RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX                                                                     CASE:  PD-2014-03339
BRANCH OF SERVICE:  NAVY  		SEPARATION DATE:  20090902  

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-2, Electrical Mechanical Equipment Repairman medically separated for “May-Thurner syndrome secondary to left iliac vein compression,” with a disability rating of 10%.

CI CONTENTION:  His condition continues to worsen and negatively impact his daily activities.  His 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 - 20090519	VARD - 20100209	
Condition	Code	Rating	Condition	Code	Rating	Exam	
May-Thurner Syndrome Secondary to Left Iliac Vein Compression	7199-7121	10%	May-Thurner Syndrome	7199-7121	10%	20091204	
RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

May-Thurner Syndrome.  This is an uncommon congenital condition associated with an anatomical variant causing a major leg vein (left common iliac) to be compressed by the adjacent artery, predisposing patients to superficial phlebitis (inflammation of surface veins) and the development of deep venous thrombosis (DVT).  The service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM) documented an onset of left lower extremity (LLE) weakness and edema in boot camp (12 months before separation).  The edema persisted and the CI was eventually diagnosed with May-Thurner syndrome.  There was no evidence of DVT in-service, and anticoagulation was not indicated.  Some outpatient STR entries documented a history of intermittent LLE edema depending on activities (although not resolving to baseline), but all of the examinations in evidence indicated varying degrees of edema.  The condition was judged to be incompatible with continuing military service and the CI was referred for MEB, which in turn forwarded “phlebitis and thrombophlebitis of superficial vessels of lower extremities” to the PEB.

The NARSUM examination on 19 March 2009 (5 months prior to separation) documented, “Examination of his [LLE] demonstrates persistent swelling of the [LLE] compared to the right.”  The examiner referenced earlier LLE measurements greater than the right, 1¼ inches at the calf and 1¾ inches at the thigh.  

A VA Compensation and Pension (C&P) examination on 4 December 2009 (3 months after separation) documented, “Currently, the patient has progressive swelling of his leg down to just above the ankle if he has been up and walking more than 15-20 minutes at a time.”  The examiner noted that the CI did not use compressive stockings and, “Other than elevation, there is no current treatment.”  The physical examination recorded only a 1 centimeter difference in calf measurements and stated, “No pitting edema of the [LLE].”  There was no documentation of ulceration, stasis pigmentation or eczema in the VA or STR files.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB and the VA both rated analogously to code 7121 (post-phlebitic syndrome).  Although analogous rating under code 7120 (varicose veins) might be considered, the relevant rating criteria are identical.  Either code is fairly specific to the condition in this case; thus, members agreed that it was not justified to leverage any alternate code to achieve a higher rating.  The 10% criteria of 7121 are “intermittent edema of extremity or aching and fatigue in leg after prolonged standing or walking, with symptoms relieved by elevation of extremity or compression hosiery;” and, those for 20% are “persistent edema, incompletely relieved by elevation of extremity, with or without beginning stasis pigmentation or eczema.”  The higher ratings require stasis pigmentation or ulceration, not in evidence.  There was no rationale in the PEB or VA decisions for why “intermittent edema” (10%) better characterized the evidence than “persistent edema, incompletely relieved by elevation” (20%); but, the Board found room to deliberate this distinction.

Members agreed that, although the evidence indicated that the edema responded positively to rest and elevation, it was never (or at best rarely) completely relieved.  All of the examination evidence, with the possible exception of the minimal findings from the C&P examiner, demonstrated the presence of at least some edema.  Members concluded, therefore, that the evidence was better aligned with the 20% criteria than with those for 10%.  After due deliberation, considering all of the evidence and conceding VASRD §4.3 (reasonable doubt), the Board recommends a 20% rating for the May-Thurner syndrome under code 7199-7121.  

BOARD FINDINGS:  In the matter of the May-Thurner syndrome, the Board unanimously recommends a Service disability rating of 20%, coded 7199-7121 IAW VASRD §4.104.  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	
May-Thurner Syndrome (Left Iliac Vein Compression)	7199-7121	20%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140526, 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 27 Jul 16 XXXXXXXXXXXXXXXXXXXX   
	(c) PDBR ltr dtd 27 Jul 16 XXXXXXXXXXXXXXXXXXXX
	(d) PDBR ltr dtd 27 Jul 16 XXXXXXXXXXXXXXXXXXXX

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

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

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

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

     c. XXXXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 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.