RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2017-05419
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20080404

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Command Post Craftsman, medically separated for “right upper extremity pain and mild weakness due to upper trunk brachial plexopathy” with a   disability rating of 20%.  

CI CONTENTION:  “Problem/Incident cause[d] during TOS surgery.”    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 - 20071217	VARD - 20090223	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Upper Extremity Pain and Mild Weakness Due to Upper Trunk Brachial Plexopathy	8710	20%	Thoracic Outlet Syndrome	8519	10%	20090209	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Right Upper Extremity Pain and Mild Weakness due to Upper Trunk Brachial Plexopathy.  According to the service treatment record and MEB narrative summary (NARSUM), the right-hand dominant CI’s right upper extremity condition began in October 2004 when she first experienced tingling and numbness in her right arm and hand with periodic weakness with no known history or injury.  Evaluation in August and September 2005 revealed right carpal tunnel and right cubital tunnel syndromes for which surgery, consisting of a carpal tunnel release and ulnar nerve transposition, was performed in October 2005. The CI was subsequently diagnosed with thoracic outlet syndrome and underwent surgery on 13 July 2006 consisting of a first rib resection and a scalenectomy (removal of scalene muscles), which was followed by weakness and pain in her right arm and numbness of the first three fingers of her right hand.   With physical therapy her symptoms resolved, but she had some discomfort in the right posterior shoulder unlikely related to the thoracic outlet syndrome or the residuals of the surgery.  

The 17 August 2007 MEB NARSUM examination, 8 months prior to separation, noted complaints of constant pain and weakness in the right shoulder and arm.  Physical examination showed no pronator drift.  Muscle strength was 4+/5 in all muscles tested, with some weakness with abduction of the right arm at the shoulder, but the maneuver also provoked pain.  There was no gross deformity of the right shoulder or upper extremities.  Surgical incisions were well healed.  Right shoulder range of motion (ROM) was 0-145 degrees flexion (normal 180) and 0-145 degrees abduction (normal 180).  ROM of the right elbow was full and unrestricted.  Muscle tone and bulk were normal.  The spine was normal and nontender.  Neurological evaluation was unremarkable except for a positive Tinel’s sign (to determine nerve irritation) in the right anterior cervical triangle.  

At the 9 February 2009 VA Compensation and Pension (C&P) examination, 10 months after separation, the CI reported right arm pain for which she took Neurontin (for nerve pain).  Additionally, she had right shoulder pain secondary to a bone spur, which was surgically removed in September 2008.  She used an over-the-counter wrist splint periodically.  Physical examination showed right shoulder flexion and abduction were 0-180 degrees each with minimal pain with flexion, and internal and external rotation were 0-90 degrees each.  There was no change in motion with repetition.  The right wrist ROMs were dorsiflexion, 70 degrees (normal), palmar flexion 0-70 degrees (normal 80), ulnar deviation 0-45 degrees (normal), and radial deviation 0-20 degrees (normal), all without pain.  Right elbow extension was 0 degrees and flexion was 145 degrees, with pain with repetition.  Pronation was 0-80 degrees (normal) and supination was 0-85 degrees (normal).   Neurologic evaluation revealed 2+ reflexes, intact sensation, and normal muscle strength in the upper and lower extremities.  X-rays of the right wrist, right elbow, right shoulder, and cervical spine were normal.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right upper extremity condition 20%, coded 8710 (upper radicular (fifth and sixth cervicals neuralgia: mild), citing a full ROM and strength of her upper extremity.  The VA rated the thoracic outlet syndrome (right extremity brachial plexopathy) condition 10%, coded 8519 (long thoracic nerve, incomplete paralysis: moderate), based on the C&P examination, citing incomplete paralysis of arm movements, which was moderate.  The VA also rated the right cubital tunnel syndrome 0%, coded 8511, based on the C&P examination, citing a noncompensable evaluation unless there is incomplete paralysis of arm, elbow, and wrist movements.  The VA also rated the right carpal tunnel syndrome 0%, coded 8515, based on the C&P examination, citing a noncompensable evaluation unless there is incomplete paralysis of hand movements which are mild.

The panel noted the CI significant resolution of symptoms after right carpal tunnel and right cubital tunnel surgeries.  However, after development of symptoms post-surgery to relieve thoracic outlet syndrome, by the time of the VA examination she was left with residual pain in the right scapula/shoulder area with normal motor strength and sensation and normal ROMs of the shoulder, elbow, and wrist.  A higher rating of 40% for the dominant extremity using code 8710 requires a moderate disability, but shoulder and elbow motions were reasonably normal thereby not supporting a moderate disability.   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 upper extremity pain and mild weakness due to upper trunk brachial plexopathy condition.    

BOARD FINDINGS:  

In the matter of the right upper extremity pain and mild weakness due to upper trunk brachial plexopathy 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.  

SAF/MRB

Dear XXXXXXXXXXXXXX:

		Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2017-05419.

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.