RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX 	CASE:  PD-2015-02520
BRANCH OF SERVICE:  NAvY	SEPARATION DATE:  20081112

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Aviation Boatswain’s Mate, medically separated for “chronic left testicular pain;” and “tarsal tunnel syndrome, left s/p release;” each rated 10%, with a combined disability rating of 20%.  

CI CONTENTION:  “I was not afforded the opportunity to appeal the PEB decision or be present during the PEB review.  The PEB only considered my health /medical conditions in part per their final decision.”  The CI submitted his VA rating decision in support of his application.  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 - 20080605	VARD - 20081212	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Left Testicular Pain	7525	10%	Left Testicular Orchitis and Epididymitis	7525	0%	20080930	
Chronic Suprapubic Pain	CAT II	Chronic Groin Syndrome	5319	NSC	20080930	
Tarsal Tunnel Syndrome, Left S/P Release 	8625	10%	Decreased Sensation Left Foot Secondary to Tarsal Tunnel/Plantar Fascial Release of the Left Foot	8599-8625	10%	20080930	
			Status Post Tarsal Tunnel/Plantar Fascial Release of the Left Foot	5299-5284	10%	20080930	
			Residual Scar S/P Tarsal Tunnel … 	7804	10%	20080930	
Achilles Tendinitis, Left	CAT II	See Above Tarsal Tunnel Conditions	
Low Back Pain 	CAT III	Degenerative Changes, Lumbar Spine	5003-5237	20%	20080930	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  70%	

ANALYSIS SUMMARY:  

Chronic Left Testicular Pain.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI had a several year history of testicular and suprapubic pain and was treated by Urology since 2005 without relief of his symptoms.  An ultrasound showed normal testes, but thickened epididymis.  Specialty testing including diagnostic imaging (Magnetic Resonance Imagining (MRI) and Computed Tomography (CT scan)) and cystoscopy were negative.  

The 19 March 2008 MEB NARSUM examination, 8 months prior to separation, noted complaints of ongoing pain in the left testicle that was described as constant and rated as 10/10.  He also complained of nocturia (2-3x per night), as well as feelings of urinary urgency and a sense of incomplete emptying of the bladder.  His 10/10 suprapubic area pain was described as “constant and totally disabling.”  The CI urinated approximately every 1 to 4 hours, but on an average about every 2 to 3 hours, with a few episodes of incontinence and urgency, but the examiner indicated that this was “not his predominant complaint.”  Physical examination showed slight tenderness to palpation over the suprapubic area.  Both testes appeared unremarkable, and the right testes was normal on examination.  The CI was “exquisitely tender” about the left testis, epididymis, spermatic cord, as well as in the inguinal region.  There was no evidence of inguinal hernia.  

At the 30 September 2008 VA Compensation and Pension (C&P) evaluation, 1 month before separation, the CI reported chronic groin syndrome with 10/10 left testicular pain made worse with activity.  Pain was relieved with rest, narcotic pain medication and steroid injections.  There were no complaints of starting urination or of urinary incontinence.  Physical examination showed suprapubic tenderness to deep palpation without rebound.  There was tenderness to the testicles.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left testicular pain condition 10%, coded 7525 (epididymo-orchitis, chronic).  The Navy PEB also listed “chronic suprapubic pain” as a related Category II condition (a condition that contributed to the primary unfitting condition but was not separately ratable).  The impairment from the suprapubic pain was properly subsumed under the overall rating for the left testicular conditions IAW §4.14 (avoidance of pyramiding; more than one rating based on the same impairment is prohibited).  The VA rated the left testicular orchitis and epididymitis condition 0%, coded 7525, based on the C&P examination 1 month before separation, citing tenderness to palpation.  

The panel noted that code 7525 is rated as “urinary tract infection” and that the CI’s significant symptoms and multiple medical evaluations and interventions were analogous to intermittent intensive management.  There was no evidence of renal dysfunction, more than two hospitalization per year, frequent urinary tract infections or requiring chronic intensive management for any rating higher than that adjudicated by the PEB.  There was no hernia or inguinal surgery for alternative rating analogous to 7338 (hernia, inguinal), and no higher rating analogous to ilioinguinal nerve coding (8530, 8630, or 8730).  

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 left testicular condition.  

