RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW NAME: XXXXXXXXXXXXXXXX BRANCH OF SERVICE: ARMY CASE NUMBER: PD1200517 SEPARATION DATE: 20040318 BOARD DATE: 20130312 SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SPC/E-4 (31U/Signal Support Systems Specialist), medically separated for left upper extremity (LUE) lymphedema status post (s/p) modified radical mastectomy with reconstruction after being diagnosed with Stage 3 breast carcinoma. The CI was cancer free at the time of separation. The CI began having left breast symptoms in October 2000. Biopsies revealed multifocal ductal carcinoma. In March 2001 she had a left modified radical mastectomy and trans rectus abdominal myocutaneous (TRAM) flap reconstruction. In April 2002, the CI elected to have a right prophylactic simple mastectomy with reconstruction with a latissimus dorsi flap. Chronic LUE and chest edema developed and continued despite extensive therapy. The CI was unable to meet the physical requirements of her Military Occupational Specialty (MOS) or satisfy physical fitness standards. She was issued a permanent P2U3L3 profile and referred for a Medical Evaluation Board (MEB). Chronic abdominal and low back pain (LBP), bilateral upper extremity weakness and asthma conditions, identified in the rating chart below, were also identified and forwarded by the MEB. The Physical Evaluation Board (PEB) adjudicated the LUE lymphedema as unfitting, rated 20%, with application of the Veterans Affairs Schedule for Rating Disabilities (VASRD). The remaining conditions were determined to be not unfitting. The CI made no appeals, and was medically separated with a 20% disability rating. CI CONTENTION: “PEB rated me at 20% for 3 conditions combined. Veterans affairs rated me separately for each condition that was combined by PEB. Also Veterans affairs rated me 100% total and permanent disability. During MEB proceedings MEB DX 3-5 were found not unfitting and were unrated; however, they were secondary to MEB DX 1&2. Harvesting during the radical mastectomy caused Dx 3 and diagnosis 2&4 are linked because they are both related to left upper extremity and lymphedema.” SCOPE OF REVIEW: The Board wishes to clarify that the scope of its review as defined in DoDI 6040.44, Enclosure 3, paragraph 5.e. (2) is limited to those conditions which were determined by the PEB to be specifically unfitting for continued military service; or, when requested by the CI, those condition(s) “identified but not determined to be unfitting by the PEB.” The ratings for unfitting conditions will be reviewed in all cases. The conditions abdominal and LBP, bilateral upper extremity weakness and asthma, as requested for consideration meet the criteria prescribed in DoDI 6040.44 for Board purview; and, are addressed below, in addition to a review of the ratings for the unfitting condition (LUE lymphedema s/p radical mastectomy with reconstruction after being diagnosed with Stage 3 breast carcinoma). Any conditions or contention not requested in this application, or otherwise outside the Board’s defined scope of review, remain eligible for future consideration by the Army Board for Correction of Military Records. RATING COMPARISON: Service IPEB – Dated 20031212 VA (2 Mos. Pre-Separation) – All Effective Date 20040319 Condition Code Rating Condition Code Rating Exam Left upper extremity lymphedema s/p radical mastectomy w/reconstruction after stage 3 breast cancer dx 7627-7199- 7121 20% Residuals of carcinoma of left breast w/Lymphedema LUE 7627- 7121 60%* 20040115 Left Radical Mastectomy 7626 50% 20040115 Asthma Not Unfitting Asthma 6602 30% 20040115 Abdominal and low back pain Not Unfitting Low Back Pain NSC 20040115 Bilateral upper extremity weakness Not Unfitting NO Separate VA Entry (see codes 7627-7121 above, and 5024-5203 below) .No Additional MEB/PEB Entries. Left Shoulder Tendinitis 5024- 5203 10% 20040115 Right modified radical mastectomy 7626 40% 20040115 Total Hysterectomy 7618 30% 20040115 0% X 2 / Not Service-Connected x 2 20040115 Combined: 20% Combined: 100% *Rating for residuals of carcinoma of left breast w/lymphedema was increased from 20% to 60% on 20040910 VARD based on additional evidence effective DOS (combined 100% effective 19 March 2004. ANALYSIS SUMMARY: Left upper extremity lymphedema condition. The narrative summary (NARSUM) stated that the CI had a left modified radical mastectomy for breast cancer with a TRAM flap reconstruction in March 2001 followed by chemotherapy and radiation, approximately 3 years prior to separation. In April 2002 she had a prophylactic right simple mastectomy with immediate reconstruction using a latissimus dorsi