RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-01401
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20071109

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Security Forces, medically separated for “chronic left shoulder pain, left brachial plexopathy with some weakness of the hand” with a disability rating of 20%.  

CI CONTENTION:  “Review all conditions.”  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 - 20070918	VARD - 20080214	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Left Shoulder Pain, Left Brachial Plexopathy with Some Weakness of the Hand	8513	20%	Brachial Plexus Nerve Root Neuropathy, Left Upper Extremity	8513	30%	20071009	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

Chronic Left Shoulder Pain, Left Brachial Plexopathy with Some Weakness of the Hand.  According to the service treatment record and MEB narrative summary (NARSUM), the CI’s left shoulder pain began in October 2005 after he injured his arm in a defensive class when a colleague performed a take-down move on him.  He was referred to orthopedics where an arthrogram was determined normal.  Despite steroid injections (2), no relief was achieved.  The CI was referred to neurology and diagnosed with a left brachial plexus injury.  
The 25 May 2007 neurology examination, approximately 6 months prior to separation, noted complaints of pain in the left upper extremity.  The neurologist found “some weakness is noted in the hand, particularly with grip or fine motor movement.  It has not changed since I've seen him last.”  There was tenderness in the cervical paraspinal muscles and no atrophy in the shoulder girdle.  There was no Hoffmann's reflex noted.  Grip strength was 4+/5 on the left.  Elsewhere muscle strength was 5/5 symmetric.  There was decreased sensation noted to pinprick and temperature in the left hand compared to the right, with normal sensation in all other modalities.  EMG testing revealed no abnormalities of the left trapezius serratus anterior and trapezius infraspinatus.  The neurologist tested the proximal arm muscles, which were normal.  The 11th cranial nerve that innervates the sternocleidomastoid and trapezius was not affected.  An MRI of the CI’s cervical spine showed no evidence of compressive nerve lesions, although there was “some curvature of the cervical spine.”  Recommendations included continuing current treatments and gentle exercise, but no heavy calisthenics.  

The 26 July 2007 MEB NARSUM examination, approximately 4 months prior to separation, noted complaints of left shoulder problems in the right hand dominant CI.  Physical examination showed strength was “slightly decreased (4+) left hand grip strength compared to right hand.  Muscle bulk was normal.  Muscle tone was normal.  No shoulder weakness was observed.  No elbow weakness was observed.  No forearm weakness was observed.  No wrist weakness was observed.  No paralysis was noted.  No involuntary movements were seen.”  There was decreased sensation of the left hand.  Reflexes were normal.  The arthrogram from December 2005 was normal.  MRI of the cervical spine from May 2007 indicated mild left curvature of the neck, but otherwise normal.  Left shoulder X-rays were normal.  The physician stated the CI “should avoid activities that aggravate his condition such as overhead work and push-ups.  He should continue NSAIDs as needed for pain relief.”  

At the 9 October 2007 VA Compensation and Pension (C&P) examination, 1 month prior to separation, the CI reported pain and a loss of grip strength.  The examiner reported paresthesia of the left palm, fingers, and left medial elbow skin.  Left hand strength was 4/5.  Reflexes were normal.  The left shoulder x-ray was negative.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the nerve condition 20%, coded 8513 (all radicular groups, paralysis of), citing slight decreased left hand grip strength but otherwise normal muscle strength, bulk, and tone.  The VA rated the nerve condition 30%, also coded 8513, based on the C&P examination, citing paresthesia of the left palm, left fingers, and left medial elbow skin, secondary to brachial plexus nerve root neuropathy; and weakness of the left extremity at the wrist, hand, and finger areas, with strength graded at 4/5.  

The panel considered the results of the neurology, MEB, and C&P examinations along with the whole recorded history to accurately identify and assess the level of peripheral nerve disability (§4.2) at the time of separation.  The panel noted that both the PEB and the VA utilized VASRD diagnostic code (DC) 8513 and not 8613 (neuritis) or 8713 (neuralgia).  4+/5 left hand grip strength was found by both the neurologist and MEB examiners.  The VA examiner reported 4/5 left hand grip strength.  EMG testing from the neurologist demonstrated no proximal left upper arm involvement.  MRI, arthrogram, and X-rays were essentially normal.  Greater probative value was assigned for the specialty evaluation by the neurologist, which was noted for depth and detail.  It would be overly speculative to link 4+/5 left hand grip strength according to the neurologist and MEB examiner, or the 4/5 left hand grip strength per the VA examiner, with more than mild functional impairment for all radicular groups IAW VASRD DC 8513 of the non-dominant hand.  Members deliberated whether the functional limitation in evidence justifies a higher rating recommendation, but members agreed there was insufficient support for concluding that the neurological impairment could be fairly characterized as moderate or greater.  After due deliberation, considering the totality 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 nerve condition.  

BOARD FINDINGS:  In the matter of the nerve condition and IAW VASRD §4. 124a, 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 20170227, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs 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-2017-01401.

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