Tarsal Tunnel Syndrome Left S/P Release.  According to the STR and the NARSUM addendum, the CI’s left foot complaints began in August 2006 without any trauma.  Electrodiagnostic testing (EMG) was positive for tarsal tunnel syndrome and the CI underwent a left foot tarsal tunnel release on 13 September 2007 for complaints of pain and tingling in the foot.  

The 15 March 2008 MEB NARSUM addendum examination, 8 months prior to separation, noted complaints of left foot pain, left Achilles pain, and decreased sensation over the posterior plantar surface.  Physical examination from 22 February 2008 showed tenderness over the left Achilles and an antalgic gait.  Urology examination from 19 March 2008 showed an antalgic gait.  

The 13 May 2008 MEB NARSUM addendum examination, 6 months prior to separation, noted complaints of continued left foot pain and tingling.  Physical examination revealed mild edema to the left ankle and a positive Tinel’s sign (nerve irritation) upon percussion at the incision site.  “The protective threshold is absent per use of monofilament testing,” but light touch, and vibratory sensation were intact.  Reflexes, muscle strength, light touch, and vibratory sensation were intact.  The examiner stated left “ankle range of motion is within normal limits, at least 10 degrees of dorsiflexion with the knee bent or extended.”  There was a positive straight leg test (provocative test for radicular symptoms) on the left.  The assessment was “radiculopathy, status post tarsal tunnel release” and therefore the three MEB physicians indicated that the left foot tingling and numbness was due to radiculopathy from his back and not his tarsal tunnel.  

At the 30 September 2008 VA Compensation and Pension (C&P) evaluation, 1 month before separation, the CI reported constant 10/10 pain in the left foot described as squeezing, burning, aching, sharp, sticking and cramping.  Physical examination showed a normal posture and gait.  There was normal strength with symmetric reflexes in the lower extremities.  There was marked decreased sensation on the bottom of the left foot.  There was tenderness along the incision scar of the posterior medial ankle and foot and tenderness with toe walk and inversion against resistance.  There was no tenderness at the plantar fascia insertion.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left tarsal tunnel syndrome condition 10%, coded 8625 (neuritis of the posterior tibial nerve).  The Navy PEB also listed “Achilles tendinitis, left” as a related Category II condition (a condition that contributed to the primary unfitting condition but was not separately ratable).  Members concluded that a preponderance of evidence indicated the Category II Achilles tendinitis condition was justified as separately unfitting; given that impairment from the Achilles tendinitis would be rated under VASRD §4.71a (schedule of ratings–musculoskeletal system) and is separable from the PEB’s tarsal tunnel syndrome (neuritis) rating, which is ratable under VASRD §4.124a (schedule of ratings–neurological conditions and convulsive disorders).  The panel therefore considered if the Achilles tendinitis were separately or in combination an unfitting and separately ratable condition.  

The VA rated the tarsal tunnel syndrome of the left foot condition 10%, coded 5299-5284, (foot injuries, other), based on the C&P examination 1 month before separation, citing decreased sensory function in the plantar aspect of the left foot secondary to surgical incision.  The VA also rated the left status post tarsal tunnel/plantar fascial release of the left foot, tarsal tunnel syndrome of the left foot condition at 10%, coded 5299-5284 (foot injury other) citing painful motion from the same examinations; as well as a 10% rating for a tender scar, and coded 7804.  

The panel considered that there was no higher rating for the left lower extremity peripheral nerve condition regardless of the etiology being at the tarsal tunnel or as a lumbar radiculitis as code 8625 (posterior tibial nerve) was the nerve level of the CI’s disability condition.  There was no motor loss for partial paralysis and “moderate” is the highest neuritis rating available under code 8625 IAW VASRD §4.123 (neuritis).  However, the panel considered the multiple symptoms and signs from the CI’s tarsal tunnel syndrome following surgical release with category II Achilles tendinitis, and noted the VA’s multiple ratings for a combined 30% disability for the CI’s left foot and ankle.  The panel adjudged that the CI’s foot/ankle pain, sensory loss, pain on motion (or STR antalgic gait findings), and tender scar, when considered as the entirety of the CI’s left foot condition, that the CI’s disability picture more nearly approximated the “moderately severe” (20%), rating criteria analogous to foot injuries other (8625-5284).  There was insufficient evidence for any higher rating if each condition (tarsal tunnel syndrome, left s/p release and Achilles tendinitis, left) was rated separately, or under any other rating schema.  

After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 20% for the left tarsal tunnel syndrome condition, coded 8625-5284.  

