RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02553
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060806

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Infantyman, medically separated for “left leg pain, post vein stripping” with a disability rating of 0%.  

CI CONTENTION:  The CI asks for consideration of all conditions, and that he was given a higher rating for his condition by the VA.  The applicant’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 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 - 20060630	VARD – 20070501	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Leg Pain Status Post Vein Stripping	5099-5003	0%	Varicose Veins, Surgical Residuals, Multiple Scars, Left Leg	7120	40%	20070207	
			Associated Neuropathy, Left Leg	8520	10%	20070207	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  80%	

ANALYSIS SUMMARY:  

Left Leg Varicose Veins (Subsuming Associated Neuropathy).  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI initially developed left lower extremity (LLE) pain in November 2003 while deployed to Afghanistan.  This was diagnosed as varicose veins after redeployment, and a vein-stripping procedure was performed in August 2004 (2 years pre-separation).  The initial response was favorable, but the pain and varicosities recurred, resulting in a repeat vein-stripping procedure in July 2006 (a month prior to separation) with referral to a MEB.  The condition “left leg pain status-post vascular vein stripping” was referred to the Physical Evaluation Board (PEB).  

There were STR entries which documented the occurrence of intermittent LLE edema with exercise or prolonged ambulation, some which documented the presence of edema by examination, but more which documented the absence of LLE edema by examination.  There were a few entries which noted the presence of discoloration, but more which documented the absence of discoloration or abnormal pigmentation.  There was no STR evidence indicating ulceration or eczema.  Imaging confirmed the absence of deep venous thrombosis.  The CI was diagnosed with a LLE neuropathy complicating the vascular surgery, and underwent a series of nerve blocks with limited success.  There was STR documentation of associated sensory impairment as well as hypersensitivity; but, multiple neurologic examinations documented normal strength, with none to the contrary.  There were a few entries noting gait disturbance with the use of a cane, and others which recorded a normal gait.

The MEB NARSUM examination on 3 January 2006 (7 months prior to separation) “chronic left extremity pain although he does not have noticeable evidence of varicosities at this time” and “intermittent” LLE edema “primarily around the ankle.”  The physical examination recorded tenderness and “some [LLE] paresthesias,” without mention of concurrent edema, motor weakness, or gait disturbance.  

The VA Compensation and Pension (C&P) examination on 07 February 2007, performed 6 months after separation, documented “leg pain occurring at rest ... [with] ... edema occurring intermittently which is not completely relieved by foot elevation or compression hosiery.”  The physical examination recorded the use of a cane for LLE pain, the presence of varicose veins, “there is no edema; elevated edema is present” (interpretation unclear), “stasis pigmentation” and “no eczema.”  The LLE neurological findings were normal strength and reflexes with impaired sensation of the “lateral and anterior tibia;” and, in addition to the diagnosis of LLE varicose veins, the VA examiner listed a separate diagnosis of “neuropathy, [LLE], equally likely as not secondary to surgery.”  

The Board directed attention to its recommendation based on the above evidence.  The PEB assigned a 0% rating under the analogous code 5099-5003 (degenerative arthritis) referencing the U. S. Army Physical Disability Agency (USAPDA) pain policy.  The VA assigned a 40% rating using the 7120 code (varicose veins) “based on the findings of your VA examination, which show persistent edema and stasis pigmentation of the left leg.”  Members agreed that code 7120 is quite specific to the rated condition and, IAW VASRD §4.7 (higher of two evaluations), was the fairest basis for the Board’s rating recommendation.  
Members readily agreed that the 0% criteria were exceeded, and first considered whether the VA’s 40% rating was justified by the overall evidence.  The presence of stasis pigmentation was specified on the post-separation VA examination, although it was consistently excluded by STR examinations, and the NARSUM challenged even the presence of varicosities.  Furthermore, even if the “stasis pigmentation” criterion was conceded based on the C&P finding, members agreed that the “persistent edema” criterion for the 40% rating was inconsistent with the documentation by all examiners (including the C&P) that the edema was intermittent (and fairly mild by the NARSUM description).  Having concluded that the 40% criteria were not adequately supported, members considered a 20% recommendation.  Although the 20% criterion “beginning stasis pigmentation” was reasonably satisfied by the C&P evidence, it remains that the 20% rating also specifies “persistent” edema; and, as above, the evidence is compelling that the edema was intermittent.  Members therefore agreed that the only code 7120 rating language that was well supported by the evidence was that for 10%.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a 10% rating for the LLE varicose vein condition under code 7120.

Members then deliberated whether an additional rating was justifiably recommended for the associated LLE neuropathy.  The VA assigned a 10% rating for “mild” nerve impairment under code 8520 (sciatic), based on the C&P findings and diagnosis.  Contrary to the VA’s imperative to confer a disability rating based on the presence of a service-connected condition, the Board requires a functional impairment linked to fitness to support a recommendation for the addition of a peripheral nerve rating to the rating for the primary unfitting condition.  The pain component of the neuropathy cannot be added to the code 7120 rating without violation of VASRD §4.14 (avoidance of pyramiding).  The sensory component was relatively mild (aligned with the VA 8520 rating) and without functional significance.  There was no motor weakness in evidence.  Members thus agreed that there was no evidence of significant functional impairment from the associated neuropathy, and additional Service disability rating was not supported.

BOARD FINDINGS:  In the matter of the left lower extremity varicose vein condition, the Board unanimously recommends a disability rating of 10%, coded 7120, IAW VASRD §4.104.  With regard to the left lower extremity neuropathy as a surgical residual of the above condition, the Board unanimously agrees that it cannot be recommended for additional disability rating.  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 his prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Varicose Veins with Surgical Residuals, Left Lower Extremity	7120	10%	
COMBINED	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140331, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB

MEMORANDUM FOR Commander

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation
for XXXXXXXXXXXXXXXXXXXXX, AR20160007628 (PD201402553)

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