RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2014-01682
BRANCH OF SERVICE:  Army	BOARD DATE:  20150331
SEPARATION DATE:  20070307

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-3 (Motor Transport Operations) medically separated for chronic right inguinal pain and atypical chest pain.  The conditions 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 P3/L3 profile and referred for a Medical Evaluation Board (MEB).  The “right inguinal area pain” and “atypical chest pain,” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded one other condition (chololithiasis) for PEB adjudication.  The Informal PEB adjudicated “chronic right inguinal pain” and “atypical chest pain” as unfitting, rated 0% and 0%, citing application AR 635-40.  The remaining condition was determined to be not unfitting.  The CI made no appeals and was medically separated.

CI CONTENTION:  “Please consider all conditions”

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 Veterans Affairs Schedule for Rating Disabilities (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:

IPEB – Dated 20070206	VA* - (~2 Mos. Post-Separation) 	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Right Inguinal Pain	8799-8730	0%	Residuals, Right Inguinal Hernia Repair	7338	0%	20070511	
Atypical Chest Pain	5099-5003	0%	Residuals Neonatal Pneumothorax w/Thoracic Chest Pain	6843	0%	20070511	
Chololithasis	Not Unfitting	Not Addressed	
Other x 0 (Not In Scope)	Other x 2 	
RATING:  0%	RATING:  10%	
*Derived from VA Rating Decision (VARD) dated 20070703 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Chronic Right Inguinal Pain Condition.  Treatment records evidence that the CI presented on 26 April 2006 with reports of a few weeks history of a painful lump in the lower right quadrant of his abdomen.  The physical examination demonstrated a mildly tender bulge in the right inguinal region which increased in size with Valsalva (bearing down abdominal pressure) and reduced easily.  A diagnosis of right inguinal hernia (RIH) was rendered.  On 12 July 2006 the CI underwent a RIH repair.  There was post-operative resolution of his pain until 31 August 2006 when he experienced gradually worsening right groin pain while stretching during physical training.  The abdominal examination was normal except for a very tender right inguinal surgical scar.  A diagnosis of adherent scar was rendered.  A primary care physical dated 29 September 2006 documented two visits to the emergency department in September 2006, diffuse abdominal pain to palpation and no recurrence of the inguinal hernia.  A diagnosis of chronic pain syndrome was rendered.  At a pain management evaluation on 19 October 2009 the CI reported sharp, unbearable abdominal pain.  The pain was worse in the morning or with coughing, sneezing, lifting, walking and other physical activities.  The examination was significant for right inguinal tenderness to palpation and changed sensation to touch on the right side of the abdomen.  The examiner opined that the CI had ilio-hypogastric and possible ilio-inguinal neuropathies secondary to the RIH repair and performed an ilio-hypogastric nerve block.  The CI continued to report severe right inguinal pain and was referred to the MEB.  The narrative summary (NARSUM) notes that the CI’s groin pain was constant, but was aggravated by exercise.  The abdominal examination was normal except right inguinal scar tenderness.  The VA Compensation and Pension abdominal examination performed two months after separation was normal.

The Board directed its attention to its rating recommendation based on the above evidence.  
The PEB adjudicated the chronic right inguinal pain condition as unfitting.  The PEB and VA rated the condition at 0%.  The condition was coded 8799-8730 (analogous to ilio-inguinal nerve neuralgia) by the PEB and 7338 (Hernia, inguinal) by VA.  The Board considered whether there was evidence for a higher than 0% rating for the chronic right inguinal pain condition.  There was no evidence of postoperative recurrence of an inguinal hernia for a 10% rating under VASRD code 7338.  IAW VASRD § 4.124 the maximum rating for a neuralgia is equal to moderate incomplete paralysis of the nerve.  Moderate incomplete paralysis of the ilio-inguinal nerve is rated at 0%; therefore, there was no avenue to a higher rating using this VASRD code 7338.  

