RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02414
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050825

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an National Guard E4, CH-47 Helicopter Repairer, medically separated for “chronic splenomegaly…,” and “chronic right inguinal pain…,” and “chronic radiating low back pain…”  rated at 0% each, with a combined disability rating of 0%.

CI CONTENTION:  The CI requested consideration of all conditions.  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 review of disability ratings assigned 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 or non-compensable.  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 determination 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(s) 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 - 20050810	VARD - 20060616	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Splenomegaly…	7799-7707	0%	Splenomegaly, Scar	7707	0%	20060208	
Chronic Right Inguinal Pain…	8730	0%	Status Post Biopsy Scar, Right Groin Pain; Right Ilioinguinal Nerve Impingement	8730-7804	10%	20060208	
Chronic Radiating Low Back Pain	5243	0%	Degenerative Disc Disease, Low Back	5242	40%	20060124	
			S1 Radiculopathy, Left Lower Extremity 	8620	10%	20060124	
Diarrhea Functional	Not Unfitting	Irritable Bowel Syndrome 	7319	0%	20060124	
Chronic Fatigue	Not Unfitting	Chronic Fatigue Syndrome	6354	NSC	20060124	
Hearing Loss, Tinnitus	Not Unfitting	Tinnitus  	6260	10%	STR	
		Bilateral Hearing Loss	6100	NSC	STR	
Depressive Disorder, NOS	Not Unfitting	Posttraumatic Stress Disorder with Major Depressive Disorder	9411-9434	70%	20060221	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  90%	

ANALYSIS SUMMARY:  

Chronic Splenomegaly.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI was found to have enlarged inguinal lymph nodes on a CT scan of the pelvis in 2004.  He also had a CT of the abdomen to look for kidney stones as a source of the pain.  An enlarged spleen (splenomegaly) was found and he was referred to hematology-oncology for further evaluation.  The CI also reported a 40 pound weight loss while deployed of which 15 pounds had been regained.  An evaluation including a bone marrow biopsy, laboratory testing, X-rays studies failed to show an etiology of the splenomegaly.  It was noted that he had evidence for a past infection with Epstein Barr virus (the causative agent for infectious mononucleosis, a cause of splenomegaly).  Although no definitive etiology for the splenomegaly was found, he was thought to be at increased risk for splenic rupture from blunt trauma.  He also reported chronic fatigue, again without specific etiology.  

At the MEB examination (recorded on DD Forms 2807 and 2808) dated 11 March 2005, 5 months prior to separation, the CI noted the weight loss.  On examination, the spleen was not felt (normal) and the abdominal examination was otherwise unremarkable.  The MEB NARSUM examination was dated 5 July 2005, 3 months prior to separation.  The CI reported that his weight had decreased from 180 pounds to 146 pounds while deployed, but that he had regained 10 pounds.  A review of the records showed that the CI weighed 162 pounds in April 2003, 9 months prior to his deployment, and weighed 155 pounds 5 months after the deployment on the respective DD Form 2808s.  A primary care note dated 9 November 2004, 1 month after redeployment, recorded a weight of 159 pounds.  He reported ongoing fatigue.  

At the VA Compensation and Pension (C&P) evaluation performed on 24 January 2006, 5 months after separation, the examiner thought that the prior infection with Epstein Barr virus was the likely cause of the splenomegaly.  The CI was noted to be asymptomatic and the spleen was smaller than on prior examinations and non-tender.  He was noted to have no functional or occupational impairment from the splenomegaly.  On examination, his weight was 158 pounds.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic splenomegaly condition 0%, coded analogously as 7799-7707 (spleen, injury of, healed), citing the condition as ‘mild’.  The VA also rated the chronic splenomegaly condition 0%, coded 7707, based on the VA C&P examination 5 months after separation, citing the condition was not active at the time of examination.  The panel considered the evidence.  The consensus was that the splenomegaly was most likely secondary to a prior infection.  It was improving over time and no limitations were present.  It was determined to fail retention standards due to the increased risk of rupture if there was blunt trauma.  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 chronic splenomegaly condition.  

