RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2014-01460
BRANCH OF SERVICE:  Army	BOARD DATE:  20150121
SEPARATION DATE:  20090104

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Automated Logistics Specialist) medically separated for chronic chest wall pain following bilateral prophylactic mastectomies and chronic right shoulder pain.  The conditions could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty or satisfy physical fitness standards.  She was issued a permanent U3/L3/S3 profile and referred for a Medical Evaluation Board (MEB).  “Chronic chest wall pain” and “chronic right shoulder, rotator cuff diseases” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded seven other conditions.  The Informal PEB adjudicated “chronic chest wall pain following bilateral prophylactic mastectomies” and “chronic right (dominant) shoulder pain” as unfitting, rated 10% and 10% respectively, referencing application of the VA Schedule for Rating Disabilities (VASRD).  The remaining conditions (musculoskeletal cervical pain, degenerative facet disease of the lumbosacral spine, scar formation of the left ankle, bilateral chondromalacia patella and migraines) were determined to be not unfitting and therefore not rated.  Chronic pain disorder associated with both psychological factors and general medical condition and mood disorder were not rated to avoid pyramiding.  The CI made no appeals and was medically separated.

CI CONTENTION:  “Chronic pain in chest wall from mastectomies with numerous surgeries.”

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e.(2).  It is limited to those conditions determined by the PEB to be unfitting for continued military service and when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting.  Any conditions outside the Board’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/Naval Records.  Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the VASRD standards to the unfitting medical condition at the time of separation.  The Board 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, operating under a different set of laws.  The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation. 

RATING COMPARISON:

Service IPEB – Dated 20080924 | VA - (2.5 Mos. Post-Separation)
Condition | Code | Rating | Condition | Code | Rating | Exam
Chest Wall Pain Following Bilateral Mastectomies | 5099-5003 | 10% | S/P Bilateral Simple Mastectomies w/Residual Pain and Scars | 7626 | NSC | 20090326
Right Shoulder Pain (Dom) | 5099-5003 | 10% | Right Shoulder Tendinopathy | 5299-5201 | 20% | 20090326
Other x 0 (Not in Scope) | Other x 13 |
Combined:  20% | Combined:  60%
Derived from VA Rating Decision (VARD) dated 20090610 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:  The Board noted the CI had undergone bilateral simple mastectomies with separate incisions in separate anatomic areas: one on the right chest and one on the left chest.  Both of these areas became symptomatic.  The PEB combined these conditions and rated as a single entity.  The Board’s initial charge in this case was, therefore, directed at determining if the PEB’s approach of single rating as a single entity was justified in lieu of separate ratings.  The Board must apply separate codes and ratings in its recommendations if compensable ratings for each condition are achieved IAW applicable VASRD sections.  If the Board judges that separate ratings are warranted in such cases, however, it must satisfy the reasonable requirement that each “unbundled” condition was unfitting in and of itself or at least an indispensable element of a combined effect rating.  The Board will discuss these conditions together to avoid clerical redundancy as they are presented together in the record, but then separate them for fitting and rating considerations.

