RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXX	CASE:  PD-2017-05572
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050430

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E6, Human Resources Specialist, medically separated for “bilateral breast pain post reduction mammoplasty” with a disability rating of 20%.  

CI CONTENTION:  “Conditions have worsened by far.  Conditions were bad at time of separation but only given 20%.  I now require full-time care giver.”  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 - 20050216	VARD - 20060109	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bilateral Breast Pain… 	5099-5003	20%	Residuals, Bilateral Breast Scars Due to Mammoplasty	7804	10%	20050614	
Keloid Scars…	Not Unfitting					
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

Bilateral Breast Pain.  According to the service treatment record and MEB narrative summary (NARSUM), the CI underwent bilateral breast reconstructions in January 2004 with subsequent bilateral breast pain rated at 10/10.  The pain was exacerbated by any movement, but especially of the upper extremities.  She was treated with multiple narcotic and non-narcotic analgesics, as well as physical therapy, with no success.  An examination by plastic surgery found healed mammoplasty incisions with very large tender hypertrophic scars consistent with keloids not amenable to excision.  An anti-scarring ointment was recommended, and the provider noted  the breast pain significantly impacted her ability to perform physical work, and to a lesser extent to perform light duty.  

During the 23 November 2004 MEB examination (recorded on DD Forms 2807-1 and 2808), 5 months prior to separation, physical examination revealed marked tenderness in both breasts and healed surgical incisions.  The 25 January 2005 MEB NARSUM neurology addendum, 3 months before separation, noted complaints of constant intense burning and electrical-like pain around the breast incisions which radiated through the breasts and entire chest.  She reported pain with arm movement, walking or running, and that the mere touching of clothes against her chest wall induced pain.  She was managed by the pain clinic and took three medications for pain and one for depression/anxiety.  Physical examination showed she was in no acute distress, with well-healed surgical incisions and no lesions or masses.  Range of motion in all extremities was full, but with pain in the breasts.  She had significant pain with light touch to the chest and both breasts/skin, and the examiner diagnosed neuropathic chest wall/breast pain manifested by dysesthesias (abnormal sensations) and allodynia (pain from nerve-related conditions), noting that the pain required narcotic medications and limited performance of military activities.  

At the 14 June 2005 VA Compensation and Pension (C&P) examination, 1 month after separation, the CI complained of residual postoperative scarring with associated tenderness and limitation of motion.  She reported disfigurement due to scar and keloid formation and had continued breast pain and mild back discomfort, but denied any recent time lost from work.  The examiner noted that she was in no acute distress and had “appreciable scar formation” of both breasts with horizontal inferior scars measuring 30 x 1 cm, and areolar scars measuring 7 x 5.5 cm in diameter by 1 cm.  There were also ventral longitudinal scars measuring 7 cm on the left and 7.5 cm on the right.  The scars were elevated with tenderness and some mild disfigurement due to keloid and hyperpigmentation of greater than 6 square inches.  However, there was no abnormal texture, ulceration, adherence, instability, tissue loss or hypopigmentation.  There was appreciable limitation of motion due to pain from the scars during stretching movements.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral breast condition 20%, analogously coded 5003 (arthritis, degenerative), citing well-healed incisions post-surgery with keloid formation and clinically diagnosed chest wall/breast pain manifested by dysesthesias and allodynia and requiring multiple medications.  The VA rated the bilateral breast condition 10%, coded 7804 (scars, unstable or painful), based on the C&P examination, citing tender and painful scars.  Panel members noted that the NARSUM addendum documented the presence of significant, abnormal nerve-related sensations in both breasts after surgery, and that the pathology in this case was not a good clinical fit under code 5003.  Bilateral breast neuropathic pain would logically lend itself to separate nerve code ratings for each breast.  However, the most applicable VASRD §4.124a nerve code is 8719 (neuralgia, long thoracic), which provides ratings of 0% for “mild,” 10% for “moderate,” and 30% for “severe.”  The panel agreed that the level of impairment could not be reasonably characterized as more than moderate, and thus separate nerve code ratings would be of no benefit to the CI.  The condition did not meet criteria for a higher rating under other codes.  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 bilateral breast condition.  

Contended PEB Condition:  Keloid Scars.  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 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 bilateral breast condition and IAW VASRD §4.71, the panel recommends no change in the PEB adjudication.  In the matter of the contended keloid scars, 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.  

ARXXXXXXXXXXX, XXXXXXXXXXX 

Dear XXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found your separation disability rating and your separation from the Army for disability with severance pay to be accurate.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed), and I accept its recommendation.  I regret to inform you that your application to the DoD PDBR is denied.  

	This decision is final.  Recourse within the Department of Defense or the Department of the Army is exhausted; however, you have the option to seek relief by filing suit in a court of appropriate jurisdiction.