RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW NAME: XXXXXXXXXXXXXXXXXX BRANCH OF SERVICE: ARMY CASE NUMBER: PD1201055 SEPARATION DATE: 20020606 BOARD DATE: 20130320 SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SPC/E-4 (92A/Automated Logistical Specialist), medically separated for chronic bilateral breast pain, status post (s/p) reduction mammoplasty. Despite bilateral breast reduction surgery, medication, follow-up with General Surgery, and a Pain Management evaluation, the CI failed to meet the physical requirements of her Military Occupational Specialty (MOS) or satisfy physical fitness standards. She was issued a permanent P3 profile and was initially referred for a MOS/Medical Retention Board (MMRB) in January 2002. However, the MMRB directed that she be referred for a Medical Evaluation Board (MEB). The MEB forwarded “Bilateral Chronic Breast Pain” to the Physical Evaluation Board (PEB). The MEB forwarded no other conditions for PEB adjudication. The PEB adjudicated “Chronic Bilateral Breast Pain S/P Reduction Mammoplasty” condition as unfitting, rated 10% for moderate/frequent pain with application of the US Army Physical Disability Agency (USAPDA) pain policy. The CI made no appeals, and she was medically separated with a 10% disability rating. CI CONTENTION: “I have steady pain during heavy periods, also fever and cramping. Still unable to conceive. Left shoulder has lost of range of motion. Had to change jobs due to the inability of % 100 percent of use of left and right shoulder. I’ve revived an injection of Lanacane & steroid in left shoulder that increased pain. From PM & RS musculosketetal office at VA in Houston, TX Debakey. Room 2B-301, 2nd floor.” 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 condition of chronic bilateral breast pain, as requested for consideration, meets the criteria prescribed in DoDI 6040.44 for Board purview and is addressed below. The other requested conditions are not within the Board’s purview. 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 20020514 VA (3 Mos. Pre-Separation) – All Effective Date 20020606 Condition Code Rating Condition Code Rating Exam Chronic Bilateral Breast Pain, status post reduction mammoplasty 5099-5003 10% Residual Painful Scar from status post Bilateral Reduction Mammoplasties 7626-7804 10% 20020318 .No Additional MEB/PEB Entries. Status Post Bilateral Salpingectomy 7614 30% 20020318 Right Shoulder Strain 5203-5014 10% 20020318 0% X 2 / Not Service-Connected x 3 20020318 Combined: 10% Combined: 40% ANALYSIS SUMMARY: The Board’s authority as defined in DoDI 6040.44, resides in evaluating the fairness of Disability Evaluation System (DES) fitness determinations and rating decisions for disability at the time of separation. The Board utilizes service and VA evidence proximal to separation in arriving at its recommendations and DoDI 6040.44 defines a 12-month interval for special consideration of post-separation evidence. Post-separation evidence is probative only to the extent that it reasonably reflects the disability and fitness implications at the time of separation. Chronic Bilateral Breast Pain, S/P Reduction Mammoplasty Condition. The CI started with complaints of swollen breasts and soreness that caused back pain during running in February 1999. The breast complaints were unrelated to her menstrual cycle but instead were attributed to the breast size of an estimated 40D. At that time, a potential breast reduction was first considered and the CI underwent a bilateral breast reduction mammoplasty in September 1999. The CI’s post-operative history of breast pain and tenderness in the scar area bilaterally is well documented in the service treatment record (STR). The CI was given a sick slip in April 2000 for complaints of unbearable pain and soreness under the left breast, along the incision scars with tenderness to palpation, and around the nipples after running with activity restrictions for a week. There was more soreness in the left breast and the surgeon ordered an ultrasound to rule out a fluid collection or mass lesion; however, the ultrasound was negative. Pain management evaluated the CI in June 2000 for chronic bilateral mastalgia and recommended a medication for neuropathic pain (Neurontin). The CI was issued a permanent P3 Profile in January 2001 for bilateral breast pain with limitations of no running or high impact aerobic activities. Because of continued bilateral breast pain, the CI was again seen by General Surgery and the P3 Profile was continued. The MEB narrative summary (NARSUM) examination 2 months prior to separation indicated that the CI had moderate and frequent pain made worse by lifting overhead and bending over as well as an inability to run or perform greater than twenty five pushups, all due to pain. The physical examination findings were scars under both breasts and bilateral breast tenderness to palpation in the outer aspects of her breasts. The commander’s statement opined that the CI’s condition was worse that her profile stated and that she was unable to lift more than twenty pounds or raise her arms above shoulder level without severe discomfort which rendered her “totally incapable” of performing her MOS duties in a combat environment. The VA Compensation and Pension (C&P) examination 3 months prior to separation documented pain, bruising, and itching at the level of the breast scars especially with activities. The physical exam findings were a right breast inferior scar measuring 20cm x 0.3cm and a left breast inferior scar measuring 20cm x 0.3 cm, linear in shape, dark color with disfigurement, and tenderness. The examiner opined that there was chronic tenderness overlying the disfiguring scars. The Board directs attention to its rating recommendation based on the above evidence. The PEB coded the chronic bilateral breast pain, s/p reduction mammoplasty condition analogous to 5003 Arthritis, degenerative (hypertrophic or osteoarthritis) rated 10% with application of the USAPDA pain policy. The VA coded the residual painful scar from reduction mammoplasties 7626 Breast, surgery of with 7804 Scars, unstable or painful rated 10% for one or two scars that are unstable or painful. All exams throughout the STR documented painful scars and tenderness to palpation over the scars under both breasts. The NARSUM and C&P exams indicated that there was bilateral breast tenderness to palpation in the outer aspects and chronic tenderness overlying the disfiguring scars. The Board agreed that the CI clearly met the criteria for 7626 Breast, surgery of with 7804 Scars, unstable or painful: One or two scars that are unstable or painful. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 Reasonable doubt, the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the chronic bilateral breast pain, s/p reduction mammoplasty condition. 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. As discussed above, PEB reliance on the USAPDA pain policy for rating the chronic bilateral breast pain, s/p reduction mammoplasty condition was operant in this case and the condition was adjudicated independently of that policy by the Board. In the matter of the chronic bilateral breast pain, s/p reduction mammoplasty condition and IAW VASRD §4.116, the Board unanimously recommends no change in the PEB adjudication. 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: UNFITTING CONDITION VASRD CODE RATING Chronic Bilateral Breast Pain, status post Reduction Mammoplasty 5099-5003 10% COMBINED 10% The following documentary evidence was considered: Exhibit A. DD Form 294, dated 20120706, w/atchs Exhibit B. Service Treatment Record Exhibit C. Department of Veterans’ Affairs Treatment Record xxxxxxxxxxxxxxxxxxxxx, DAF Acting Director Physical Disability Board of Review FMR-RB MEMORANDUM FOR Commander, US Army Physical Disability Agency (TAPD-ZB / xxxxxxxxxxxx), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557 SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for xxxxxxxxxxxxxxxxxxxxx, AR20130007448 (PD201201055) 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 xxxxxxxxxxxxxxxxxxxxxx Deputy Assistant Secretary (Army Review Boards)