RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02529
BRANCH OF SERVICE:  Army  	SEPARATION DATE:  20050531

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Military Police, medically separated by the Informal Physical Evaluation Board (IPEB) for left testicular and right foot, rated at 0% and 0% respectively, with a combined disability rating of 0%.   

CI CONTENTION:  The CI requested that the Board review all conditions.  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 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 – 20050315	VARD - 20060330	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Testicular/Scrotal Pain	8799-8730	0%	Hernia /Testicular Pain 	7804	10%	20050103	
Right Foot Pain	5099-5022	0%	Right Ankle Sprain	5271	0%	20050103	
GERD	Not Unfitting	GERD	7346	10%	20050103	
Headaches	Not Unfitting	Headaches	8100	10%	20050103	
Low Back Pain	Not Unfitting	Degenerative Disc Lumbar 	5010-5242	10%	20050103	
Hypertension	Not Unfitting	Hypertension	7101	0%	20050103	
Pityriasis Rosea, Recurrent	Not Unfitting	Pityriasis Rosea	7817	NSC	20050103	
Recurrent Knee Pain	Not Unfitting	PFS, Left Knee	5299-5260	0%	20050103	
		PFS, Right Knee	5260	0%	20050103	
Non-Cardiac Chest Pain	Not Unfitting	Not Rated	
Amblyopia	Not Unfitting	Amblyopia, Left Eye	6099-6019	NSC	20050103	
Pes Planus	Not Unfitting	Right Hallux Valgus/Pes Planus	5276-5280	0%	20050103	
		Left Hallux Valgus/Pes Planus	5276-5280	0%	20050103	
Somatization Disorder	Not Unfitting	Somatization Disorder	9421	0%	20050103	
Mixed Personality Disorder	Not Unfitting	Not Rated	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDTIIONS:  30%	

ANALYSIS SUMMARY:  The Board noted that the VA Compensation and Pension (C&P) evaluation of 3 January 2005 applied to the VA ratings (as charted above) was not available in evidence before the Board, and could not be located after appropriate inquiries.  Further attempts at obtaining the relevant documentation would likely be futile and introduce additional delay in processing the case.  Members agreed that the available evidence (which included a description of C&P findings in the VARD) was sufficiently probative, and that the missing evidence would not materially affect the Board’s recommendations.  

Left Testicular/Scrotal Condition.  The service treatment record (STR) corroborated the history in the narrative summary (NARSUM) of persistent left testicular, scrotal and inguinal pain complicating surgical repair of a left inguinal hernia in July 2003.  Imaging and specialty evaluations were negative for a distinct etiology, but positive temporary relief with ilio-inquinal nerve blocks strongly suggested a post-operative neuralgia as the likely cause of the pain.  An STR specialty note in August 2004 (9 months prior to separation) documented “left groin testicular/scrotal pain ... near constant [rated 3-9/10] ... increased by driving, standing, walking, physical activity ... [and] ... coughing.”  The physical exam recorded a “mildly tender” left spermatic cord and epididymis (affixed to testicle).   

The NARSUM was conducted 24 February 2005 (10 weeks prior to separation) and documented “constant pain in the left testicle aggravated by standing more than 20 minutes, sitting more than 20 minutes, riding in vehicles, especially with vibration and bumps, any type the strenuous exertion, running, or any impact activities.”  The NARSUM physical examination recorded “mild tenderness to pressure in the left scrotum and testicle and a left inguinal hernia scar [no comment with regard to scar tenderness].”  A urology addendum to the NARSUM (from 6 weeks earlier) documented “pain in the region of the left groin that radiates to the testicle ... worse with activity, and it limits his ability to do [physical training],” and only a tender epididymis on exam.  The examination findings from the missing VA C&P examination (4 months prior to separation) were documented in the VARD as “left testicle tenderness” and a non-tender surgical scar (with negative findings for other ratable scar features).  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB’s 0% rating was under the analogous code 8730 (neuralgia of the ilio-inquinal nerve), which confers a 0% rating for “mild or moderate” impairment and a maximum 10% for “severe.”  The VA’s 10% rating was under 7804 (scars, unstable or painful), citing “residual painful scar and testicular (scrotal) pain on examination.”  Members agreed that the best clinically aligned code for this case is 8730, which is anatomically accurate and captures the pathology as closely as can be ascertained.  Alternate rating under the scar code as applied by the VA was considered; but, members agreed that the unfitting condition was almost certainly the post-operative neuralgia, not a painful surgical scar.  There are no additional coding options under the VASRD which are applicable to this case, even for analogous rating.  Having agreed that code 8730 was indicated as the basis for the Board’s rating recommendation, the Board notes that VASRD §4.124 does not permit a rating for more than moderate impairment for neuralgia.  Members agreed that the §4.123 criteria for rating as neuritis (reflexes, atrophy, sensory in addition to constant pain) were not supported by the evidence; thus eliminating the option for a 10% rating under 8630 (ilio-inquinal neuritis) as “severe”; and, this notwithstanding, “moderate,” rather than “severe,” more fairly characterizes the degree of impairment in evidence.  Within the constraints imposed by the VASRD, therefore, members agreed that no rating higher than 0% can be supported by the facts in evidence.  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 neuralgia.

