RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2014-01176
BRANCH OF SERVICE:  Army	BOARD DATE:  20150408
SEPARATION DATE:  20040820

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-6 (Armor Crewman) medically separated for recurrent thrombophlebitis.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty or satisfy physical fitness standards.  He was issued a permanent P3U2L2 profile and referred for a Medical Evaluation Board (MEB).  The thrombophlebitis condition, characterized as “recurrent thromboembolic disease” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded “low back pain and mild mitral valve prolapse” conditions for PEB adjudication.  The PEB adjudicated “recurrent lower extremity thrombophlebitis,” and rated 0% with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The remaining conditions were determined to be not unfitting (low back pain and mild mitral valve prolapse).  The CI made no appeals and was medically separated.

CI CONTENTION:  “Veteran prescribed Warfarin (blood thinners) for rest of life/chances of bleeding and bruising greatly increased/lifestyle change (reduced activities)/pain and swelling comes with activity/cannot sit or stand for long periods of time( causes swelling and pain)/ reduction in job opportunities/considered more of a liability than an asset or benefit (as said by the military).”

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 20040316	VA- (>2 Mos. Pre-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Recurrent Lower Extremity  Thrombophlebitis	7199-7121	0%	Deep Venous Thrombosis; Right Lower Extremity	7121	20%	20040607	
			Deep Venous Thrombosis; Left Lower Extremity	7121	10%	20040607	
Other x 0 (Not In Scope)	Other x 3	
Combined:  0%	Combined:  60%	
Derived from VA Rating Decision (VARD) dated 20040920 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Recurrent Lower Extremity Thrombophlebitis Condition.  The MEB narrative summary (NARSUM) noted that the CI suffered a left femoral deep vein thrombosis (DVT) in July 2002.  An extensive workup, including search for genetic factors, was negative.  There were no symptoms to indicate an associated pulmonary embolism.  The hematologist opined that the blood clot was most likely secondary to stasis from long travel.  It was treated with restricted duties (modified profile) and Coumadin (blood thinner) for 6 months.  The CI noticed right thigh and calf area swelling and pain on 24 December 2003 (after two long trips), and was diagnosed with a second DVT.  There were no symptoms to indicate an associated pulmonary embolism.  Ultrasound was reported to show DVT of the right femoral vein, and the CI was restarted on Coumadin.  At the MEB NARSUM exam on 5 January 2004, 8 months prior to separation, the CI complained of severe right calf pain and required crutches to walk.  On examination, the skin had no erythema or rashes.  The CI was tender to touch in the mid-calf area with positive Homan's sign (pain with dorsiflexion of the ankle, indicative of possible DVT), and tender to touch in the right inguinal area.  There was no appreciable edema (swelling) in the calf area, no palpable cords, and no significant erythema.  At the MEB examination on 21 January 2004, there was right leg pain with range-of-motion and weight bearing (with no mention of presence or absence of edema).  At a clinic appointment on 1 April 2004, 5 months prior to separation, the CI still used crutches part-time.  A recent ultrasound showed no change from January 2004.  On examination, there was no edema or erythema of the lower extremities.  At the VA Compensation and Pension (C&P) exam on 7 June 2004, 3 months prior to separation, the CI reported no current pain and that he used a cane when going up and down stairs to keep pressure off his right leg.  He stated that he felt some weakness in both legs, that at times he felt that his legs were going to give way, but that he had not fallen “which may be due to him being on bedrest and took it easy since 2002.”  On examination, hematic and lymphatic systems were “within normal limits” (presumably, no edema of the lower extremities).  The CI was admitted with a third DVT while he was on Coumadin, on 23 June 2004.  On examination there was moderate (2+) edema up to the mid-shin of the legs, and a cord was palpable in the left popliteal region (behind left knee).  However by 25 June 2004, 2 days after admission to the hospital, there was no edema of the lower extremities.  Repeat examination on 27 June 2004 also recorded that there was no edema of the lower extremities.  A Doppler ultrasound of the lower extremities revealed extensive bilateral DVT.  Computed tomography (CAT scan) showed probable chronic occlusion of the inferior vena cava, the main vein in the abdomen, and common iliac vein below the renal veins.  The CAT scan demonstrated the formation of new veins in the pelvis (collateral veins; the enlargement of existing small veins) to accommodate the blood flow previously served by the inferior vena cava.  