IN REPLY REFER TO

1850
CORB:003
19 Feb 20

From: To:

Director, Secretary of the Navy Council of Review Boards PD-2017-02402

Subj: Ref:

PHYSICAL DISABILITY BOARD OF REVIEW (PDBR)

(a) DoDI 6040.44
(b)	PDBR ltr of 30 Aug 19

1.	Pursuant to reference (a), the PDBR reviewed your case and forwarded its recommendation (reference (b)) to the Department of the Navy for appropriate
·	action.

2.	On 12 February 2020, the Assistant Secretary of the Navy took action in your case by accepting the correct recommendation of the PDBR.	Accordingly, your records will be corrected to reflect an increase in the disability rating awarded by the Physical Evaluation Board from 20 to 40 percent with assignment to the Permanent Disability Retired List.

3.	The Assistant Secretary's determination, which represents final action in your case by the Department of the Navy, was sent to the office of the Deputy Commandant, Manpower and Reserve Affairs, for correction of your records as stated above.	You will be notified once those changes are complete.

RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXX		CASE: PD-2017-02402 BRANCH OF SERVICE: MARINE CORPS	SEPARATION DATE: 20060131

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E6, Nuclear Biological and Chemical Defense Specialist, medically separated for “bilateral arterial thoracic outlet syndrome” with a disability rating of 20%.

CI CONTENTION: “Final disability rating did not take into consideration all medical issues.” He requested review of damage to the nerves on the right and left side as well as shoulder and arm pain.  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 - 20051108	VARD - 20060427	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Arterial Thoracic Outlet Syndrome Status Post (S/P)  Right Transaxillary First Rib Resection	8599-
8513-
8725	
20%	S/P Thoracic Outlet Syndrome Surgery, 1st Right Rib Re-Section with Residual Myofascial Muscle Pain and Scar	
5299-5297	
10%	
20051206	
Chronic Regional Pain Syndrome	Cat II	Left Shoulder Strain	5024	10%	20051206	
		Right Shoulder Strain with Scar	5024	10%	20051206	
COMBINED RATING: 20%	COMBINED RATING OF ALL VA CONDITIONS: 80%	

ANALYSIS SUMMARY:

Bilateral Arterial Thoracic Outlet Syndrome. The PEB combined the right and left arterial thoracic outlet syndrome as a single unfitting condition analogously coded 8599-8513-8725 (all radicular

groups, paralysis of: incomplete: mild-posterior tibial nerve neuralgia) and rated 20%. The approach by the PEB commonly reflected its judgment that the constellation of conditions was unfitting, and there was no need for separate fitness adjudications or implied adjudication that each condition was separately unfitting. The panel’s initial charge in this case was therefore directed at determining if the PEB’s approach of 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. The evidence for the right and left arterial thoracic outlet conditions are presented together, with attendant recommendations regarding separate unfitness, and separate ratings, if indicated.

According to the service treatment record and MEB narrative summary (NARSUM), the right hand dominant CI experienced pain in both shoulders and anterior chest wall in 2000 after he nearly fell from a tree and grabbed a limb with his right arm. At a vascular clinic visit on 15 July 2005, it was noted that his symptoms began years earlier. He also had chronic right shoulder pain from a labial tear that was surgically repaired in 2001 and a subsequent arthroscopy in 2004. Pain radiated down his arms, and he also had bilateral cervical paraspinal muscle pain. He had a negative cervical spine MRI and a normal EMG study. On examination, he had diminished, and then absent, bilateral radial pulses with provocative testing (Adson’s test). An angiogram on 18 July 2005 revealed complete occlusion of both subclavian arteries with provocative maneuvers. He was diagnosed with bilateral arterial thoracic outlet syndrome, right greater than left, and counseled to undergo staged bilateral first rib resections. On 15 September 2005, he had a right transaxillary first rib resection with an uneventful postoperative course; however, he did not feel any significant relief from the preoperative right upper extremity paresthesias. Subsequently, he chose not to have the left rib surgery since there was no guarantee of symptom relief.

During the 4 October 2005 MEB NARSUM examination, 4 months prior to separation, the CI reported problems with both shoulders. Physical examination showed a healing surgical incision, and with abduction of both arms, the radial pulse on the right side no longer disappeared. However, but arterial pulse on the left continued to disappear, and he had subjective paresthesias in both extremities with provocative maneuvers. The 17 October 2005 MEB addendum noted complaints of upper extremity paresthesias for approximately 4 years. Physical examination showed full range of motion of the extremities without clubbing, cyanosis, or edema. Sensation was diminished to pinprick and light touch to the ulnar aspect of both hands, and also in the distribution of the bilateral shoulders. Tinel’s testing (to determine nerve irritation) was negative at the wrists and elbows, and motor strength and muscle tone were normal with no abnormal movements, wasting, or atrophy.

