RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02742
BRANCH OF SERVICE:  MARINE CORPS 	SEPARATION DATE:  20080531

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E6, Electronic Maintenance Technician, medically separated for “chronic testicular pain,” with a disability rating of 10%.

CI CONTENTION:  His conditions continue to worsen and negatively impact his daily activities.  He was given a lower rating than he believes he should have received.  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 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 - 20071115	VARD - 20081222	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Testicular Pain	8730	10%	Chronic Epididymitis	7525	0%	20080507	
Intermittent Knee and Hand Pain	Not Unfitting / 
Cat III	Status Post Bilateral Hand Sprains	5220	0%		
History of Partial Knee MCL Tear		Bilateral Patellofemoral Syndrome with Status Post Right Knee MCL Tear	5257	0%		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:   

Chronic Testicular Pain.  The service treatment record (STR) indicated the CI had a vasectomy in 2002 followed within a month by a hematoma or an infection.   Additionally, the STR noted that the CI had a surgical procedure relating the left testicle at age 12.  In August 2006 the CI had left testicular diagnosed as epididymitis.  Treatment consisted of Cipro (ciprofloxacin, an antibiotic) and a nonsteroidal anti-inflammatory drug (NSAID).  An ultrasound study demonstrated both testes showed multiple punctate calcific densities consistent with microlithiasis.  Additionally, there was a left varicocele (a collection of veins), but no evidence of torsion of the testicle.  In November 2006 the CI still had tenderness of the left testicle with an irregularly shaped mass 1.0 cm x 1.5 cm posterior to the testicle.  Urology examination in January 2007 revealed enlargement of both the left and right epididymis with tenderness on the tail of the left and a small left varicocele.  Because of the chronicity of the condition, the CI was referred for pain management.  At his initial pain medicine consultation, he described the pain as an aching, sharp, tender, continuous and miserable, which was made worse by running, jumping, riding a bike, or driving on a bumpy road.  Medication was switched from Motrin (ibuprofen, an NSAID) to Celebrex (celecoxib, an NSAID) and a left genitofemoral nerve block was recommended. Before resorting to the nerve block, Lyrica (pregabalin, to relieve nerve pain) was prescribed.  A 6 month LIMDU [limited duty] in March 2007 was recommended while pain management was in progress.  Because the pain was within the epididymal area, rather than an ilioinguinal or genitofemoral nerve block, the pain management specialist felt either a left splenic nerve or an S3/S4 nerve block would be more appropriate.  In May 2007 S2 and S3 nerve root blocks were carried out.  However, the blocks did not alleviate the CI’s pain; a lumbar (L1-L3) transforaminal epidural steroid injection was given on 5 June 2007.  The CI did not obtain relief with the injections and no further pain management was offered.  Oxycodone/APAP (a narcotic/pain reliever combination) was added to the treatment regimen in September 2007.  Urologic examination in October 2007 noted extreme sensitivity in the genital area with sensitivity to touching the skin in the area, but there were no masses palpated.  The diagnoses were chronic epididymitis and chronic testicular pain, left greater than right.  A sonogram again showed stable microlithiasis without an internal mass and a stable left varicocele in the setting of a small left hydrocele (collection of fluid).  Seminal fluid culture showed no growth in October 2007.  

LIMDU was started on 20 March 2007 for a disorder of the male genital organs (testicular pain) with restrictions of no running and biking, no strenuous activity, and no jumping jacks.  The Non-Medical Assessment dated 27 August 2007 indicated the CI could take a partial PRT [physical readiness test].  The CI was often in pain; standing in front of the class to lecture made it worse.   His athletic activities had been dramatically impaired due to his injury.  He was no longer able to run, jog, stand for long periods, lift, push or pull.  All activity due to running or impact caused him to be bent at the knee trying to stifle the pain.  The pain had been primarily from the left testicle, but from time to time it included the right testicle.

The MEB narrative summary (NARSUM) dated 14 August 2007 noted the pain was tolerable and the CI could do his activities with the pain; however, he was unable to run because after about one mile he developed severe left testicle pain, which lasted for a couple of days.  On examination he had tenderness to palpation on the left testicle without swelling, masses, atrophy or varicocele.  His epididymis was normal on both sides with no pain and defects (S/P vasectomies) were noted in both vas deferens.  At the MEB examination, the CI reported on DD Form 2807-1 dated 21 September 2007 “chronic testicular pain both and chronic epididymitis (enlarged both) . . . very tender on left.” Also “nerve block did not work and all urologists said surgery would cause more damage due to nerve damage I have in the area.”  The MEB physical examiner noted on DD Form 2808 also dated 21 September 2007 noted “testicle tender to palpation chronic epididymitis.”   