There were no respiratory symptoms to indicate a pulmonary embolism complicating this event.  Due to the recurrent nature, he was recommended to continue anticoagulation therapy for life at a higher dose than before.  A venous duplex scan (ultrasound) on 19 November 2004, 3 months after separation, showed persistence of clot within the distal (lower thigh) superficial femoral veins bilaterally.  At a VA cardiac evaluation on 11 August 2005, 12 months after separation, the CI reported lower extremity edema which was relieved with elevation.  There were no lung related symptoms.  On examination there was no swelling (edema) of the lower extremities, or varicosities (dilated superficial veins) below the knees.  At an anticoagulation therapy monitoring check on 12 August 2005, the CI complained of left ankle edema; an area on the ankle looked like fungus and was treated with an anti-fungal agent.  An ultrasound on 20 November 2005 was still positive for DVT of the right and left lower extremities.  The CI was wearing compression socks.  At a VA C&P exam on 28 November 2005, 15 months after separation, the CI stated that both legs would swell up with mild exercise, such as walking greater than a-half mile.  It did not necessarily affect his work because he did a desk job, although he was no longer able to play sports such as basketball.  If he travelled he had to stop every hour and walk around.  On examination, the left calf and both thighs were tender to touch, and several distended veins were felt on the left lower calf and right upper thigh.  A Coumadin Clinic encounter on 9 December 2005, recorded the CI experienced muscle pain when he overdid activities such as standing too long or playing basketball.  He walked without apparent difficulty and no swelling was noted.  At a VA clinic visit on 20 January 2006, the CI had no cyanosis or edema of the extremities.  At an anticoagulation therapy monitoring check on 24 March 2006, 20 months after separation, skin examination was normal, skeletal/muscle/extremities were normal, and there was no ankle pitting (swelling).  At a clinic visit on 17 July 2006, he had no edema of the extremities.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the condition analogous to code 7121 (Post-phlebitic syndrome of any etiology) at 0%.  The VA rated the condition under code 7121 at 20% for the right lower extremity and 10% for the left lower extremity citing the examination from 24 June 2004 while hospitalized showing 2+ edema up to the mid shin as evidence of persistent edema which was incompletely relieved by elevation of the extremity.  However, examinations on 25 June 2004 and 27 June 2004 documented resolution of the edema.  Although the ultrasound abnormalities persisted, there was no edema of the legs on subsequent exams on 25 June 2004, 27 June 2004, 11 August 2005, 20 January 2006, 24 March 2006, or 17 July 2006.  The CI complained of edema of the lower extremities relieved with elevation on 11 August 2005, left ankle edema on 12 August 2005, swelling of both legs with mild exercise in November 2005, and edema of both lower extremities in January 2006.  Despite significant residual venous obstruction due to his DVT (confirmed by vena cavagram and ultrasounds), the record clearly demonstrated that the CI’s lower extremity symptoms were not persistent, but intermittent.  The record did not support a rating of 20% for either lower extremity (Persistent edema, incompletely relieved by elevation of extremity, with or without beginning stasis pigmentation or eczema).  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for both the right and left leg thrombophlebitis conditions (combined rating of 20% with application of the bilateral factor).

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 right leg thrombophlebitis condition, the Board unanimously recommends a disability rating of 10%, coded 7199-7121 IAW VASRD §4.104.  In the matter of the left leg thrombophlebitis condition, the Board unanimously recommends a disability rating of 10%, coded 7199-7121 IAW VASRD §4.104.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of his prior medical separation:

UNFITTING CONDITION	VASRD CODE	RATING	
Recurrent right lower extremity thrombophlebitis  	7199-7121	10%	
Recurrent left lower extremity thrombophlebitis  	7199-7121	10%	
COMBINED (w/ BLF)	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140307, 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, AR20150013304 (PD201401176)

1.  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 to modify the individual’s disability rating to 20% without recharacterization of the individual’s separation.  This decision is final.  

2.  I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum.   

3.  I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures.

 BY ORDER OF THE SECRETARY OF THE ARMY:

Encl		XXXXXXXXXXXXXXX
			Deputy Assistant Secretary of the Army
			    (Review Boards)

CF: 
(  ) DoD PDBR
(  ) DVA