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)