Chest Wall Pain following Bilateral Mastectomies.  The narrative summary (NARSUM) noted that the CI was determined to be at high risk for breast cancer, based on family history, and to undergo elective, prophylactic simple mastectomies and breast reconstruction with placement of breast prosthetics.  This was accomplished in stages with initial placement of tissue expanders to prepare the site for the prosthesis at the time of mastectomy in December 2004 and placement of saline pad prosthesis in August 2005.  In October 2005, a cosmetic liposuction revision of the left implant site was undertaken.  A plastic surgery (PS) evaluation on 6 January 2006, the CI reported tenderness at the implant sites after exercising and dissatisfaction with her cosmetic result.  On examination, some “drooping” of the breasts with capsule formation (scaring under the skin around the implants) was reported.  The examiner opined that the discomfort was related to the capsule formation.  On 24 January 2006, further revision of the surgical sites was undertaken.  On a post-operative examination, dated 3 February 2006, the CI was satisfied with the results and reported no breast or chest wall symptoms.  A PS exam on 29 August 2006, the surgical scars were well healed and the CI reported no pain.  In early 2007, the CI developed increasing tightness and pain in both surgical sites.  A PS evaluation on 17 August 2007, the CI reported tightness with chest discomfort in both implant sites.  Significant capsule formation was reported at both sites.  The examiner opined that the chest symptoms were caused by recurrent capsule formation.  On 11 October 2007, the CI underwent open revision of the implant sites with removal of the capsules and replace of the saline implants with larger silicone filled implants.  Post-operatively the CI had continued pain, discomfort and feelings of tightness at both implant sites requiring narcotics for pain control.  At the MEB/NARSUM chest wall addendum evaluation on 10 June 2008, 9 months prior to separation, the CI reported pain in her surgical scars with clothing contact and when lifting her arms over her head.  On examination, the right scar was “very sensitive, and the left scar less sensitive to palpation.”  No mention was made of other areas of chest wall tenderness.

At the VA Compensation and Pension (C&P) exams performed approximately 3 months after separation, the CI was reported to be in no distress.  Chest and respiratory examinations were normal with, good lung expansion and no respiratory distress and no chest wall defects.  Both chest wall surgical scars were healed and were “quite tender to palpation.”  At this time, the CI was a “full-time” student 

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the conditions together as chest wall tenderness, rated 10% for painful motion IAW §4.59.  The VA adjudicated the condition as “not service-connected” and not ratable noting that the VA “cannot grant service-connection for an elective procedure nor known side effect of a procedure,” based on “a preventative measure, not a diagnosed medical condition.”  The Board agreed that the record in evidence reasonably supported each surgical site to be unfitting per se given the commander’s statement and the permanent profile.

Right Chest Rating.  The Board considered a rating under code 7804 (Painful scars), IAW §4.118 (Disorders of the skin).  Under this code a rating of 10% may be given for one or two scars that are painful or unstable.  The Board agreed that the record in evidence supported a rating under this code.  The Board considered a rating under code 5003 IAW §4.59 for painful motion of the chest wall, but agreed that the record in evidence supported the scar condition, for which a specific VASRD rating is extant, to be the direct source of the painful condition.  The Board, thus, concluded that the scar code was more clinically relevant.  The Board considered a rating under code 7626 (Breast surgery), IAW §4.116 (Disorders of the Breast).  Under this code, a rating of 30% (single breast) or 50% (both breasts) may be given following simple mastectomy with “significant alteration of size or form.”  The Board agreed that the CI had undergone bilateral simple mastectomies, but that this code did not apply as successful reconstruction of the breast with reestablishment of size and form was accomplished.  The Board considered a rating under code 6843 (Traumatic chest wall injury) and 6844 (Post-surgical residual) IAW §4.97 (Respiratory System) and §4.73 (Muscle impairment) but was unable to do so as the record in evidence documented that there was no muscle injury related to the surgery (simple mastectomy) and that no chest wall deformity, or respiratory or pulmonary function impairment was present and chest X-rays were normal.  The Board considered a rating IAW §4.124 (Neuralgia, cranial or peripheral), but was unable to do so as the record provided no evidence of specific or identifiable nerve impairment.  The Board found no other appropriate codes for consideration.

Left Chest Rating.  The Board considered a rating under code 7804 (Painful scars) IAW §4.118 (Skin).  Under this code a rating of 10% may be given for one or two scars that are painful or unstable.  The Board agreed that the record in evidence supported a rating under this code.  The Board consensus was that the adjudication of other coding considerations and determinations as discussed above for the right chest condition were also applicable for the left chest condition.  In summation, the Board agreed that the CI had two painful chest wall scars.  The Board agreed that the appropriate code for rating was 7804.  No higher rating than 10% is achievable under this code.  The Board, thus, recommended a rating of 10% for the right and left chest conditions.  As this provides no rating benefit to the CI, the Board, under precedent, recommends no change in the PEB adjudication for the chest condition.

