RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-02482
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060714

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E1, Fuel Handler, medically separated) for “chronic right lower extremity venous insufficiency” with a disability rating of 20%.

CI CONTENTION:  “Review 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 - 20060605	VARD - 20061101	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Right Lower Extremity Venous Insufficiency	7199-7120	20%	Right Lower Venous Insufficiency	7199-7120	NSC	STR	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  N/A	

ANALYSIS SUMMARY:  

Chronic Right Lower Extremity Venous Insufficiency of Undetermined Etiology with Persistent Edema.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI began to have lower extremity swelling in September 2004 after approximately 2 weeks of guard duty following return from leave.  He had no symptoms during or immediately after his leave and he denied any trauma.  X-ray studies on 24 November 2004 of the right lower leg (tibia and fibula) were normal, but there was soft tissue swelling of the right ankle.  An ultrasound study of the right lower extremity showed no evidence of a deep venous thrombosis and computerized tomography (CT) of the abdomen and pelvis demonstrated no evidence of pelvic adenopathy or other lesion obstructing venous outflow.  Treatment consisted of compression stockings and aspirin.  On 3 December 2004, the CI complained of a 4-5/10 (10 being the worst pain) soreness of his right inner thigh, calf and foot.  There was 2+ edema of the right foot which extended to the mid-calf.    An ultrasound study of the right lower extremity on 3 December 2004 was also normal.  The examiner diagnosed the condition as right lower extremity venous insufficiency of undetermined etiology and treatment was continued with recommendations to elevate the right lower extremity at least 30 minutes twice daily and discontinue smoking.  A follow-up CT scan of the abdomen and pelvis on 7 January 2005 was normal.  Pain decreased over several months when he avoided prolonged standing and wore the compression stockings. The CI sustained an inversion injury to the right ankle on 16 January 2006, which resulted in swelling of the entire ankle and foot up to the toes as compared to the daily swelling below the right knee for the prior year as a result of venous insufficiency.  X-rays of the right ankle on 20 January 2006 showed considerable soft tissue fullness over the lateral ankle without any evidence of fracture, dislocation or other significant bone abnormality.  When not on the treatment protocol, pain would increase to 6-7/10 and the CI would have increased swelling at the end of the day.

During the April 2006 MEB examination (recorded on DD Forms 2807-1 and 2808), 3 months prior to separation, the CI reported a swollen leg due to venous insufficiency.   Physical examination showed non-pitting edema of the right lower leg (anterior medial tibia and calf) and non-pitting edema of the right ankle (medial and lateral malleoli).  There was no tenderness to palpation and no limitation of motion.  The 22 April 2006 MEB NARSUM examination, 3 months prior to separation, noted complaints of persistent edema and pain of the right lower extremity.  Physical examination of the right lower extremity showed 2+ pitting edema of the right foot to the mid-calf with a 1-2+ dorsal pedis pulse on the right.  The left calf had trace edema above the stocking line.  The NARSUM examiner’s diagnosis chronic right lower extremity deep venous insufficiency of undetermined etiology.  He opined the condition would be a life-long problem requiring modification of activities, continued wearing of compression stockings throughout the day, taking enteric coated aspirin daily, elevating the right leg above his heart twice daily, and avoiding prolonged or ambulatory activities that would increase the swelling and pain.

There was no VA examination proximate to separation; however, the CI did have a VA ambulatory clinic visit on 9 November 2006, 4 months after separation, where the CI reported a 4 day history of fever, increased edema, warmth and tenderness of the right lower extremity.  Examination revealed 2+ right leg edema with pitting, which was warm with erythema (redness) from the foot to the knee.  Treatment for the edema/cellulitis included Augmentin (an antibiotic combination of amoxicillin and clavulanic acid) and ibuprofen, a nonsteroidal anti-inflammatory drug (NSAID).  A new vascular workup consisting of an MRI (magnetic resonance imaging), an MRA (magnetic resonance arteriography), an ankle brachial index of both legs, and complete clotting lab studies.  A vascular surgical consult was also recommended.  On 12 December 2006 the CI was fitted and issued Jobst compression stockings.  At a clinic visit also on 12 December 2006 the CI noted chest pain 2 weeks earlier where he had a negative Emergency Room evaluation for a deep venous thrombosis.  The pain lasted 45 minutes and he had no weakness or numbness in the extremities.  Examination revealed trace to 1+ edema of the right leg with no calf tenderness, cords, redness or increased warmth.  Homan’s sign (to determine a deep venous thrombosis) was negative and dorsal pedis pulses were 1+ bilaterally.  A screen for skin rash/lesions revealed no persistent skin rash.  An examination on 14 September 2007, 14 months post-separation, revealed edema over the lower leg and ankle that was non-pitting.  There was normal skin color no ulcers, no stasis pigmentation, no eczema, no lesions, no visible or palpable varicose veins, and slight maceration (moisture with wrinkling and lightening of the skin) and erythema between the toes of the right foot.  Dorsal pedis and posterior tibial pulses were 1+.

The panel directed attention to its rating recommendation based on the above evidence.   The PEB rated the chronic right lower extremity venous insufficiency condition 20%, coded 7199-7120 (varicose veins), citing persistent edema.  The VA initially rated the right lower extremity venous insufficiency condition not service connected, coded 5271 (post-phlebitic syndrome of any etiology), based on failure to report for a scheduled examination, citing the condition neither occurred in nor was caused by service and because there was no evidence the claimed condition exists.  However, on 21 September 2007 the VA rated the right lower extremity venous insufficiency 20%, coded 7199-7121, based on an examination 14 months after separation, citing the CI did not have ulcers, stasis pigmentation, eczema, pitting, or palpable varicose veins and the CI had normal skin color except for the toes.  Panel members considered whether the CI’s condition warranted a higher rating of 40% using either code 7120 or 7121; however, both codes required “persistent edema and stasis pigmentation or eczema, with or without intermittent ulceration.”  Neither the STR nor the VA examinations noted stasis pigmentation, eczema or any intermittent ulceration of the right lower extremity.  Therefore, the CI’s condition did not rise to the level required for a 40% rating.  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 right lower extremity venous insufficiency condition.  

PANEL FINDINGS:  In the matter of the chronic right lower extremity venous insufficiency of undetermined etiology with persistent edema condition and IAW VASRD §4.104, the panel unanimously recommends no change in the PEB adjudication.  There are 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 20151021, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170013252, XXXXXXXXXXXXXXXXXXX. 

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

	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