Right Foot Condition.   The STR documented an onset of right “metatarsalgia” (no trauma) in January 2003 (>2 years prior to separation).  Additionally the CI suffered a right ankle sprain in July 2003.  Right ankle and foot pain persisted, and some entries document associated, but significantly less prominent, left foot pain.  Serial bones scans demonstrated bilateral metatarsal and tarsal stress reactions (no distinct fractures) which were more numerous and severe on the right; and, which improved but did not resolve over time.  The right ankle/foot was treated with a temporary walking cast, and there were no surgical indications.  Various STR entries note a normal gait and grossly normal range-of-motion (ROM) at the ankle, with none to the contrary.  There is no STR documentation of joint deformity or instability, or of any periods of incapacitation.  The NARSUM documented “mild constant pain ... worsened by any weight-bearing ... can stand or walk at his own pace and distance no more than 5 minutes ... unable to tolerate running or any impact activities.”  An orthopedic addendum was referenced for physical exam findings; which consisted of antalgic gait, metatarsal and calcaneal tenderness on the right, and fifth metatarsal tenderness on the left.  The prior to separation VA C&P evidence cited in the VARD was “bilateral limp ... feet revealed painful motion and tenderness;” and, right ankle ROM was recorded as dorsiflexion to 15 degrees (normal 20) and plantar flexion to 45 degrees (normal).

The Board directed attention to its rating recommendation based on the above evidence.  It is first noted that, although there was some bilateral involvement of the foot pathology, there is insufficient evidence to counter the PEB opinion that only the right foot was unfitting (scope limitations [as above] notwithstanding).  The PEB’s 0% rating under the analogous code 5099-5022 (periostitis) was concordant with the 5003 (degenerative arthritis) criteria to which that code defaults, in that the “two or more major joints” stipulation for a 10% rating was not satisfied.  The VA’s 0% rating under 5271 (ankle, limitation of motion) was rationalized as a failure to reach the minimum 10% rating under that code for “moderate” limitation.  Neither of these coding and rating approaches, however, accommodated VASRD §4.59 (painful motion) or §4.40 (functional loss) which would provide for the minimum 10% rating under 5022 or 5271.  Painful motion is fairly conceded from the prior to separation VA evidence, and functional loss is fairly supported by the limitations documented in the NARSUM, and by the gait disturbance noted by the Medical Evaluation Board (MEB) orthopedic and VA examiners.  Furthermore, IAW VASRD §4.7 (higher of two evaluations), a more favorable and clinically compatible coding option is 5279 (metatarsalgia); which confers a 10% rating for unilateral or bilateral involvement without regard to other criteria.  The Board also considered analogous rating under either 5283 (tarsal, or metatarsal bones, malunion of, or nonunion of) or 5284 (foot injuries, other).  Both of the latter codes provide identical rating parameters: 10% for “moderate”, 20% for “moderately severe,” and 30% for “severe” disability.  Members agreed, however, that the disability in evidence was fairly characterized as moderate; thus, neither of these options offers an advantage over 5279.  After due deliberation, considering all evidence and with deference to reasonable doubt, the Board recommends a 10% rating for the right foot condition under code 5279.

Contended Conditions.  All of these conditions (GERD [gastroesophageal reflux disease], headaches, low back pain, hypertension pityriasis rosea, knee pain, non-cardiac chest pain, amblyopia, pes planus, somatization disorder, personality disorder) were listed, but not elaborated, in the NARSUM; and, all were judged to meet retention standards by the MEB examiner.  None of them were clinically active in the STR for an extended period preceding separation.  The amblyopia was evaluated by a VA ophthalmologist who documented corrected vision to 20/20 on the right and 20/30 on the left; and, service connection was denied since there had been no worsening of a pre-existing condition over the length of service.  The mental health conditions were addressed by an addendum to the NARSUM.  The MEB psychiatric examiner noted that the CI was not engaged in psychotherapy or prescribed any psychotropic medications, and did not manifest any severe symptoms.  The mental status examination was normal and the examiner opined that the “Axis-I and Axis-II psychiatric conditions remain fitting for military duty at this time.”   No conditions other than the foot and testicular conditions were ever profiled.  The commander’s performance statement specifically addressed the unfitting testicular and right foot) conditions, with no mention or implication of any other condition or performance limitations.

The Board directed attention to its recommendations based on the above evidence; and, its main charge with respect to these conditions is an assessment of the fairness of the PEB’s determinations that they were not unfitting.  The Board’s threshold for countering Service fitness determinations is higher than the VASRD §4.3 (reasonable doubt) standard used for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  As noted above, none of these conditions were clinically acute at separation; none were profiled or implicated by the commander; and, all were judged to meet retention standards.  Furthermore, all of these conditions were subject to DoDI 1332.38 (E3.P3.3.3 - Adequate Performance Until Referral); which stipulates, “If the evidence establishes that the Service member adequately performed his or her duties until the time the Service member was referred for physical evaluation, the member may be considered fit for duty even though medical evidence indicates questionable physical ability to continue to perform duty.”  All members agreed that there was no performance based evidence suggesting that any of the above listed conditions significantly interfered with 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 any of these conditions; thus none can be recommended for additional Service disability rating.  

BOARD FINDINGS:  In the matter of the right foot condition, the Board unanimously recommends a disability rating of 10%, coded 5279 IAW VASRD §4.71a.  In the matter of the contended GERD, headache, lumbar, hypertension pityriasis rosea, knee, non-cardiac chest pain, amblyopia, pes planus, somatization disorder, and personality disorder 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 to medical separation:

CONDITION	VASRD CODE	RATING	
Chronic Left Testicular and Scrotal Pain  	8799-8730	0%	
Metatarsal Stress Reactions and Chronic Pain, Right Foot	5279	10%	
11 Additional Conditions (Listed Above)	Not Unfitting	
COMBINED	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140531, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB

MEMORANDUM FOR Commander

JUL 13 2016

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation
for XXXXXXXXXXXXXXXXXX, AR20160005114 (PD201402529)

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 10% 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