Right Shoulder Pain (Dominant).  The NARSUM notes the CI to develop right shoulder pain with overhead reaching in 2006.  On a physical therapy (PT) evaluation on 29 June 2007, active range-of-motion (ROM) of the right shoulder was forward flexion of 88 degrees flexion and abduction (ABD) of 72 degrees (Normal: 180 degrees for both).  ROM of both shoulders was limited by pain across the chest wall and axilla.  A magnetic resonance imaging of the right shoulder on 29 September 2007 revealed tendinitis of two shoulder tendons with underlying “bone edema.”  On PT evaluation on 20 November 2007, the CI reported primarily right shoulder pain.  On examination, movement of the right shoulder produced shoulder but not chest pain wall pain.  ROM of motion of the right shoulder was of 100 degrees; ABD of 75 degrees with pain.  On PS evaluation on 5 December 2007, the CI reported increasing breast discomfort.  Exam at this time revealed new “capsules” around the breast implants.  At the MEB/NARSUM orthopedic evaluation on 8 April 2008, 9 months prior to separation, the CI reported continued right shoulder pain with overhead work.  The MEB physical exam noted motor strength with abduction, elbow flexion, and extension slightly reduced from shoulder pain.  ROM findings are summarized in the chart below.

At the VA C&P general exam performed approximately 3 months after separation, the CI reported constant moderate pain in the shoulder area with severe flares approximately twice weekly.  On physical examination, no deformity, instability or tenderness of the shoulder was reported.  Results of the ROM evaluation are summarized below.

The goniometric ROM evaluations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized below.

Right Shoulder ROM
(Degrees)

MEB ~ 9 Mo. Pre-Sep
(20080408)

VA C&P ~ 2.5 Mo. Post-Sep
(20090326)

Flexion (180 Normal) | 98 | 90
Abduction (180) | 116 | 90
Comments | Limited by shoulder pain | Pain at 90 degrees.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the shoulder condition 10%, code 5003 for painful motion IAW §4.59.  The VA rated the condition 20% Code 5201 (Limitation of motion) IAW §4.71a, citing limitation of arm motion to shoulder level.  A higher rating of 30% under this code, for dominant extremity, required limitation of arm motion to midway between the side and shoulder level.  The Board noted that early PT evaluations related the decreased ROM of the shoulder to the painful chest wall condition.  The Board agreed that the record provided conflicting evidence as to whether this relationship was continued in the period proximal to separation but consensus was that that evidence reasonably supported the ROM of the shoulder was affected by the adjacent chest wall condition.  The Board was unable to ascertain the precise degree of impact on shoulder ROM of the chest condition.  The Board agreed that, the shoulder had identifiable etiologic pathology, but that this was insufficient to explain alone the degree of ROM loss on the C&P examination.  The Board noted the differences in the shoulder ROM between the NASUM and C&P exams, and presumed this was contributed to by the development of new “capsules” around the implants of the chest wall condition, noted two months after the final surgical revision in October 2007, a source of chest wall pain, previously surgically addressed.  On review of the complete record, the Board consensus was the chest painful condition contributed to some extent to the reduction of ROM of the shoulder and that a rating of 10% fairly and equitably reflected the functional disability for the right shoulder condition itself at separation.  The Board found no other appropriate codes for rating consideration.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends no change in the PEB adjudication for the shoulder 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.  The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised.  In the matter of the chest wall pain condition and IAW VASRD §4.118, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the right shoulder condition and IAW VASRD §4.71a the Board, by majority vote, recommended no change in the PEB adjudication.  The dissenting voter chose not to submit a minority opinion.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  The Board, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination.

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140324, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

XXXXXXXXXXXXXXX
President
DoD Physical Disability Board of Review

SAMR-RB									

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXX, AR20150010996 (PD201401460)

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			     XXXXXXXXXXXXXXX
			     Deputy Assistant Secretary of the Army
			          (Review Boards)
						         
CF: 
(  ) DoD PDBR
(  ) DVA

PD-2014-01460