RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  pd-2016-01537
BRANCH OF SERVICE:  navy	SEPARATION DATE:  20041223

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Tactical Air Navigation Technician, medically separated for “long thoracic injury” with a disability rating of 20%.  

CI CONTENTION:  “At the time of separation there was still issues that were unknown.  They separated me simply because of the length of time I was on limited duty and it was enough for 20%.  The damage to my back and the loss of feeling in my legs were not considered.  At the time of separation I had not completed physical therapy or noticed that I have neuropathy in my legs.  I am 80% rated by the VA and all ratings from the VA were a result from my accident that lead to my discharge.  All are service connected as indicated in my VA records.”  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 Medical Evaluation Board (MEB), but determined by the PEB 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 conditions 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 (VA), 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 - 20040927	VARD - 20041220	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Long Thoracic Injury	8519	20%	Left Long Thoracic Nerve Injury	8519	20%	20041119	
Bilateral Shoulder Dysfunction	Cat II	No VA placement	
Musculoskeletal Injuries of Trunk and Lower Back	Not Unfitting	Musculoskeletal Injuries Trunk and Lower Back 	5243-5237	0%		
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Long Thoracic Nerve Injury and Bilateral Shoulder Dysfunction.  The PEB combined the left long thoracic nerve injury and bilateral shoulder dysfunction conditions under a single disability rating, coded 8519 (complete paralysis of the long thoracic nerve, non-dominant side) and rated 20%.  This approach by the PEB not uncommonly reflected its judgment that the constellation of conditions was unfitting and there was no need for separate fitness adjudications.  The panel’s initial charge in this case was therefore directed at determining if combining conditions under a single rating was justified in lieu of separate ratings.  When considering a separate rating for each condition, the panel considers each bundled condition to be reasonably justified as separately unfitting unless a preponderance of evidence indicates the condition would not cause the member to be referred into the DES or be found unfit because of physical disability.  When the panel recommends separate fitness recommendations in this circumstance, its recommendations may not produce a lower combined rating than that of the PEB.  

According to the service treatment record (STR) and the MEB narrative summary (NARSUM), the CI’s long thoracic nerve injury and bilateral shoulder dysfunction conditions began in February 2003 after a fall from a height of 30 to 35 feet causing multiple traumatic injuries.  One of those injuries was a transection of the thoracic aorta requiring emergent thoracotomy with repair of the aorta.  The repair was successful but left the CI with a winged scapula which his surgeons attributed to transection of the long thoracic nerve during the thoracotomy.  A 14 January 2004 neurodiagnostic study confirmed severe chronic injury to the long thoracic nerve with no signs of reinnervation.  

The 3 June 2004 MEB NARSUM examination, 6 months prior to separation, noted complaints of left shoulder pain and winging of the scapula with movements at the shoulder.  CI complained of not being able to extend his arm above the shoulder level primarily on the left.  Physical examination showed “obvious left winged scapula” and inability to lift his arms above his shoulders.  A 1 July 2004 MEB NARSUM Addendum examination, 5 months prior to separation, did not contribute new complaints with respect to his shoulders.  Physical examination showed full active range of motion (ROM) with dramatic scapular winging on the left.  Additionally, his right shoulder revealed full active ROM without tenderness or painful motion.  

At the 19 November 2004 VA Compensation and Pension (C&P) evaluation, 1 month before separation, the CI reported he was unable to raise his left arm above the shoulder level and he did not have pain in the shoulder, just weakness.  Physical examination showed winged scapula on the left with abduction of the left shoulder limited to 85 degrees (normal 180).  Flexion, internal rotation and external rotation of the left shoulder were all recorded as normal. Crepitation with movement was demonstrated by the right shoulder but full ROM and no mention of painful motion.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left long thoracic nerve injury condition 20%, coded 8519, citing a winged scapula and limited arm ROM.  The Navy PEB listed the bilateral shoulder dysfunction conditions as related diagnoses (Category II) contributing to the disability in this case.  The panel concluded the left shoulder condition was not a separate condition which could be reasonably justified as separately unfitting; nor would separate ratings be achievable without violation of VASRD §4.14 (avoidance of pyramiding) due to the shoulder ROM being included as a criteria for the most severe rating under code 8519.  The right shoulder dysfunction will be considered below.  The VA also rated the left long thoracic nerve injury condition 20%, coded 8519, based on the C&P examination 1 month before separation, citing the CI’s inability to raise his arm above shoulder level with a winged scapula.  

The panel noted the PEB assigned the highest rating under the 8519 code and there are no other applicable codes.  There is no VASRD §4.124a or §4.71a route to a higher rating that the 20% adjudicated by the PEB.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded there was insufficient cause to recommend a change in the PEB adjudication for the left long thoracic nerve injury with left shoulder dysfunction condition.  

Right Shoulder Dysfunction.  The panel first considered if the right shoulder dysfunction, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The right shoulder was not implicated in the non-medical assessment, only the left shoulder.  In the examinations most proximate to separation, there was no evidence of dysfunction of the right shoulder which would have contributed to his inability to perform his military duties and accordingly cannot recommend a separate rating for it.  

Contended PEB Condition:  Musculoskeletal Injuries of the Trunk and Low Back.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended condition was not unfitting.  The contended condition did not carry attached duty limitations, was not implicated in the commander’s non-medical assessment and was not judged to fail retention standards. There was no performance-based evidence from the record that the condition significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded there was insufficient cause to recommend a change in the PEB fitness determination for the contended condition and so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the left long thoracic nerve injury condition and IAW VASRD §4.124a, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the right shoulder dysfunction condition and IAW VASRD §4.71a, the panel unanimously cannot recommend if for additional disability rating.  In the matter of the contended musculoskeletal injuries of the trunk and back condition, the panel unanimously recommends no change from the PEB determination as not unfitting.  There are no other conditions within the panel’s scope of review for consideration.  Therefore, the panel recommends no modification or re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20161019, w/attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

MEMORANDUM FOR DIRECTOR, SECRETARY OF THE NAVY COUNCIL OF REVIEW
               BOARDS 

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS
 
Ref:   (a) DoDI 6040.44

      In accordance with reference (a), I have reviewed the cases listed below and approve the recommendations of the PDBR that the following individual’s records not be corrected to reflect a change in either characterization of separation or in the disability rating previously assigned by the Department of the Navy’s Physical Evaluation Board:

		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USMC

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