RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00516
BRANCH OF SERVICE:  army	SEPARATION DATE:  20050109

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

CI CONTENTION:  The CI made no specific contention.  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 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 - 20041102	VARD - 20051027	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Abdominal and Chest Wall Pain	5099-5003	10%  	Chest and Abdominal Wall Pain 	6843	20%	20050623	
COMBINED RATING:  10%.  	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

Chronic Abdominal and Chest Wall Pain.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), on 13 November 2003 the CI sustained multiple shrapnel injuries from a 122 mm rocket at Forward Operating Base, Sainte Mere in Fallujah, Iraq.  He sustained an open wound to the thorax, a traumatic hem thorax (blood between chest wall and lungs causing lung collapse), diaphragm injury, and a torn spleen capsule.  The CI underwent an emergent exploratory laparotomy (surgical incision into abdominal cavity), thoracotomy (chest wall surgical incision), diaphragm repair, and splenorrhaphy (suturing of a ruptured spleen).  Following medevac to Landstuhl regional medical center, a chest tube was placed secondary to a residual pneumothorax (gas between chest wall and lungs causing lung collapse).  On hospital day two, the chest tube was pulled and a follow-up chest radiographic (X-ray) study revealed an asymptomatic residual pneumothorax.  A dart catheter was placed (2nd intercostal space), left in place for less than 24 hours, and discontinued secondary to improved chest X-ray.  

The 27 July 2004 chest X-rays revealed a left upper abdominal quadrant 2 mm density that could represent a radiopaque foreign body.  There was blunting of the left cost phrenic angle (angle between the costal and diaphragmatic parietal pleura) which could represent chronic change or a small effusion.  The 27 July 2004, baseline pulmonary function tests (PFTs) revealed the forced expiratory volume in 1 second (FEV-1) was 73% predicted, the forced vital capacity (FVC) was 71% predicted, the FEV-1/FVC was 105%.  The 19 August 2004 PFTs documented the FEV-1 was 75% predicted, the FVC was 81% predicted, and the FEV-1/FVC was 95%.  

At the 19 August 2004 pulmonary evaluation, the CI complained of persistent postoperative pain which significantly limited his activity.  The examiner documented only minor pain, pain with exercise, and pain with contact.  Occasional pleuritic (pain from inflamed pleural membranes) component.  Local pain, and pain with carrying heavy objects.  No breathing problems prior to injury.  The physical examination revealed the lungs were clear to auscultation bilaterally with slight decreased chest wall excursion secondary to pain.  The 27 July 2004 PFTs were interpreted as showing a restrictive pattern, and the 19 August 2004 PFTs were interpreted as normal.  The assessment listed persistent chest wall pain status post injury leading to mild splinting.  The pulmonologist opined there was no evidence of underlying lung disease and that the initial PFTs were abnormal due to pain precluding full efforts, consistent with a restrictive pattern.  The examiner documented there was no need for further evaluation.  

The 2 September 2004 MEB examination (recorded on DD Forms 2807-1 and 2808), 4 months before separation, revealed the abdomen was soft with normal bowel sounds and no rebound tenderness.  There was mild tenderness along the linear vertical scar and at the left subcostal margin.  The examination noted complaints of chronic, sharp, 3/10 abdominal wall and chest wall pain.  Pain was exacerbated to 7/10 by exercise and relieved with decreased activity and rest.  He did not experience significant improvement with activity modification, physical therapy, and non-steroidal anti-inflammatory drugs.  Under physical examination, the author documented “Performed by the Physical Examination Section of Ft. Bragg North Carolina on 2 September 2004 … His examination is unremarkable with the exception of the findings of his abdominal and chest walls.”  The diagnosis listed chronic abdominal and chest wall pain secondary to multiple shrapnel injuries.  

The 23 June 2005 VA Compensation and Pension (C&P) evaluation, 6 months after separation, recounted the history and interventions.  “The veteran states that since January he has had two episodes when he is exerting himself he gets some shortness of breath and an irregular heartbeat, which lasts for two to three minutes and then it goes away.  He states that this last happened about a month ago.  He states that all the areas where he has had the chest tubes, penetration, needle thoracentesis and his laparotomy scar are sensitive to touch.  He also gets sort of a pleuritic pain at times in the left chest wall.  He states that he gets some bad spasms also in his chest.  The veteran's current medications are Advil as needed about once every two to three weeks for chest soreness.”  The thorax examination documented “The veteran has a 0.3 cm scar in the left upper anterior chest wall where he had a needle thoracentesis.  It seems to be slightly sensitive to touch.  He has a 1.5 x 1.5 ovoid scar in the lower left anterior chest wall where he had the shrapnel penetrate.  That scar is also sensitive.  He has a 4 cm scar in the lower left lateral chest wall where he had a chest tube.  This is also sensitive to touch.”  The lungs were clear to auscultation without rales (abnormal respiratory sounds from fluid accumulation), rhonchi (abnormal respiratory sounds from airway secretions), or wheezes.  The abdominal examination documented “There is a 28.5 cm scar, which goes from the epigastric area to the pubic area.  This scar is sensitive especially in the upper 5 or 6 cm of the scar.  No masses can be palpated.”  The examiner recounted the findings of the chest X-rays and 27 July 2004 PFTs (FEV-1 was 73% predicted and FVC was 71% predicted).  The assessment listed chest and abdominal wall pain secondary to shell fragment penetrating wound status post diaphragm surgical repair, splenorrhaphy, and pneumothorax chest tube.  The 6 July 2005 PFTs documented the FEV-1 was 75% predicted, the FVC was 80% predicted, and the FEV-1/FVC was 80%.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating, under an analogous 5003 code (arthritis, degenerative), citing chronic abdominal and chest wall pain secondary to multiple shrapnel injuries, tender scars, soft abdomen, and normal bowel sounds by physical examination, and self-reporting of using over-the-counter pain medications.  The VA assigned a 20% rating, under the 6843 code (traumatic chest wall defect, pneumothorax, hernia, etc.), citing chest and abdominal wall pain secondary to shell fragment wound penetrating the left chest and status post splenorrhaphy.  

Serial PFTs revealed FEV-1 values that were consistent with the 10% rating (FEV-1 of 71- to 80% predicted, or; FEV-1/FVC of 71 to 80%, or; DLCO (SB) 66- to 80% predicted) under 6843.  Serial FEV-1 values were not consistent with the higher 30% rating (FEV-1 of 56- to 70% predicted, or; FEV-1/FVC of 56 to 70%, or; DLCO (SB) 56- to 65% predicted) under 6843.  The CI reported pain with exercise and exertion.  Panel members agreed this was consistent with the 20% rating (Note [3]: Gunshot wounds of the pleural cavity with bullet or missile retained in lung, pain or discomfort on exertion, or with scattered rales or some limitation of excursion of diaphragm or of lower chest expansion shall be rated at least 20% disabling) under 6843.  

The C&P examination findings of four scars that were “sensitive” was consistent with the 20% rating (three or four scars that are unstable or painful) 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.  

Panel members agreed that the disability more closely approximated the severe/moderately severe (20%) than the moderate (10%) rating under 5321 (muscle group XXI).  The panel 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 panel recommends a disability rating of 20% for the abdominal and abdominal and chest wall pain condition, coded 6843.  

BOARD FINDINGS:  In the matter of the chronic abdominal and chest wall pain condition, the panel unanimously recommends a disability rating of 20%, coded 6843 IAW VASRD §4.71a.  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	
Chronic Abdominal and Chest Wall Pain	6843	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160705, with attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

AR20170015806, 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