RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01544
BRANCH OF SERVICE:  aIR FORCE	SEPARATION DATE:  20040607

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, SERE Operations Craftsman, medically separated for “thoracic outlet syndrome” with a disability rating of 20%.

CI CONTENTION:  “This was one of many conditions the VA has indicated as service connected.  I continue to suffer and be limited by this condition today.  Current 70% VA rating.”  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.  The panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections when appropriate.  The panel’s assessment of the PEB rating determination is based on review of medical records and all available evidence relevant to application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards for 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, which operates 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 disability at the time of separation.  

RATING COMPARISON: 
 
SERVICE PEB - 20040319	VARD - 20040802	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Thoracic Outlet Syndrome	8513-8599	20%	Thoracic Outlet Syndrome, Right Upper Extremity	8513	20%	20040415	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  50% 	

ANALYSIS SUMMARY:  

Thoracic Outlet Syndrome.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s thoracic outlet syndrome symptoms first appeared in January 2000 after shoveling snow for 5 hours.  Electrodiagnostic testing was normal with no evidence of carpal tunnel syndrome on the right in February 2000 and he was treated with NSAIDs and physical therapy with symptom improvement.  

During a primary care clinic appointment on 10 March 2003, the CI complained of right shoulder pain on and off for 4 years, which was aggravated by pack wear.  Usually the right arm went numb if the CI wore a pack weighing greater than 10 pounds.  The numbness began with an ulnar distribution first, then continued to the elbow and past the forearm.  Treatment with physical therapy helped; however, he could not bench press as much as previously since it tended to cause shoulder pain.  On examination he had full range of motion (ROM) of the shoulders with crepitus (grinding sensation) on the right and without laxity.  X-rays of the right shoulder on 11 March 2003 were unremarkable.  The CI reported his right arm more than the left arm went numb at night or with overhead reach.  There was full ROM of the neck with no rotatory limitations.  The shoulders also had a full ROM and Tinel’s sign was negative at the median and ulnar nerves. Electrodiagnostic studies on 20 June 2003 revealed no evidence for median or ulnar neuropathy or lower brachial plexus neuropathy in either arm.  There was no evidence for motor nerve root injury in the C5-T1 distribution on the right.  

On 15 July 2003 at a primary care clinic appointment, the CI had approximately 1.0 cm of laxity of the shoulders with distal traction.  There was a full ROM of the shoulders with no muscle atrophy of the biceps or triceps and strength was good in the arms.  Tinel’s tests were negative. There were no signs of inflammatory arthritis on examination.  The examiner considered a brachial plexus issue versus thoracic outlet syndrome with pack wear.  X-rays were negative for a cervical rib.  At a rheumatologic evaluation on 3 September 2003 the examiner noted the CI initially noted pain in the right upper extremity associated with carrying heavy backpacks and he developed cyanosis as well as numbness and paresthesias.  Examination showed the cervical spine and thoracic spine to be normal as were the shoulders, wrists, and hands; however, the CI was able to hyperextend his elbows 10 degrees.  Provocative testing (dampened radial pulses with Adson’s and hyperabduction maneuvers) for thoracic outlet syndrome reproduced his symptoms.  The CI was referred to physical therapy for exercises for thoracic outlet syndrome as well as an exercise program including shoulder shrugs and corner pushups.  

At a rheumatology clinic appointment on 15 October 2003, the CI reported frequent spontaneous dislocations of the shoulder related to hypermobility and pain with simple activities such as reaching for a gallon of milk.  Physical examination showed some tenderness along the arch of the right glenohumeral joint of the shoulder with pain on abduction past 90 degrees.  Shoulder girdle strength appeared intact. Thoracic spine X-rays, dated 16 April 2004, were normal.  

The 18 February 2004 MEB NARSUM examination, 4 months prior to separation, noted complaints of thoracic output symptoms and impingement in the right shoulder, which caused the CI chronic pain and prevented him from working more than 40 hours per week in the classroom and precluded field SERE (survival, evasion, resistance, and escape) duties and participation in regular exercise.  Physical examination showed flexion and external rotation caused pain in the right shoulder.  There was no crepitus.  Tinel’s sign was negative at ulnar and median nerves bilaterally.  There were no signs of synovitis through there was tenderness over MCP (metacarpophalangeal) joints of the hands.  There was no erythema or effusions.  Strength was 5/5 and equal in the triceps, biceps, and deltoids and was 4.5/5 on the left in the interossei, thumb apposition and wrist flexion and extension.  There was no atrophy.  Sensation was decreased to light touch and cold sensation on the right forearm versus the left forearm.  

At the 15 April 2004 VA Compensation and Pension (C&P) evaluation, 2 months before separation, the CI reported complaints of constant pain in the neck which travelled to his shoulder and back, which was elicited by physical activities including working overhead and stress.  He was able to function with medications including NSAIDs and Elavil (amitriptyline for nerve pain).   Physical examination showed a supple neck with normal sensation, reflexes, and motor strength.  Appearance of the shoulder joints was within normal limits bilaterally with crepitus in the right shoulder.  Flexion of the right shoulder was 0 to 120 degrees (normal 180) and the left was 0 to 128 degrees.  Abduction was 0 to 80 degrees on the right (180 normal) and 0 to 90 degrees on the left.  ROM of the joints was limited by pain and weakness.  X-rays of the cervical spine showed mild degenerative arthritis; those of the thoracic spine were normal; and X-rays of the chest were normal.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the thoracic outlet syndrome 20%, coded 8513-8599 (incomplete paralysis of all radicular groups), citing mild neurological deficit of the right upper extremity.  The VA also rated the thoracic outlet syndrome 20%, coded 8513, based on the C&P examination 2 months before separation.  Panel members noted in this case the thoracic outlet syndrome arose when the neurovascular bundle (brachial plexus) was compressed as it passed from the thoracocervical region to the axilla through the thoracic outlet, the boundaries of which include the first rib, scalenus anterior muscle and scalenus medius muscle.  Panel members agreed the condition was mild and was predominately related to overhead work or wearing a heavy pack for an extended period of time and did not rise to a higher rating in the absence of abnormal findings on electrodiagnostic studies and/or vascular symptoms since the subclavian artery also passes through the thoracic outlet.  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 thoracic outlet syndrome.  

BOARD FINDINGS:  In the matter of the thoracic outlet syndrome condition and IAW VASRD §4.124a, the panel unanimously recommends no change in the PEB adjudication.  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/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

SAF/MRB
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD  20762

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2016-01544.

After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was appropriate.  Accordingly, the Board recommended no re-characterization or modification of your separation.

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding and their conclusion that re-characterization of your separation is not warranted.  Accordingly, I accept their recommendation that your application be denied.

						Sincerely,

		

								XXXXXXXXXXXXXXXXXX
								Director
								Air Force Review Boards Agency

Attachment:
Record of Proceedings