flap. The CI had the onset of left arm swelling in June 2002 after completion of external beam radiation. She was referred to a lymphedema specialty clinic where the left arm was found to be 24% larger than the right arm secondary to edema. With outpatient compressive care this decreased to 12%, with noted clinical reduction in left arm edema. However, by time of the NARSUM examination, the lymph edema had returned (17%); felt by the clinic to be secondary to CI difficulty with recently initiated home care. On multiple evaluations in the 3 months prior to the NARSUM, the arm was described as firm without fibrosis, having normal skin without lesions, redness, or persistent pitting. At the MEB exam 23 April 2003, approximately 11 months prior to separation, the CI reported that her left hand swelled with any activity. She reported left chest pain and spasms; chronic back and abdominal pain; weakness of both upper extremities; that she was unable to wear her uniform due to her arm compression device. The MEB physical exam noted that the CI wore a compression device on the left arm. There was a scar and edema of the left chest with 3+ (range 1-4) lymphedema in the LUE. Range-of-motion (ROM) of the left shoulder was limited with abduction of 175 degrees (normal 180 degrees); internal rotation 70 degrees (normal 90 degrees); strength was decreased throughout at 4+/5. Grip strength was noted to be “50% of normal.” The MEB neurological exam was normal. Skin was normal except for scars of the chest, back and left and right lower abdomen. The examiner stated that the CI had chronic significant LUE edema and almost no functional use of the LUE. An addendum to the NARSUM stated that following treatment for breast cancer, the CI had no evidence of disease. At the VA Compensation & Pension (C&P) exam 15 January 2004, approximately 2 months prior to separation, the CI reported being cancer free; taking medication for asthma; and occasional LBP. The exam noted “+3 brawny edema of the entire left arm to the top of the fingers.” Left shoulder ROM was extension 105 degrees (normal 180 degrees) and abduction 80 degrees (normal 180 degrees). The impression was the left arm decreased ROM caused the CI a moderate amount of physical impairment. All scars were noted to be well-healed and non- tender. The skin was otherwise not mentioned. The Board directs attention to its rating recommendation based on the above evidence. The PEB rated the left upper extremity and chest edema as 7627-7199-7121 (analogous to post- phlebitic syndrome following breast cancer treatment) at 20%. The VA rated left radical mastectomy 7626 at 50% and left lymphedema of the arm and chest also as 7627-7121 at 20%. The Board deliberated whether the CI’s lymphedema condition met the 20% or 40% rating criteria of 7121. The Board adjudged that the preponderance of the evidence in the record supported that the CI had moderate lymphedema, which improved significantly when attentive to treatment compliance, and was without skin changes or ulceration which most nearly met the 20% rating. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (Resolution of reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the LUE lymphedema condition. Contended PEB Conditions. The contended conditions adjudicated as not unfitting by the PEB were abdominal and LBP, bilateral upper extremity weakness, and asthma. The Board’s first charge with respect to these conditions is an assessment of the appropriateness of the PEB’s fitness adjudications. The Board’s threshold for countering fitness determinations is higher than the VASRD §4.3 (Resolution of reasonable doubt) standard used for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard. 1) Chronic abdominal and LBP condition: the CI’s abdominal and LBP condition (s/p TRAM flap harvesting) was protectively profiled consistent with standard post-operative care for the procedures performed to protect the flap during healing. This is a reasonably anticipated accompaniment of the CI’s bilateral breast reconstruction procedures, usually with a favorable outcome in response to physical therapy and flap donor site rehabilitation, which the CI had not yet pursued. At the C&P exam approximately 2 months prior to separation, the abdominal pain was not reported and no back or abdominal impairment noted in the exam. 2) Bilateral upper extremity weakness: bilateral upper extremity weakness was profiled. The commander’s statement mentioned limitations due to lymphedema of the left arm and chest and stated that this has been “determined to be a permanent condition.” The LUE disability rating was previously addressed. The VA rated