RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02391
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20040409

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an Reserve E4, Light Wheeled Vehicle Mechanic, medically separated for chronic right foot pain with a disability rating of 10%.  

CI CONTENTION:  “Please consider all conditions.”  The CI’s 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 based upon a 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 - 20040304	VARD - 20050111	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Pain…Right Foot	8725	10%	Residual Shrapnel Injury to Right Lower Leg	8599-8525	10%	20040607	
Polycythemia Vera…	Not Unfitting	Polycythemia Vera…	7704	10%		
High Frequency Sensorineural Hearing Loss both Ears		Left Ear Hearing Loss	6100	0%		
PTSD		PTSD	9411	30%		
Right Thigh, Leg and Face		Residuals…Wound to Right Thigh	7801	10%		
Extraction of Teeth		Extraction of Teeth	9913	0%		
Fracture of Left Radius…		Residuals of Left Radius Fracture	5215-8515	10%		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

Chronic Pain and Diminished Sensory Modalities in Sural Nerve Distribution Right Foot.  According to service treatment records (STRs) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s right leg chronic pain condition began in July 2003 after sustaining multiple shrapnel wounds.  Treatment consisted of shrapnel removal and the wounds were closed.  A posterior thigh wound, which was infected, was incised and drained.  Because of right foot numbness and diminished sensation, which was determined based on electrodiagnostic studies in November 2003 to be “an injury to the right lateral ankle in the distribution of the right sural sensory nerve.”  Treatment with Neurontin (gabapentin for nerve pain) was instituted.  Pain in the right foot ranged from 3-4/10 (10 being the worst pain), which was aggravated by activity, standing or walking more than 10 minutes, wearing shoes or boots, or trying to exercise.  TENS (transcutaneous electric nerve stimulation) along with Neurontin eased some of the pain.  

At the MEB examination (recorded on DD Forms 2807 and 2808) dated 9 January 2004, 4 months prior to separation, the CI reported nerve damage from a shrapnel wound.  Physical exam showed the CI’s “right foot/leg paresthesia along sural nerve.”  The NARSUM examination dated 26 January 2004, less than 3 months prior to separation, revealed a scar of the right posterior leg.  Sensation was diminished at the right foot and leg along the sural nerve path.  Vascular status was intact and range of motion (ROM) was full.   The CI could not walk or stand for more than 10 minutes or wear a rucksack, shoes or boots.  

A VA Compensation and Pension (C&P) examination was performed on 7 June 2004, 3 months post separation, indicated the CI complained of chronic paresthesias of the lateral aspect of the right foot and used a TENS [transcutaneous electrical nerve stimulation] for blocking sensation about once a day.  He described the sensation as constant tingling and was no longer using Neurontin.  EMG (electromyogram) studies showed sural nerve injury.  On examination there was hyperesthesia noted over the lateral dorsum of the right foot.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under the 8725 code (posterior tibial nerve neuralgia-mild), citing chronic pain and diminished sensory modalities in sural nerve distribution right foot, secondary to shrapnel injuries.  The VA assigned a 10% rating using an analogous 8599-8525 code (posterior tibial nerve incomplete paralysis- mild) based on the VA C&P examination 10 months after separation, citing (residuals shrapnel injury to right lower leg).  Board members discussed whether the sural nerve disability rose to a moderate or even a severe level.  Only one reference in the STR noted a full, normal range of motion ROM of the right ankle; however, there was no pain equivalent to paralysis of muscles of the sole of the foot with or without causalgia, an inability to flex his toes, weakened adduction or impairment of plantar flexion since the CI’s pain was eased with medication.  Therefore, the Board was unable to find a route to a higher 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 for the chronic pain and diminished sensory modalities in sural nerve distribution right foot condition.  

Contended PEB Condition-Polycythemia Vera/Splenomegaly, Chronic.  The Board’s main charge is to assess the fairness of the PEB’s determination that polycythemia vera/splenomegaly was not unfitting.  The polycythemia vera/splenomegaly, chronic condition was profiled and implicated in the commander’s statement, but was not judged to fail retention standards, although the MEB noted it failed to meet retention standards IAW 40-501 3-7g.  

Polycythemia Vera/Splenomegaly, Chronic.  The CI was diagnosed with polycythemia vera (increased red blood cells) at which time his hemoglobin was 18.8 with mild to moderate splenomegaly (enlarged spleen), confirmed by computed tomography, in February 2002.  Bone marrow findings were not inconsistent with polycythemia vera, but were not specific.  Treatment consisted of multiple phlebotomies (removal blood) with the goal of maintaining the hemoglobin between 15 and 16.  Treatment also consisted of Hydrea (hydroxyurea) for a year.  Despite the condition, the CI was deployed in March 2003.  A computerized tomography (CT) scan in December 2003 revealed mild splenomegaly.  The CI had mild headaches approximately once or twice a month, tinnitus, pruritus after taking showers, and facial hot flashes.  He did sweat, mostly at night; however, he had not taken his medication, Hydrea, for 1 year since his hemoglobin had been in the acceptable range, although in December 2003 the hemoglobin was elevated at 17.2. Due to his symptoms, he felt he was no longer able to perform in the military.  After due deliberation, the Board agreed that the preponderance of the evidence with regard to the functional impairment of polycythemia vera/splenomegaly condition favors its recommendation as an additionally unfitting condition for disability rating.  It is appropriately coded 7704 (polycythemia vera-stable with or without continuous medication) and meets the VASRD §4.117 criteria for a 10% rating.  