At the 6 December 2005 VA Compensation and Pension (C&P) examination, 2 months before separation, the CI reported tingling, numbness, and burning pain involving both hands which happened 4-5 times a week, and lasted from 1-3 hours. He also reported numbness confined to the right upper arm after the surgery. Physical examination showed no edema, cyanosis, or clubbing of the extremities, normal motor strength without focal deficits, and symmetrical reflexes. There was a diminution of sensation to light touch over the right arm without conforming to a specific dermatome, with the sensory deficit distal to the chest wall scar. There was tenderness, which was diffuse over the right shoulder, and along the anterior aspect of the left shoulder. Flexion of the right and left shoulders was each 0-150 degrees (normal 0-180), and abduction was 0-80 degrees (normal 0-180) on the right and 0-100 degrees on the left. Painful motion was present bilaterally. Shoulder X-rays demonstrated the possibility of previous internal fixation devices in the proximal humerus or glenoid fossa on the right, but joint spaces were maintained and the soft tissues were unremarkable; the left shoulder showed no significant

findings. Right chest X-rays showed resection of most of the first rib with only the posterior end remaining.  Cervical and thoracic spine X-rays were normal.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the bilateral arterial thoracic outlet syndrome 20%, analogously coded 8513-8725, and listed “chronic regional pain syndrome” as a Category II condition contributing or related to the disability in this case. Panel members concluded this not a condition which could be reasonably justified as separately unfitting; nor would a separate rating be achievable without violation of VASRD §4.14 (avoidance of pyramiding). The VA rated the thoracic outlet syndrome 10%, analogously coded 5297 (ribs, removal of), based on the C&P examination, citing removal or resection of one rib or resection of two or more ribs without regeneration, residual muscle or fascia pain with the sensory deficit distal to the chest wall scar, and an overall disability picture demonstrating a level of functional impairment closer to the 10% evaluation criteria. The VA also assigned a 10% rating for right shoulder strain and a 10% rating for left shoulder strain, each coded 5024 (tenosynovitis), based on the C&P examination, citing painful or limited motion of a major joint or group of minor joints for each shoulder.

The panel first considered whether the right arterial thoracic outlet syndrome, having been de- coupled from the combined PEB adjudication, remained separately unfitting as established above, and concluded that there was not a preponderance of evidence that overcame the panel’s presumption that the condition was reasonably considered separately unfitting. Panel members then considered a rating recommendation for the unfitting right arterial thoracic outlet syndrome at the time of separation, noting that the PEB assigned a 20% rating using analogous code 8599- 8513-8725 for mild incomplete paralysis. However, code 8725 appears to have been used in error since it refers to the tibial nerve. The CI still had residual symptoms of tingling and numbness postoperatively, although he no longer had loss of the right upper extremity arterial pulse with overhead work. Therefore, the panel determined that a 20% rating for a mild disability, and no higher, was reasonable. Furthermore, the CI had a decreased abduction of 80 degrees of the right upper extremity at the VA examination, which was the most proximate examination to separation. Whether the decrease in abduction was a result of the residuals of the thoracic outlet syndrome, the right cervical rib excision, or prior surgery to the right shoulder is unclear; however, a 20% rating using code 5201 (arm, limitation of motion) is also a viable rating option since the VASRD §4.71a threshold for rating for ROM impairment under code 5201 is “at shoulder level” (approximately 90 degrees from the side) and the VA examination reflected this degree of limitation. However, to assign a separate 20% rating for the right thoracic outlet syndrome and the limited shoulder ROM would be in violation of VASRD §4.14 (avoidance of pyramiding). The panel considered use of code 5297-8513-5201, however, it was decided that dual coding 8513-5201 was also applicable and consistent with VASRD §4.20 (analogous ratings) and §4.21 (application of the rating schedule). After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 20% for the right arterial thoracic outlet syndrome, coded 8513-5201.

The panel then considered whether the left arterial thoracic outlet syndrome was separately unfitting as established above, and concluded that there was not a preponderance of evidence that overcame the presumption that it was reasonably considered separately unfitting since the CI had significant symptoms with overhead work, loss of the arterial pulse with provocative testing, did not undergo surgery, and had decreased abduction. Therefore, the panel determined that a 20% rating for a mild disability using code 8513, and no higher, was reasonable. Additionally, he had a decreased abduction to 100 degrees of the left upper extremity at the VA examination, which likewise warrants a 20% rating under code 5201. Panel members noted that although “at shoulder level” suggests 90 degrees, the difference of 10 degrees between 90 degrees and 100 degrees is sufficiently and reasonably close to the shoulder level to justify the 20% rating. However, to rate for both code 8513 and 5201 would be in violation of VASRD §4.14. Thus, the panel determined code 8513-5201 at 20% addresses the left thoracic outlet syndrome

symptoms and functional limitations. After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 20% for the left arterial thoracic outlet syndrome, coded 8513-5201.

BOARD FINDINGS: In the matter of the bilateral arterial thoracic outlet syndrome, the panel recommends a separately unfitting right and left arterial thoracic outlet syndrome, rated 20% each, and both coded 8513-5201 IAW VASRD §4.124a and §4.71a. In the matter of the contended chronic regional pain syndrome, the panel recommends no change from the PEB Category II determination. There are no other conditions within the panel’s scope of review for consideration.

The panel recommends the CI’s prior determination be modified as follows; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective the date of medical separation:

CONDITION	VASRD CODE	PERMANENT RATING	
Right Arterial Thoracic Outlet Syndrome	8513-5201	20%	
Left Arterial Thoracic Outlet Syndrome	8513-5201	20%	
	COMBINED	40%	

The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20170304, w/atchs Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record