RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX 	CASE:  PD-2017-01320
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20051201

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Infantryman, medically separated for “chronic pain in the right chest” rated 10%, and “tenosynovitis and arthritis of the right (dominant) first [metacarpophalangeal] joint” rated 0%, with a combined 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 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 - 20051012	VARD - 20060224	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Pain in the Right Chest	5099-5003	10%	Chronic Right Costochondritis and Pleural Pain	5399-5321	0%	20051128	
Tenosynovitis and Arthritis First Metacarpophalangeal Joint	5024	0%	Right Carpometacarpal Degenerative Joint Disease	5215-5010	10%	20051128	
COMBINED RATING:  10%%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

Chronic Pain in the Right Chest at T-5 Dermatome.  According to the service treatment record and MEB narrative summary (NARSUM), the CI’s chronic right chest condition began in May 2004 when he ran into a crossbar, striking it with his chest and falling to the ground.  X-rays showed a minimally displaced left anterior seventh rib fracture.  The right side ribcage was normal.  The X-rays also showed a mass in the lungs which proved to be a tuberculosis mass; this was surgically removed on 10 September 2004.  Following surgery, he continued to report ongoing pain over the right ribs, shoulder blade, and thoracic vertebrae.  A bone scan on 8 October 2004 showed increased uptake over the right and left anterior ribs.  X-rays of the right cage on 19 November 2004 were normal.  An X-ray of the shoulder showed mild degeneration of the acromio-clavicular joint (the joint between the shoulder blade and collar bone).  An MRI on 30 December 2004 was normal other than a post-surgical scar in the upper lobe of the right lung.  A repeat bone scan on 4 January 2005 showed that the uptake seen over the right and left ribs was improving.  In orthopedics on 13 January 2005, the pain was thought to be due to irritation of the lung lining and the CI was referred to pulmonary medicine.  There he was noted to have pain along the fifth right rib from the spine around to the front, and was diagnosed with chest wall discomfort.  The CI was again seen in pulmonary medicine on 22 March 2005 and thought to have residual pain from the prior surgery.  A chest X-ray that day was normal.  

During the 13 April 2005 MEB examination (recorded on DD Forms 2807-1 and 2808), 8 months prior to separation, the CI reported breathing problems and chest pain.  The physical examination showed discomfort over the upper thoracic spine and right shoulder blade, but clear lungs.  The 17 May 2005 MEB NARSUM examination, 7 months prior to separation, noted the above information.  On examination, he had tenderness in the T5 distribution and at the incisional sites.  

At the 28 November 2005 VA Compensation and Pension (C&P) examination, 3 days before separation, the CI reported chronic thoracic pain.  The physical examination showed tender ribs from 4-8 on the right with pain reproduced by pressure over them.  The lungs were clear.  A CT scan on 27 March 2006, 4 months after separation, showed an old right posterior ninth rib fracture (not the site of the pain) and scarring from the lung biopsy.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic right chest condition 10%, coded 5099-5003 (analogous to degenerative arthritis), noting multiple imaging and diagnostic studies had failed to identify an etiology for the pain.  The VA rated the chronic right chest condition 0%, analogously coded 5399-5321 (thoracic muscle group and muscles of respiration), based on the C&P examination.  The rationale for the rating was not in the evidence available for review.  Absent a definitive diagnosis for the etiology of the pain, the panel found no rating higher than the 10% adjudicated by the PEB.  After due deliberation, considering all 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 chronic right chest condition.  

Tenosynovitis and Arthritis of the Right (Dominant) First Metacarpophalangeal Joint.  The panel observed that the unfitting condition was mislabeled and should have been the first metacarpophalangeal joint (MCPJ, part of the thumb) rather than metatarsophalangeal joint, which is part of the foot.  In orthopedics on 11 March 2005, the CI reported pain at the base of the right thumb since an injury in May 2004.  His pain was reproducible with loading of the thumb.  A review of the X-rays showed mild arthritis at the base of the thumb.  

During the MEB examination the CI reported wrist pain.  The physical examination revealed full range of motion (ROM) with tenderness over a wrist bone near the thumb (scaphoid).  Testing for nerve irritation was negative.  The MEB NARSUM examination noted complaints of right wrist pain.  The physical examination mirrored that recorded on the DD Form 2808.  

At the C&P examination the CI reported right thumb pain aggravated by push-ups and cold weather.  The wrist was tender to pressure of the right first MCPJ, but without swelling or deformity.  Use of the hand and fingers was normal.  The ROM was pain free and normal other than radial deviation of the wrist limited to 15 degrees (normal 20).  Mild arthritis was noted on X-ray.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right thumb condition 0%, coded 5024 (tenosynovitis), noting tenderness but full ROM.  The VA rated the right thumb condition 10%, coded 5215-5010 (limitation of motion of the wrist due to traumatic arthritis).  The rationale for the rating was not in the evidence available for review.  The criteria for a 10% rating under codes 5003 or 5010 are the same: X-ray evidence of pathology and limitation of motion.  The latter must be confirmed by objective findings such as swelling, muscle spasm, or painful motion.  While X-rays showed early arthritis and limitation of radial deviation to 15 degrees on the VA examination (normal otherwise), the remaining criteria were not met and a rating greater than 0% under these codes is not supported.  Additionally, the limitation of motion present on the VA examination does not support a rating greater than 0% under code 5215.  After due deliberation, considering all 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 right thumb condition.  

BOARD FINDINGS:  In the matter of the right chest condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the right thumb condition and IAW VASRD §4.71a, the panel 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 20170221, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20180007417, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX

	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