Chronic Right Inguinal Pain.  According to STR and the MEB NARSUM, the CI had multiple hernia repairs prior to accession.  He initially reported bilateral groin pain after playing football in 1990, but had no further complications until he lifted a heavy helicopter blade (350 pounds) while deployed in 2004.  There are various conflicting reports in the record on exactly what happened, but the most consistent is that he was part of a 4-person team carrying the blade when one member slipped and the CI was left holding his end by himself.  The first record in evidence is a general surgery note dated 12 October 2004 which recorded that he had injured himself 1 month earlier.  He underwent an ultrasound and a CT scan and did not have a recurrent hernia.  He was also seen in urology and placed on antibiotics for a possible prostatitis.  Inflammation of the inguinal (groin) lymph nodes (lymphadenopathy) was also noted, but none were pathologically enlarged.  At a follow-up appointment in urology on 3 November 2004, he also reported erectile dysfunction since his return from deployment.  On 27 December 2004, he underwent a surgical exploration and scar excision of the right groin.  No significant lymphadenopathy was present nor was a hernia.  However, the soft tissue was scarred down from the previous operations and the vas deferens was inadvertently cut (partial thickness) in 2 locations.  These were surgically repaired.  On 22 January 2005, it was noted that no etiology for the chronic abdominal, groin, and back (below) pain had been found and the CI wished to pursue an MEB.  An MRI of the lower back on 15 March 2005 showed a disc protrusion at L5-S1 displacing the left S1 nerve root.  On 4 April 2005, a neurosurgeon observed that this would not explain the right groin pain and that source of the pain was unknown.  At the MEB examination, the CI had a tender right inguinal scar.  The MEB NARSUM examination also showed tenderness to deep palpation (to check for a hernia).  No hernia was present on examination.  

At the VA C&P evaluation, performed on 24 January 2006, the CI reported ongoing pain.  The scar was well healed, but painful on palpation.  Impingement of the right ilio-inguinal nerve by scar tissue was diagnosed.  The panel noted that this was not diagnosed on previous evaluations by general surgery, urology, or neurosurgery.  The urology C&P dated 8 February 2006 noted that the symptoms were typical of ilio-inguinal nerve entrapment (by scar tissue).  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right inguinal pain condition 0%, coded 8730 (ilio-inguinal nerve neuralgia), citing the condition as moderate.  The VA rated the right inguinal pain condition 10%, dual coded as 8730-7804 (ilio-inguinal nerve neuralgia and unstable or painful scar[s]), based on the VA C&P examination 5 months after separation, citing a scar that has some tenderness to palpation.  The panel considered the evidence.  The groin pain was not attributed to a particular source by the PEB.  The prior history of surgery and scars were not cited as unfitting by the PEB or addressed by the MEB.  These are therefore outside the Scope of the panel and no rating recommendation can be made for the scar(s).  IAW VASRD §4.124 (neuralgia), a maximal rating of 0% is supported by a mild or moderate level of pain.  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 right inguinal pain condition.  

Chronic Radiating Low Back Pain (LBP).  According to STR and the MEB NARSUM, the CI also reported that the LBP condition began in September 2004 after lifting the rotor blade.  However, contemporaneous records show that the CI initially complained of the right groin and abdominal pain.  A herniated disc was found at L5-S1 on an MRI done as part of the evaluation for the right groin pain.  In neurosurgery on 4 April 2005, he was noted to have normal sensation to light tough, generalized weakness of the right leg (opposite the side of the herniated disc) and normal left leg strength.  Reflexes were symmetrically diminished.  The gait was slightly abnormal due to pain.  He was referred to physical therapy.  There, on 11 May 2005, 3 months prior to separation, he was noted to have normal flexion and extension.  Painful motion was not documented.  Electrodiagnostic studies on 16 June 2005 were normal without evidence of either a radiculopathy or neuropathy.  In physical medicine on 16 June 2005, the CI had tenderness to palpation and reduced sensation on the left lateral leg.  The reflexes, gait, and motor function were normal.  The range of motion (ROM) was normal.  

At the MEB examination (recorded on DD Forms 2807 and 2808), the CI reported that his back was always tight and the right leg tingled.  The ROM was decreased, but the neurological examination and heel to toe gait were normal.  The MEB NARSUM examination on 5 July 2005, 3 months prior to separation, noted complaints of lower back pain that radiated to his right foot.  On examination, he was noted to have decreased sensation on the right sole and shin.  Flexion and extension were normal.  Review of the medical record did not show an abnormal gait or spinal contour due to spasm or guarding of the spine and did not show episodes of incapacitation.  

