RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX 	CASE:  PD-2017-02271
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20050408

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

CI CONTENTION:  “Please review all MEB/PEB conditions considered for being unfit for duty and rated.”  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 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 - 20050408	VARD - 20070329	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Thoracic Outlet Syndrome…	8513	20%	Limitation of Motion Left Shoulder (Claimed as Thoracic Outlet Syndrome)	5299-5203	10%	20060124	
Cubital Tunnel Syndrome, Bilateral	Cat II	Bilateral Neurological Condition of Both Hands	8599-8516	NSC		
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  10% 	

ANALYSIS SUMMARY:  

Thoracic Outlet Syndrome.  According to the service treatment record and MEB narrative summary (NARSUM), the right-handed CI’s began to notice a gradual increase in symptoms of numbness, tingling and weakness in his left upper extremity in 1999, and a subsequent workup revealed the presence of cervical ribs on X-rays.  He was diagnosed with thoracic outlet syndrome and a surgeon felt that removal of the ribs would be necessary at some point in the future.  The CI debated having surgery and chose to take Zoloft (anti-depressant), which made symptoms more tolerable.  He did not seek further treatment until 25 May of 2004, when he reported left arm swelling and numbness which affected his job performance.  Nerve conduction studies in June 2004 revealed bilateral ulnar neuropathy at the elbows, and at a June 2004 thoracic surgery consult, he endorsed pain, numbness when lifting his left arm past 90 degrees, swelling after excessive activity, and mildly decreased hand and forearm strength.  
On 12 July 2004, the CI underwent a left transaxillary resection of the first thoracic rib.  A cervical rib was not resected due to the high risk given its close proximity to the brachial plexus, but nevertheless, he had complete relief of the thoracic outlet obstruction with the procedure.  A month later, he reported mild swelling and pain with hyper-abduction, which was treated with physical therapy.  At a clinic visit in October 2004, he complained of persistent chest wall pain and difficulty taking a full breath, but was able to work through it.  A thoracic surgery follow-up on 19 October 2004 noted progress in regaining left arm strength and range of motion (ROM).  The chest pain was felt to be musculoskeletal and related to tenderness along the costochondral junction with the sternum.  Nonspecific neuromuscular tingling and burning along the right side of the chest was also documented, but the surgeon was reluctant to aggressively pursue a workup until the CI recovered as much as possible from the surgery; full recovery was expected to take several months to a year.  A nonsteroidal anti-inflammatory drug was prescribed for the chest pain secondary to costochondritis. 

The 2 December 2004 MEB NARSUM examination, 4 months prior to separation, recorded complaints of left arm numbness and pain and a past medical history of left shoulder subacromial bursitis.  Physical examination showed a well-healed incision and slight tenderness over the left-sided third and fourth ribs.  Pulses were good in the radial arteries bilaterally.  

At the 24 January 2006 VA Compensation and Pension (C&P) examination, 9 months after separation, the CI reported vague left upper extremity pain and that his left arm and hand would turn blue about once a week and with any overhead activity.  The examiner found no shoulder tenderness or inflammation, and thoracic outlet testing was negative with no loss of radial pulses, vascular insufficiency, or sensory symptoms on either side.  Left shoulder flexion was to 180 degrees (normal), but abduction was to 100 degrees (normal 180), at which point there was pain and the shoulder remained fixed and could not even be passively abducted further.  Both internal and external rotation were to 70 degrees (normal 90), with mild pain. The examiner stated there was no thoracic outlet syndrome, but rather left shoulder limitation of motion.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the thoracic outlet syndrome 20%, analogously coded 8599-8513 (paralysis of all three radicular groups), citing DoD and VASRD guidelines.  The VA rated the thoracic outlet syndrome 10%, analogously coded 5299-5203 (clavicle or scapula, impairment of), based on the C&P examination, citing a malunion or nonunion of the clavicle or scapula.  Panel members noted that the PEB assigned a 20% rating for a mild disability of all radicular groups using analogous code 8513.  There was no postoperative evidence to support a moderate disability or higher for the left arm since there was recovery of the radial pulse, although there were complaints of pain and numbness.  The NARSUM examination did not address shoulder ROMs, but the VA examination noted limitation of left arm abduction to 100 degrees, which would warrant a 20% rating for limitation of motion using code 5201 (arm, limitation of motion of).  However, whether that was related to the thoracic outlet surgery or to a shoulder bursitis was not clear prior to separation.  Therefore, an additional rating at the time of separation is not warranted.  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 thoracic outlet syndrome.  

Contended PEB Condition:  Bilateral Cubital Tunnel Syndrome.  The panel’s main charge is to assess the fairness of the PEB determination that the contended condition was not unfitting.  The contended condition was not specifically profiled or implicated in the commander’s statement or MEB NARSUM.  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, so no additional disability rating is recommended.  
BOARD FINDINGS:  In the matter of the thoracic outlet syndrome and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the contended bilateral cubital tunnel syndrome, the panel 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 20170220, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

SAF/MRB
3351 Celmers Lane
JBA NAF Washington, MD 20762-6435

Dear XXXXXXXXXXXXXXXXXXXX:

		Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2017-02271.

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 rating modification or re-characterization 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 modification of your disability rating or characterization of your separation is not warranted.  Accordingly, I accept the recommendation that your application be denied.

						Sincerely,

Attachment:
Record of Proceedings