RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXX	CASE:  PD-2017-04597
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20061204

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Pavements and Construction Equipment Journeyman, medically separated for “long thoracic nerve palsy” with a 10% disability rating.  

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 - 20061018	VARD - 20070720	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Long Thoracic Nerve Palsy	8519	10%	Long Thoracic Nerve Palsy	8519	30%	20070703	
Hearing Loss with Tinnitus	Cat II	Tinnitus	6260	10%	20070703	
		Hearing Loss	6100	0%	20070703	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Long Thoracic Nerve Palsy.  According to the service treatment record and MEB narrative summary (NARSUM), the CI’s dominant side (major) long thoracic nerve palsy began in approximately May 2004.  The CI reported right shoulder pain related to work activities and weightlifting, without specific injury.  In April 2005 he reported increased pain in the right shoulder radiating across the right scapula and down the triceps muscle to the elbow.  Right shoulder MRI in May 2005 was normal and imaging of the cervical and thoracic spines showed degenerative changes at C3-4 and in the thoracic spine (Schmorl’s nodes).  A nerve block at C4 for was tried with improvement only for a few hours.  At an orthopedic examination on 13 December 2005, physical examination showed significant scapular winging and wasting of the deltoid muscle on the right compared to the left.  There was no other weakness and no sensory changes of the right upper extremity.  Electrodiagnostic studies performed on 4 January 2006 showed an active lesion of the right long thoracic nerve.  There was evidence the condition was resolving to some degree, but there was still moderate denervation.  Screening for systemic inflammatory conditions associated with radiculitis was negative.  At an orthopedic follow-up examination on 12 January 2006, the examiner indicated the condition was most likely post-traumatic in nature and he would follow the CI with repeat electrodiagnostic testing in 6 months to look for continued recovery, and if none present surgery may be indicated.  

At a neurology consultation on 26 January 2006, 10 months prior to separation, the CI reported he could not raise his right arm all the way up over his head and he was concerned the same symptoms were beginning on the left side.  Physical examination showed scapular winging on the right, with inability to lift the arm above 90 degrees.  Grip strength, finger adduction, and triceps strength were graded 5/5.  Strength of the biceps and wrist extensors was graded 4+/5.  Sensation was intact to touch, pin, temperature, vibration, and proprioception throughout.  Reflexes were normal.  The neurologist concurred with the diagnosis of long thoracic nerve palsy.  The CI’s dose of Neurontin (medication for nerve related pain) was increased.  

The 31 August 2006 MEB NARSUM examination, 3 months prior to separation, noted complaints of loss of mobility of the right shoulder and inability to elevate the arm in forward motion (flexion) or lateral side motion (abduction) and pain along the medial scapular border. Physical examination showed tenderness of the upper back on the right side.  Sensation was normal and upper extremity strength was normal, the CI could only flex his arm to “about 120 degrees” and abduct his arm “about 120 degrees.”  The MEB NARSUM examiner noted that the long thoracic nerve decompression surgery had not been approved yet.  Physical therapy measured shoulder ROM on 14 September 2006, 3 months prior to separation, and shoulder flexion and abduction were 90 degrees each.  

At the 3 July 2007 VA Compensation and Pension (C&P) examination, 7 months after separation, the CI reported progressive worsening of the long thoracic nerve palsy condition.  No surgery had been performed due to insurance issues.  The CI reported problems with lifting and carrying, decreased strength of the upper extremity and pain.  Physical examination noted the CI was right- hand dominant.  Right shoulder ROM was flexion and abduction of 90 degrees each, with painful motion.  No weakness or sensory loss of the right or left side were noted.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the long thoracic nerve palsy condition 10%, coded 8519 (incomplete paralysis of the long thoracic nerve), citing general DoD and VASRD guidelines.  The VA rated the long thoracic nerve palsy condition 30%, also coded 8519, based on the C&P examination, citing complete paralysis with the inability to raise the arm above shoulder level and a winged scapula deformity.
Panel members noted there was evidence of inability to lift the shoulder above 90 degrees and/or winged scapula documented at the neurology, PT MEB ROM, and VA examinations.  However, the plastic surgery, orthopedic (May 2006), and MEB NARSUM examinations which occurred between the PT MEB and post-separation VA examinations, cited shoulder ROM limited to approximately 120 degrees.  

The ability of the CI to raise the arm above shoulder level at intermittent examinations, especially the MEB NARSUM examination proximate to separation, argued against a 30% rating for complete paralysis.  Panel members agreed that the CI’s functional impairment due to the long thoracic nerve palsy was more nearly approximated by the 20% rating criteria for severe incomplete paralysis than those of the 30% rating.  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 (major) long thoracic nerve palsy, coded 8519.  

Contended PEB Conditions:  Hearing Loss With Tinnitus.  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 profiled or implicated in the commander’s statement and did not fail retention standards.  There was no performance-based evidence from the record that the contended 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 long thoracic nerve palsy condition, the panel recommends a disability rating of 20%, coded 8519 IAW VASRD §4.124a.  In the matter of the contended hearing loss and tinnitus conditions, the panel recommends no change from the PEB determinations as not unfitting.  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, effective the date of medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Long Thoracic Nerve Palsy	8519	20%	

The following documentary evidence was considered:

SAF/MRB

Dear XXXXXXXXXX:

		Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2017-04597.

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 not in accordance with the guidelines of the Veterans Affairs Schedule for Rating Disabilities.  Accordingly, the Board recommended modification of your assigned disability rating without re-characterization of your separation with severance pay.

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding, accept the recommendation and direct that your records be corrected as set forth in the attached copy of a Memorandum for the Chief of Staff, United States Air Force.  This will not result in any change to your separation documents or the amount of severance pay you are entitled to.  Disability severance pay is computed the same regardless of a rating of 0, 10 or 20 percent.