At the VA Compensation and Pension (C&P) examination dated 7 May 2008, performed a month before separation, the CI reported being diagnosed with epididymitis after his vasectomy and trauma to his groin and also reported that he did “not experience any functional impairment from this condition.”  Examination of the testicles revealed normal findings.  Post-separation the CI received 4 tablets of Tramadol [an opioid-like medication] for the groin pain at a VA Walk-In/ER clinic in November 2008.  A testicular ultrasound performed for increased pain and swelling was unremarkable with no evidence of a hydrocele or varicocele.  Urological evaluation on 5 December 2008 noted bilateral orchalgia (testicular pain).  History revealed that about a month after the vasectomy he sustained blunt trauma to both testes jumping out of a helicopter and has had bilateral testicular pain, more so on the left than the right, with radiation into the left groin area, but without urinary symptoms.  Examination noted no intratesticular masses and the left epididymis was somewhat tender on palpation; the prostate was 25 grams without any nodules.  Various surgical options were discussed, but the urologist recommended against any surgery.  

The Board directed attention to its rating recommendation based on the above evidence.  The Navy PEB assigned a 10% rating using code 8730 (Ilio-inguinal nerve neuralgia–severe to complete) to the Category I (unfitting condition) chronic testicular pain.  The VA assigned a 0% rating using code 7525 (Epididymo-orchitis, chronic only) for chronic epididymitis.  The Board first discussed whether the condition referred solely to the left testicular pain condition or to both the left and right testicular pain conditions.  While the overwhelming evidence pointed to the left testicular pain as the primary unfitting and rated condition, the right testicular pain occurred not infrequently and was referred to indirectly in the LIMDU as genital organs (testicular pain) and in the non-medical assessment (NMA) explicitly as “from time to time the right” [testicle].  After a detailed discussion the Board members determined that the right testicular pain was unfitting.  The Board then sought a route to a higher rating, but noted code 8730 does not offer more than a 10% option for the left testicular pain, but does offer a possible 0% rating or the mild or moderate pain of the right testicle.  Code 7525, which is rated according a urinary tract infection (UTI) does offer a 30% rating option for recurrent symptomatic infection requiring drainage/frequent hospitalization (greater than two times/year), and/or requiring continuous intensive management.  While the CI did not have a UTI, he had continuous intensive management from nerve blocks to pain medication as well as multiple clinic, specialty and ER visits for the left testicular pain including findings of epididymitis by urologists prior to separation.  However, with the lack of clear and clear and credible evidence, use of code 7525 is not an option for the right testicular pain.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommended a disability rating of 30% for the chronic left testicular pain condition and a 0% for the chronic right testicular pain condition.

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that knee and hand pain and the partial knee MCL (medial collateral ligament) tear were 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 knee and hand pain and partial knee MCL tear were not listed in the LIMDU document, but the hands and knee conditions were mentioned in the NMA with a notation that the CI had lost grip strength in both hands and he suffered from a knee injury.  However, the conditions were judged to be Category III (not unfitting) conditions.   

Hand Pain.  A note dated 6 November 2007 indicated the CI had chronic right knee pain (see below) and bilateral hand pain.  The examiner indicated the right knee pain (see below) and bilateral hand pain were tolerable and only intermittent.  He had no trauma to his hands.  Hand pain had been on/off for 3 months.  His right knee pain (see below) and bilateral hand pain did not limit him from his duty.  In fact his pain had resolved and he took NSAIDs (Celebrex) as needed for any pain recurrence.  In view of the CI’s history and clinical findings the examiner felt there was no need for an orthopedic consult.  X-rays dated 7 May 2008 of the right and left hands and the right and left knees showed no significant findings.  The NARSUM indicated the CI had a partial tear of his medial collateral ligament and he had some undescribed hand problems when deployed and was unable to turn knobs.  On examination the fingers of the right hand exhibited no tenderness on palpation, no erythema or inflammation, and no nodules at the joints.  Movement was normal and no pain was elicited by motion and no instability was noted.  The fingers of the left hand exhibited no tenderness on palpation; motion was normal; no pain was elicited by motion; and no instability was noted.  At the VA C&P examination the CI noted a pain level of 5/10 (10 being the worst pain) and was relieved with an NSAID and he did not experience any functional impairment from the condition.  On examination the wrists of both hands were normal with normal range of motion (ROM) measurements, but with pain on repetition.  

