RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01637
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20081014

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Cannon Crewmember, medically separated for “left post-phlebitis syndrome” with a disability rating of 10%.

CI CONTENTION:  The CI made no specific contention.  The complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The panel’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 panel’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 panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The panel’s assessment of the PEB rating determinations is based on 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 panel 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 panel 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 - 20020702	VARD – N/A	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Post-Phlebitis Syndrome	7121	10%	No VA Examination in Evidence	
COMBINED RATING: 10%	COMBINED RATING VA CONDITIONS:  N/A	

ANALYSIS SUMMARY:  

Left Post-Phlebitis Syndrome.  According to the service treatment record (STR) and the medical evaluation board (MEB) narrative summary (NARSUM), the CI presented to the emergency room (ER) on 29 October 2007 for left leg swelling.  A left lower extremity (LLE) venous ultrasound (US) revealed extensive acute deep venous thrombosis ([DVT] blood clot [thrombus] in large vein) extending from the left popliteal vein into the left common iliac vein.  The CI was started on an anticoagulant (Heparin loading and infusion).  A venogram (X-ray of contrast injected in veins) revealed an acute LLE DVT with likely inferior vena cava ([IVC] large vein returning blood to heart) atresia (abnormal narrowing or absence of an opening or passage) and chronic clot in the iliac veins.  A computed tomography (CT) of abdomen and pelvis revealed IVC atresia and probable multiple chronic DVTs.  A 1 November 2007 LLE US showed no significant interval change in thrombus burden.  The CI was converted to 2 other anticoagulants (Lovenox and Coumadin).  On 5 November 2007, interventional radiology performed pharmacomechanical thrombolysis (pharmacological clot breakdown) and mechanical rheolytic thrombectomy (mechanical clot breakdown with jet of saline from catheter) with partial restoration of in-line flow from the popliteal vein to the external iliac vein.  The examiner opined: “Suspect with appropriate anticoagulation and adequate compression stockings the left lower extremity edema will resolve.”  He recommended resuming Lovenox and Coumadin, 20-30 mmHg Jobst compression stockings to the left lower extremity, and elevation.  The discharge summary diagnoses listed venous embolism (foreign body vessel obstruction) and thrombosis of deep vessels of proximal lower extremity and congenital (inborn physical abnormality or disease) anomaly of great veins.  A 28 January 2008 bilateral LE US revealed occlusive left superficial femoral vein DVT, partial resolution of left common femoral vein DVT, and no right LE DVT.  The CI was hospitalized overnight.  The physical examination documented a compression stocking covering the entire LLE.  The left calf was tender, especially lateral aspect, warm to touch, and had a positive Homans’ sign (calf pain with forced foot dorsiflexion suspicious for DVT).  There was essentially no difference in left and right calf circumference.  Pulses were normal and sensation was grossly intact.  The discharge summary diagnoses were persistent LLE DVT and likely thrombophlebitis (inflammation of vein wall with associated thrombosis) of left sapphenous vein.  The 6 February 2008 hematology/oncology evaluation documented: "Pt has reversible risk factors of smoking as well as irreversible risk factors of heterozygosity for Factor V Leiden, atretic IVC.  Patient has only been therapeutic for approx 2 weeks, so his additional SFV [superficial femoral vein] thrombosis is not a failure of coumadin.  Labwork has also shown a mildly elevated homocysteine level.  This can be associated with an increased risk of thrombosis."  In the 14 February 2008 vascular surgery encounter, the CI complained of left leg pain, primarily in the groin, and traveling towards the posterior knee.  The CI denied chest pain/discomfort, heart palpitations, dyspnea (shortness of breath), easy bleeding, or easy bruising.  The physical examination documented “LLE with enlarged vein over the left hip.  No stigmata of venous insufficiency over the remainder of the legs/feet.”  The assessment listed history of LLE DVT, atresia of the vena cava, heterozygous Factor V Leiden deficiency, and hyperhomocyteinemia.  The examiner documented “The risk of venous thromboembolism for heterozygous Factor V Leiden is estimated between 5-7% higher than the general population, but lifelong claudication [anticoagulation] is not recommended for a first time DVT; this does not take into account atresia of the vena cava.  In addition, hyperhomocysteinemia has also been implicated as an independent risk factor in deep venous thrombosis. … The decision for lifelong anticoagulation should be determined by hematology oncology.”  

The report of medical examination for the MEB (DD FORM 2808) LLE examination noted a compressive stocking and tenderness with movement (range of motion).  The 21 April 2008 MEB NARSUM, 6 months before separation, recounted the history and interventions.  The CI complained of 3-8/10 pain that was constant, throbbing, and shooting in the left medial thigh with radiation to the lower back.  Pain was exacerbated by standing greater than 30 minutes, walking greater than 20 minutes, running (1 mile), navigating stairs, lifting greater than 60 lbs., and exercising and was relieved by lying down and Acetaminophen.  Active medications were Coumadin and Acetaminophen.  The focused LE examination revealed left lateral hip varicose veins (swollen, tortuous veins) with no edema (excess tissue fluid swelling).  The CI experienced calf pain with forced dorsiflexion.  The physical examination documented normal pulses and strength and no focal neurologic deficits.  The diagnoses listed thrombophlebitis, inferior vena cava syndrome ([IVCS] pathological obstruction/compression/invasion of IVC), IVC atresia, primary hypercoagulable state Factor V Leiden mutation, and hyperhomocysteinemia. 

The panel directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under the 7121 code (post-phlebitic syndrome of any etiology [DVT]) citing left post-phlebitis syndrome, DVT by venographic studies, hypercoagulable state by labs requiring Coumadin, though Factor V Leiden and hyperhomocysteinemia are hereditary conditions, the presumption of service aggravation was not overcome, and rated for intermittent edema, aching or fatigue after prolonged standing or walking, with symptoms relieved by elevation or compression hosiery.  The panel agreed the constellation of findings more closely approximated the 10% rating (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).  The 20% rating would require persistent edema, incompletely relieved by elevation of extremity, with or without beginning stasis pigmentation or eczema.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded that there was insufficient cause to recommend a change in the PEB adjudication for the post-phlebitis syndrome.  

BOARD FINDINGS:  In the matter of the post-phlebitis syndrome, the panel unanimously recommends no change in the PEB adjudication.  There were no other conditions within the panel’s scope of review for consideration.  The panel, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150622, w/atchs
Exhibit B.  Service Treatment Record

AR20170008729, XXXXXXXXXXXXXXXXXX 

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Dear XXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found your separation disability rating and your separation from the Army for disability with severance pay to be accurate.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed), and I accept its recommendation.  I regret to inform you that your application to the DoD PDBR is denied.  

	This decision is final.  Recourse within the Department of Defense or the Department of the Army is exhausted; however, you have the option to seek relief by filing suit in a court of appropriate jurisdiction.

Sincerely,					       
						      					
Enclosure