left shoulder tendinitis in addition to lymphedema, but PT notes in service treatment records (STRs) state that rotator cuff tendinitis is a common disablement of uncontrolled edema in this region. A physical therapy note of 12 May 2003 stated “functional use of the arm decreased due to fatigue, fluid and ache.” The Board opined that any disability of the LUE was subsumed under the rating for lower extremity (LE) and a separate rating was not possible IAW VASRD §4.41 (Avoidance of pyramiding). The Board deliberated the condition of the right upper extremity (RUE) at the time of separation. STRs support that the CI had some disability of the RUE following the simple mastectomy. A note in the record addressed bilateral upper extremity (UE) swelling issues (post right mastectomy, about 13 months prior to separation) but indicated full ROM. The significantly decreased RUE ROM noted in the MEB NARSUM exam was from a PT exam about 9 months prior to separation. Around this period the CI had an episode of “bone pain” in bilateral arms and legs, which she rated 3 out of 10. Three days after the PT measurements, an oncology exam noted only left UE edema, nothing about the RUE, and no motor or sensory deficits. The assessment was that the pain was not related to her cancer. There are no other records relating to the RUE after that date, except for the C&P exam, 2 months prior to separation, at which the RUE was not noted to be a problem or addressed in the exam. Also, the latissimus dorsi flap procedure for reconstruction of the right breast was reasonably anticipated to cause some muscle tightness affecting the right arm until such time as physical rehabilitation could be undertaken. There was no evidence in the record of an additional diagnosis contributing to the reported RUE weakness. 3) Asthma: asthma was forwarded as medically acceptable by the MEB. The NARSUM exam noted asthma as “currently asymptomatic,” and asthma was not mentioned by the commander. At The C&P, 2 months prior to separation, the lung exam was normal and the examiner’s opinion was that the CI’s “asthma, seems to be well controlled on medications. It does not give her any physical impairment.” Although the contended conditions of abdominal and LBP, bilateral upper extremity weakness, and asthma were listed on the permanent profile, none of them were implicated in the commander’s statement. All were reviewed and considered by the Board. After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for any of the contended conditions; and, therefore, no additional disability ratings are recommended. BOARD FINDINGS: IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication. In the matter of the LUE lymphedema condition, the Board unanimously recommends no change in the PEB adjudication. In the matter of the contended chronic abdominal and LBP, bilateral upper extremity weakness, and asthma conditions, the Board unanimously recommends no change from the PEB determinations as not unfitting. There were no other conditions within the Board’s scope of review for consideration. RECOMMENDATION: The Board, therefore, recommends that there be no recharacterization of the CI’s disability and separation determination, as follows: UNFITTING CONDITION VASRD CODE RATING Left upper extremity lymphedema s/p radical mastectomy w/reconstruction after stage 3 breast cancer diagnosis 7627-7199- 7121 20% Chronic Abdominal and Low Back Pain Not unfitting Bilateral Upper Extremity Weakness Not unfitting Asthma Not unfitting RATING 20% The following documentary evidence was considered: Exhibit A. DD Form 294, dated 20120602, w/atchs Exhibit B. Service Treatment Record Exhibit C. Department of Veterans’ Affairs Treatment Record XXXXXXXXXXXXXXXXXXXXXXX, DAF Acting Director Physical Disability Board of Review SFMR-RB MEMORANDUM FOR Commander, US Army Physical Disability Agency (TAPD-ZB / XXXXXXXXXXXXXXX), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557 SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXXXXXXX, AR20130005510 (PD201200517) I have reviewed the enclosed Department of Defense Physical Disability Board of Review (DoD PDBR) recommendation and record of proceedings pertaining to the subject individual. Under the authority of Title 10, United States Code, section 1554a, I accept the Board’s recommendation and hereby deny the individual’s application. This decision is final. The individual concerned, counsel (if any), and any Members of Congress who have shown interest in this application have been notified of this decision by mail. BY ORDER OF THE SECRETARY OF THE ARMY: Encl XXXXXXXXXXXXXXXXXX Deputy Assistant Secretary (Army Review Boards)