At the VA C&P evaluation performed on 24 January 2006, the CI reported ongoing LBP since the incident with the helicopter blade and that he felt incapacitated.  Flexion was reduced to 80 degrees, but normal in other planes.  Motion was painful.  The neurological examination was normal.  The gait was slightly guarded with small steps.  He was noted to have an antalgic gait 1 week later at the neurology C&P, but had normal muscle tone and bulk.  Also, the sensory loss was on the left in an L5 distribution.  At a pain clinic appointment on 22 March 2006, 7 months after separation, the CI had a normal gait.  The ROM was painless and is charted below.  Sensation was decreased in a left L5 distribution.  The ROM examinations in evidence which the panel weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.  

Thoracolumbar ROM
(Degrees)	PT/MEB ~3 Mos. Pre-Sep	Physical Medicine ~2 Mos. Pre-Sep	VA C&P ~5 Mos. Post-Sep	Pain Clinic ~7 Mos. Post-Sep 	
Flexion (90 Normal)	90	FROM	80	90	
Combined (240)	210		230		
	Present	No comment	Present	Absent	
Comments	Painful motion	Painful motion not addressed	Painful motion	Painless motion	
§4.71a Rating	10%	0%	10%	10%	

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the LBP condition 0%, coded 5243 (intervertebral disc syndrome), citing tenderness and noting no signs of a radiculopathy.  The VA rated the back condition 40% coded 5242 (degenerative arthritis of the spine), based on the VA C&P examination 5 months after separation, citing pain with flexion of 30 degrees (albeit with a limit of 80 degrees), and the report of decreased ROM during periods of flare-ups and with repetitive movement.  The VA also rated a radiculopathy condition 10% coded 8620 (sciatic nerve neuritis), based on the VA C&P examination, citing reduced sensation over the S1 distribution and positive straight leg raises.  The panel considered the evidence.  It noted that the VA rated the CI for a radiculopathy.  This was specifically excluded by the PEB and is out of the Scope of the panel.  The panel did observe though that the examinations were not consistent between the right and left side, the findings did not match the MRI, and electrodiagnostic testing was normal.  An unfitting radiculopathy was not present at separation and no rating would have been recommended even if within the Scope of the panel.  The panel next considered the rating.  Painful motion and the limitation in motion evident on multiple examinations each support a 10% rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the LBP condition, coded 5243.  

Contended PEB Conditions:  Diarrhea, Chronic Fatigue, Hearing Loss, Tinnitus, and Depressive Disorder, NOS.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  None of the conditions were profiled or implicated in the commander’s statement.  All were judged to meet retention standards.  There was no performance-based evidence from the record that any of the conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded that there was insufficient cause to recommend a change in the PEB fitness determination for any of the contended conditions and so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the chronic splenomegaly condition and IAW VASRD §4.117, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the chronic right inguinal pain condition and IAW VASRD §4.124a, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the LBP condition, the panel unanimously recommends a disability rating of 10%, coded 5243, IAW VASRD §4.71a.  In the matter of the contended diarrhea, chronic fatigue, hearing loss, tinnitus, and depressive disorder conditions, the panel unanimously recommends no change from the PEB determinations as not unfitting.  There are no other conditions within the panel’s scope of review for consideration.  The panel recommends that the CI’s prior determination be modified as follows, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic Splenomegaly	7799-7707	0%	
Chronic Right Inguinal Pain	8730	0%	
Chronic Low Back Pain	5243	10%	
COMBINED	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150906, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170012892, XXXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found that your disability rating should be modified but not to the degree that would justify changing your separation for disability with severance pay to a permanent retirement with disability.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed) and I accept its recommendation.  This will not result in any change to your separation document or the amount of severance pay.  A copy of this decision will be filed with your Physical Evaluation Board records.  I regret that the facts of the case did not provide you with the outcome you may have desired.
  
	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. 

	A copy of this decision has also been provided to the Department of Veterans Affairs and to the counsel you listed on your application, XXXXXXXXXXXXXXXXXXX.

Sincerely,	
Enclosure