Partial (Right) Knee MCL Tear.  The CI originally injured his right knee in 2002 and was told he strained his MCL.  There was no history knee or joint pain, swelling, stiffness, or intermittent locking, and the knee did not suddenly buckle.  Examination of the both knees revealed no erythema, no misalignment, no crepitus, and no tenderness on palpation.  Motion was normal without crepitus or pain on motion.  There was no instability or evidence of a meniscal tear and patellofemoral apprehension tests were negative.  No tenderness was observed on ambulation.  Additionally, the right knee had a full ROM and was stable to varus/varus stress (to determine MCL instability).  At the VA C&P examination the CI indicated he had knee pain for 6 years with a pain level of 4/10 (10 being the worst pain).  The pain was relieved by rest and an NSAID and he was able to function with the medication and did not experience any functional impairment from the condition.  At the VA C&P examination there was tenderness of both knees with crepitus, but no instability.  ROM measurements were normal bilaterally with pain on repetition.  

The aforementioned was reviewed and considered by the Board.   There was no performance based evidence from the record that any of the conditions 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 any of the contended conditions and so no additional disability ratings are recommended.

BOARD FINDINGS:  In the matter of the chronic left testicular pain condition, the Board unanimously recommends a disability rating of 30%, coded 8730-7525 IAW VASRD §4.124a and VASRD §4.115b.  In the matter of the chronic right testicular pain condition, the Board unanimously recommends a disability rating of 0%, coded 8730 IAW VASRD §4.124a.  In the matter of the contended knee and hand pain and partial knee MCL tear 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; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective as of the date of his prior medical separation:  

CONDITION	VASRD CODE	RATING	
Chronic Left Testicular Pain 	8730-7525	30%	
Chronic Right Testicular Pain	8730	0%	
RATING 	30%	

Exhibit A.  DD Form 294, dated 20140607, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR COMMANDER, NAVY PERSONNEL COMMAND
	         DEPUTY COMMANDANT, MANPOWER & RESERVE AFFAIRS
	                          
Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS

Ref:  (a) DoDI 6040.44
	(b) PDBR ltr dtd 29 Apr 16 ICO XXXXXXXXXXXXXXX
	(c) PDBR ltr dtd 26 Jan 16 ICO XXXXXXXXXXXXXXX
	(d) PDBR ltr dtd 22 Jan 16 ICO XXXXXXXXXXXXXXX
	(e) PDBR ltr dtd 29 Apr 16 ICO XXXXXXXXXXXXXXX
	(f) PDBR ltr dtd 12 Apr 16 ICO XXXXXXXXXXXXXXX
	(g) PDBR ltr dtd 29 Apr 16 ICO XXXXXXXXXXXXXXX
	(h) PDBR ltr dtd 25 Jan 16 ICO XXXXXXXXXXXXXXX
	(i) PDBR ltr dtd 15 Apr 16 ICO XXXXXXXXXXXXXXX

1.  Pursuant to reference (a), the recommendations of the Physical Disability Board of Review set forth in references (b) through (XX) are approved.

2.  The official records of the following individuals are to be corrected to reflect the stated disposition:

     a. XXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 10 percent disability rating (increased from 0 percent) effective date of discharge.

     b. XXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge.

     c. XXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 10 percent disability rating (increased from 0 percent) effective date of discharge.

     d. XXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge.
     
     e. XXXXXXXXXXXXXXX, former USMC: Retroactive placement on the Permanent Disability Retired List with a 30 percent disability rating (increased from 10%) effect date of discharge.
 
     f. XXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 0 percent) effective date of discharge.

     g. XXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge.
     h. XXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 10 percent disability rating (increased from 0 percent) effective date of discharge.

3.  Please ensure all necessary actions are taken to implement these decisions, including the recoupment of disability severance pay, if warranted, and notification to the subject members once those actions are complete.