RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXXX	      CASE:  PD-2014-02067
BRANCH OF SERVICE:  Army	                             SEPARATION DATE:  20080422

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4, Indirect Fire Infantry, medically separated for “chronic left testicular pain” and “chronic thoracic back pain” rated 10% each condition, with a combined  disability rating of 20%.

CI CONTENTION:  “To determine the integrity of the initial review rating decision.”  The complete submission is at Exhibit A.

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44.  It is limited to those conditions determined by the Physical Evaluation Board (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 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:  

SERVICE PEB – 20080108	VARD - 20080719  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Left Testicular Pain	5099-5003	10%	Residuals, L Varicocelectomy	7599-7525	0%	20080814	
Chronic Thoracic Back Pain	5299-5237	10%	Thoracic Sprain	5237	20%	20080612	
COMBINED RATING:  20%	COMBINED RATING FOR ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Left Testicular Condition.  The service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM) documented the onset of left testicular pain in September 2006 which was diagnosed as a varicocele (engorged internal scrotal veins); and, the CI underwent a prompt laparoscopic repair (19 months pre-separation) with no complications.  The surgery provided no relief of the reported constant pain.  An ultrasound (repeated twice through the clinical course) demonstrated a “small” residual left varicocele which was stable, if not decreasing, over time.  Urology opined that no further surgery was indicated; the pain did not improve with conservative treatment (including a steroid injection and nerve block); and an MEB was initiated in July 2007.  There were STR entries confirming the absence of urinary symptoms, infections, or other complications; examinations were stable (confined to left testicular tenderness, sometimes with and sometimes without a palpable varicocele); and there was no STR documentation of periods of incapacitation (after surgical recovery).  

The NARSUM was conducted 27 November 2007 (5 months pre-separation) and documented continued “constant” pain despite multiple treatments (worse “when I run”); noting, “The only relief he received was from Percocet.”  The NARSUM physical examination recorded a palpable and tender left varicocele with no other positive findings.

A VA Compensation and Pension (C&P) examination was conducted 14 August 2008 (4 months post-separation) and documented constant pain (severity not specified) without elaborating specific functional limitations.  All urinary symptoms probative to rating were documented as negative.  The VA physical examination recorded left testicular tenderness “in the epididymis area” without noting a varicocele or other positive finding.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB’s 10% rating analogous to 5003 (degenerative arthritis) was not clinically well grounded; but, considering alternatives (as below) was not unfavorable.  The VA rated analogously to 7525 (chronic epididymo-orchitis) which defaults to the VASRD §4.115a general criteria for urinary tract infection; and, the absence of any supported criterion under that formula resulted in a 0% rating.  Analogous rating under 8730 (neuralgia of the ilio-inquinal nerve [as anatomically applicable in this case]) is subject to consideration, but the highest rating for “severe” impairment is 10%; thus, this is not an advantageous alternative to the PEB’s approach.  No other VASRD code is a rational match with the condition and it is noted in passing that even code 7524 for the loss of one testicle yields a 0% rating.  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 of the left testicular condition.

Chronic Thoracic Back Condition.  The earliest entry in the STR documented an atraumatic onset of back pain in September 2006, in the same time period as the testicular complaint.  The pain persisted, without radiation or neurological complaints, and magnetic resonance imaging was normal (plain X-rays showed a baseline [non-ratable] “exaggerated kyphosis”).  The (non-surgical) back pain persisted despite conservative measures, was also treated with narcotics, and was added to the MEB underway for the testicular condition.  Various STR entries documented grossly normal range-of-motion (ROM) albeit with painful motion, although two entries (one shortly before the NARSUM) recorded flexion to mid-tibia (~70-80 degrees).  There was no STR evidence of more severe ROM limitation.  There was ample STR documentation of normal gait, the absence of spasm, and normal strength and neurological findings.  There were no STR entries contrary to any of these ratable features, or documentation of incapacitating episodes.

The NARSUM documented “intermittent mid to upper back pain ... non-radiating” without subjective weakness or sensory symptoms, and interfering with “[CI quote] sleeping, lifting things, standing up straight.”  The NARSUM physical examination recorded a normal gait, the baseline thoracic kyphosis, tenderness, the absence of spasm, and normal neurological findings (5/5 strength).  The examiner noted “functional ROM of his entire spine in all planes.”  The NARSUM addenda physical therapy ROM measurements: flexion to 65 degrees (normal 90) and combined ROM of 165 degrees (normal 240), with normal gait and no spasm.

A VA spine Compensation and Pension (C&P) examination was conducted 12 June 2008 (2 months post-separation).  The VA rating decision (VARD) referenced “intermittent mid and upper back pain which occurs at random” and exam findings of paraspinal tenderness and normal neurological findings.  The reported ROM measurements were flexion to 60 degrees and combined 175.  The diagnosis was “thoracic sprain.”

The Board directed attention to its rating recommendation based on the above evidence.  The PEB’s 10% rating analogous to 5237 (thoracolumbar strain) was consistent with VASRD §4.71a criteria for the Service ROM evidence and other ratable findings.  The VA’s rating under the same code was premised on the spine C&P flexion of 60 degrees, which is the §4.71a 20% threshold.  There was no evidence for abnormal gait or (ratable) contour to support a 20% rating; no evidence for ratable peripheral nerve impairment which would provide for additional rating; and, no documentation of incapacitating episodes which would provide for a higher rating under that formula.  There is a disparity in this case between the MEB and later C&P ROM findings with obvious implications for the Board's rating recommendation.  The Board deliberated the probative value of these conflicting evaluations, with review of the overall evidence for corroboration.  The PEB and VA examinations were of the same temporal proximity to separation and quality.  The ample outpatient STR ROM evidence over a stable 12-month period, and the NARSUM examiner’s ROM observations, are better aligned with the MEB ROM measurements; and, there is no corroboration of the C&P measurement of flexion.  The overall clinical acuity (myofascial strain without disc disease) and functional capabilities (documented limitations, normal gait) are more consistent with the MEB ROM, as are the absent findings for spasm typically accompanying more severe ROM limitation.  After due deliberation with deference to reasonable doubt, therefore, members agreed that there was insufficient cause to recommend a change in the PEB adjudication of the thoracolumbar condition. 

BOARD FINDINGS:  In the matter of the left testicular condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the thoracic myofascial condition, the Board unanimously recommends no change in the PEB adjudication.  There were no other conditions within the Board’s scope of review for consideration.  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 20140511 w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR Commander, US Army Physical Disability Agency (AHRC-00), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXXXXXXXX AR20160006088  (PD201402067)

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:

Enclosure 

CF:
( ) DoD PDBR 
( ) OVA