Contended PEB Conditions-High Frequency Sensorineural Hearing Loss Bilaterally, Posttraumatic Stress Disorder, Right Thigh, Leg and Face Shrapnel Wounds, Extraction of Teeth and Fracture of the Left Radius.  The Board’s main charge is to assess the fairness of the PEB’s determination that high frequency sensorineural hearing loss bilaterally, posttraumatic stress disorder, right thigh, leg and face shrapnel wounds, extraction of teeth, and fracture of the left radius were not unfitting.  The high frequency sensorineural hearing loss bilaterally was profiled H2 and was implicated in the commander’s statement, but was not judged to fail retention standards.  The other conditions were not profiled or implicated in the commander’s statement and were not judged for fail retention standards.  

High Frequency Sensorineural Hearing Loss Bilaterally.  The CI participated in hearing conservation training for the use and placement of hearing protection.  In March 2003 his hearing deficit was most notable on the left with 45 dB at 3000 Hz and 55 dB at 4000 Hz, while the deficit on the right was 30 dB at both 3000 Hz and 4000 Hz.  The CI’s H2 profile for high frequency sensorineural hearing loss both ears  where the left was greater right limited him from being around hazardous noise levels in excess of 85 dB or weapons firing (not including firing for qualification with proper hearing protection) as well as performing no duties requiring acute hearing abilities.  At the MEB examination in January 2004, the deficit on the left was 50 dB at 3000 Hz and 55 dB at 4000 dB, while on the right it was 15 dB at 3000 Hz and 25 dB at 4000 Hz.  At the VA examination dated 7 June 2004 the CI had a 55 dB deficit at 4000 Hz for the left ear and a 25 dB deficit at 4000 Hz for the right ear.  Speech recognition was 96% bilaterally.  Tympanograms and ipsilateral acoustic reflexes were within normal limits.  The VA examiner noted the CI had asymmetrical hearing loss at enlistment in 1991 and there was a threshold shift from separation to the time of the VA examination.  

Posttraumatic Stress Disorder.  The CI was injured in a mortar attack while deployed with nerve damage to the right foot and depressive symptoms.  He described problems with anger and irritability post injury as well as feelings of detachment from others, diminished interest in activities previously felt enjoyable, persistent symptoms of increased arousal, intrusive thoughts, and avoidance of people, places, and things associated with his deployment.  He was diagnosed with mild posttraumatic stress disorder.  He had a very bright affect and did not appear to have severe emotional distress or trauma.  Symptoms were not severe enough to compel him to seek out treatment.  He was additionally diagnosed with alcohol dependence but did not show up for many appointments.  

Right Thigh, Leg and Face Shrapnel Wounds.  The CI sustained shrapnel wounds on 22 July 2003.  Shrapnel was removed and the wounds were closed when deployed.  He had an infected posterior thigh wound and underwent incision and drainage along with antibiotic treatment for 10 days and was followed by surgeons thereafter for wet-to-dry dressings until the wound healed by secondary intention.  Exploration of the right mandible scar on 30 September 2003 revealed no shrapnel.  However, on at a follow-up imaging study, there was evidence of a small piece of shrapnel, which was not palpable clinically, in the lower part of the cheek on the right side, possibly down near the parotid, without inflammation or radiolucency.  

Extraction of Teeth #1,16, 17, 18 and Root Fragment of #30 Due to Fractures and Non-Restorable Caries.  The CI was suspected to have a hairline fracture of the right mandible.  However, he was found to have multiple tooth fractures secondary to dental caries (cavities), which were deemed to be non-restorable.  He underwent extraction of the fractured teeth on 30 September 2003.  At a VA examination in June 2004 an X-ray showed complete healing with only a small trace of radiolucency at the junction of the inferior border of the mandible and cortex. There was no bone loss around the CI’s existing teeth; however, around the extracted teeth #18 and #30 there was a 25% bone loss in the edentulous ridge areas.  

Fracture of the Left Radius Status Post Open Reduction, Internal Fixation in 1992.  An occupational therapy evaluation in January 2004 revealed decreased forearm pronation, supination and wrist flexion, but all motions were in within functional limits to perform most ADLs (activities of daily living).  Grip strength and pinch strength were decreased compared to the right, but were likewise within functional limits.  

There was no performance-based evidence from the record that the conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, and 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 except polycythemia vera as noted above; and so, no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the chronic pain and diminished sensory modalities in sural nerve distribution right foot condition and IAW VASRD §4.124a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended polycythemia vera/splenomegaly, chronic condition, the Board unanimously agrees that it was unfitting and unanimously recommends a disability rating of 10%, coded 7704 IAW VASRD §4.117.  In the matter of the contended high frequency sensorineural hearing loss bilaterally, posttraumatic stress disorder, right thigh, leg and face shrapnel wounds, extraction of teeth and fracture of the left radius 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.  

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

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic Pain and Diminished Sensory Modalities in Sural Nerve Distribution Right Foot	8725	10%	
Polycythemia Vera/Splenomegaly, Chronic	7704	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140521, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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 XXXXXXXXXXXXXXXXXXXXX AR20160016559 (PD201402391)

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, accept the Board’s recommendation to modify the individual’s disability rating to 20% without re-characterization 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:

CF: 
(  ) DoD PDBR
(  ) DVA