The Board noted that the diagnosis of adherent scar associated with the recurrence of the CI’s chronic right inguinal pain.  There were multiple treatment notes documenting tenderness at the site of the scar and multiple reports of pain at the site of the scar with activity.  The NARSUM examiner documented tenderness at the scar area with reports of the CI feeling like it made his muscles jump.  Board member agreed that the painful scar was directly related to the unfitting chronic right inguinal pain and that the preponderance of evidence supports a separately unfitting determination.  VASRD code 7804 (scars, unstable, or painful) rates one painful scar at 10%.  Considering the totality of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the right inguinal hernia painful scar condition.

Atypical Chest Pain Condition.  Treatment records noted the CI presented with shortness of breath in October 2005 which progressed to shortness of breath with chest pain on exertion.  After a normal echocardiogram and stress test, the CI was diagnosed with atypical chest pain by a cardiologist.  The chest pain did not resolve with activity modification and pain medications.  At the NARSUM examination dated 1 December 2006 the CI reported that his chest pain occurred only after he ran.  The cardiac examination was normal and movement did not reproduce the pain.  A diagnosis of atypical chest pain was noted.  At the VA Compensation and Pension examination performed 2 months after separation, the examiner noted a childhood history of a collapsed lung.  The cardiac examination was normal and a diagnosis of residuals of neonatal pneumothorax with thoracic/chest wall pain was rendered.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB adjudicated the atypical chest pain condition as unfitting.  The PEB at 0% with cited application of the US Army Physical Disability Agency (USAPDA) pain policy.  The VA also rated the condition at 0%.  The condition was coded 5099-5003 (analogous to degenerative arthritis) by the PEB and 6843 (traumatic chest wall defect, pneumothorax, hernia,) by VA.  The Board considered whether there was evidence for a higher than 0% rating for the atypical chest pain condition.  Since the VASRD does not contain a code for atypical chest pain, the condition is rated analogous to 5321 (muscles of respiration).  The Board noted that at the time of the NARSUM the CI reported that the chest pain occurred after a run and that there was no impact on the activities of daily living.  Board members agreed that the atypical chest pain condition rose to the level of slight for a 0% disability rating under VASRD code 5321.  There was no evidence of pulmonary or cardiac dysfunction for a higher rating.  Considering the totality of the evidence and mindful of VASRD §4.3 (reasonable doubt), members agreed that a disability rating of 0% for the atypical chest pain condition was appropriately recommended in this case.

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the cholelithiasis condition was not unfitting.  The Board’s threshold for countering fitness determinations requires a preponderance of evidence, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  The chololithiasis condition was not profiled or implicated in the commander’s statement and was not judged to fail retention standards.  All were reviewed and considered by the Board.  There was no performance based evidence from the record that chololithiasis condition significantly interfered with satisfactory duty performance.  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 the chololithiasis contended condition and so 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.  The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised.  As discussed above, PEB reliance on the USAPDA pain policy AR 635-40 DoDI 1332.39 for rating atypical chest pain condition was operant in this case and the condition was adjudicated independently of that policy by this Board.  In the matter of the chronic inguinal pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the atypical chest pain condition and IAW VASRD §4.73, the Board unanimously recommends no change in the PEB adjudication; however the Board does recommend a VASRD code change to 5399-5321 to more closely approximate the CI’s anatomic location and functional impact.  In the matter of the chronic inguinal pain condition, the Board unanimously determined that the painful surgical scar was separately unfitting and recommends a disability rating of 10%, coded 7804 IAW VASRD §4.118.  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:

CONDITION	VASRD CODE	RATING	
Residual Painful scar s/p right inguinal hernia repair. 	7804	10%	
Chronic Inguinal Pain 	8799-8730	0%	
Atypical Chest Pain	5399-5321	0%	
COMBINED	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140410, 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, AR20150013458 (PD201401682)

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 10% 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