, vascular flow studies were positive for compression of vasculature in the shoulder with arm elevation.   

The MEB NARSUM physical examination showed a male, who was awake and alert.  His neck had fair mobility with symmetric carotid pulsations without any bruits (vascular murmurs) in the neck or shoulders.  Pulses were present in both upper extremities although slightly more easily elicited in the right arm than the left; however, there was a complete loss of pulses with elevation of the arms bilaterally, which also generated paresthesia into the hands, left worse than the right.  Pulses of the lower extremities were adequate and he had an adequate range of motion of the lumbar spine.   There was no tenderness at Erb’s point bilaterally (the site of the upper trunk of the brachial plexus (collection of nerves of the upper extremity) two to three centimeters above the clavicle).  His blood pressure was 138/88 in the left arm and 140/90 in the right arm at rest.  Neurologic evaluation demonstrated the CI had adequate strength without drift, atrophy, or abnormal movements.  The CI noted decreased pain, light touch and temperature sensation in an ulnar distribution of the left arm, extending into the forearm.  Reflexes were hypoactive in the upper extremity at 1/5 and 2/5 in the lower extremities.  The examiner noted that physical therapy and medication for the thoracic outlet syndrome may be of some benefit, but further activity with the use of the upper extremities such as with lifting or activity with arms at shoulder-height or above would markedly increase his difficulties.

At the 23 February 2004 VA Compensation and Pension evaluation, 10 months after separation, the CI reported numbness and tingling involving the fingers of his left hand and an aching, painful sensation in the left shoulder, which was aggravated by lifting objects more than 25 pounds.  He did not notice his arm turning blue in color.  Physical examination showed his blood pressure to be 140/70 in the right arm and 136/66 in the left arm.  Examination of the neck was normal.  Adson’s maneuver (to determine thoracic outlet syndrome) did not produce reduction of the arterial pulses in the left upper extremity; however, there was a significant decrease in pulse pressure (difference between the systolic and diastolic pressures) with the military position.  Motor strength was 4/5 of the left deltoid and triceps and motor strength of the biceps, wrists, and finger strength was 5/5.  Right upper extremity muscle strength was 5/5 and there was no winging of the scapula noted.  The examiner’s diagnosis was thoracic outlet syndrome, left upper extremity.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the thoracic outlet syndrome condition 0%, analogously coded 8513 (all radicular groups, paralysis of), citing mild, intermittent and usually relieved by change of body position and rated IAW AR 635-40, para B-15.  The condition existed prior to service (EPTS) without evidence of permanent service aggravation; however, 10 USC 1207 (8 year rule) was applicable.  The VA did not service connect the thoracic outlet syndrome condition, coded 8510 (upper radicular group (fifth and sixth cervical), citing there was no evidence that the condition permanently worsened as a result of service.  

Since the 8 year rule was invoked, neither EPTS nor service aggravation issues are applicable Members first discussed whether the PEB interpreted the thoracic outlet syndrome as a bilateral or unilateral condition since its description was unclear.  However, the CI’s contention related only to the left arm, albeit the NARSUM referenced both upper extremities, while the profile addressed only the left shoulder and commander’s statement mentioned only the left shoulder and left hand.  Therefore, panel members agreed that the left upper extremity condition was separately unfitting since the evidence was eminently clear that left upper extremity was more symptomatic and potentially disabling, albeit mild and intermittent, than the right upper extremity, which is not in the scope of review.  Therefore, panel members felt a 20% rating and no higher for the left upper extremity using code 8599-8513 (mild) is applicable since the CI had profile restrictions in regard to lifting, wearing a backpack, and carrying a rifle as well as participating in physical training.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability ratings of 20% for the left upper extremity thoracic outlet syndrome condition, coded 8599-8513.  

BOARD FINDINGS:  In the matter of the thoracic outlet syndrome, the panel unanimously recommends a disability rating for the left upper extremity of 20%, coded 8599-8513 IAW VASRD §4.124a.  There were no other conditions within the panel’s scope of review for consideration.  The panel recommends that the CI’s prior determination be modified as follows, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Thoracic Outlet Syndrome, Left Upper Extremity	8599-8513	20%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150925, w/attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170012867, XXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found that your disability rating should be modified but not to the degree that would justify changing your separation for disability with severance pay to a permanent retirement with disability.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed) and I accept its recommendation.  This will not result in any change to your separation document or the amount of severance pay.  A copy of this decision will be filed with your Physical Evaluation Board records.  I regret that the facts of the case did not provide you with the outcome you may have desired.
  
	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. 

	A copy of this decision has also been provided to the Department of Veterans Affairs.

Sincerely,	
Enclosure