Contended PEB Condition:  Low Back Pain.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended condition was not unfitting.  The CI had a 2-year history of chronic prostatitis/chronic pelvic pain syndrome and was evaluated and treated with no relief.  Possible thoracolumbar spine radiculopathy was suggested as the cause of the CI’s suprapubic and testicular pain, and especially of his left lower extremity pain (see above with the 15 March 2008 NARSUM addendum).  On 27 June 2007 lumbar MRI revealed mild osteoarthritic changes and subtle annular bulges at L4-L5 and L5-S1 as well as a posterior radial annual tear at L5-S1 with no evidence of significant central or lateral stenosis.  On 8 May 2008 the CI underwent an epidural steroid injection (ESI).  At the 16 June 2008 Pain Management clinic follow-up the CI reported limited improvement.  Any peripheral nerve disability related to any thoracolumbar spine condition was considered in rating both the suprapubic and testicular pain, and the left tarsal tunnel syndrome (lower extremity pain) conditions above.  The contended low back pain condition was not profiled, implicated in the commander’s statement nor judged to fail retention standards.  There was no performance-based evidence from the record that the condition 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 the contended condition and so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the left testicular condition and IAW VASRD §4.115a, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the left tarsal tunnel syndrome condition with Achilles tendinitis, the panel unanimously recommends a disability rating of 20%, coded 8625-5284 IAW VASRD §4.124a and §4.71a.  In the matter of the contended low back condition, the panel unanimously recommends no change from the PEB determination 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; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic Left Testicular Pain (with Cat II Chronic Suprapubic Pain)	7525	10%	
Tarsal Tunnel Syndrome, Left S/P Release (with Cat II Achilles Tendinitis, Left)	8625-5284	20%	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20151018, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

MEMORANDUM FOR DEPUTY COMMANDANT (Manpower and Reserve Affairs)
		   COMMANDER, NAVY PERSONNEL COMMAND	
	                          
Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS          

Ref:  (a) DoDI 6040.44
	(b) PDBR ltr dtd 18 Aug 17 ICO XXXXXXXXXXXXXXXXXXX
	(c) PDBR ltr dtd 18 Aug 17 ICO XXXXXXXXXXXXXXXXXXX
	(d) PDBR ltr dtd 18 Aug 17 ICO XXXXXXXXXXXXXXXXXXX
	(e) PDBR ltr dtd 18 Aug 17 ICO XXXXXXXXXXXXXXXXXXX
	(f) PDBR ltr dtd 18 Aug 17 ICO XXXXXXXXXXXXXXXXXXX
	(g) PDBR ltr dtd 18 Aug 17 ICO XXXXXXXXXXXXXXXXXXX
	(h) PDBR ltr dtd 18 Aug 17 ICO XXXXXXXXXXXXXXXXXXX
	(i) PDBR ltr dtd 18 Aug 17 ICO XXXXXXXXXXXXXXXXXXX
	(j) PDBR ltr dtd 22 Aug 17 ICO XXXXXXXXXXXXXXXXXXX
	(k) PDBR ltr dtd 18 Aug 17 ICO XXXXXXXXXXXXXXXXXXX
	(l) PDBR ltr dtd 18 Aug 17 ICO XXXXXXXXXXXXXXXXXXX
	(m) PDBR ltr dtd 18 Aug 17 ICO XXXXXXXXXXXXXXXXXXX
	(n) PDBR ltr dtd 21 Aug 17 ICO XXXXXXXXXXXXXXXXXXX
	(o) PDBR ltr dtd 18 Aug 17 ICO XXXXXXXXXXXXXXXXXXX

1.  Pursuant to reference (a), the recommendations of the Physical Disability Board of Review set forth in references (b) through (o) are approved.  The official records of the following individuals are to be corrected as follows:

     a. XXXXXXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 30 percent rating (increased from 20 percent) effective date of discharge.

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

     c. XXXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge. 

     d. XXXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge. 

     e. XXXXXXXXXXXXXXXXXXX, former USMC: Placement on the Permanent Disability Retired List with a 30 percent rating (increased from 10 percent) effective date of discharge.

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

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS

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

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

     i. XXXXXXXXXXXXXXXXXXX, former USMC: Placement on the Permanent Disability Retired List with a 30 percent rating (increased from 20 percent) effective date of discharge.

     j. XXXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge. 

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

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

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

     n. XXXXXXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 30 percent rating (increased from 10 percent) effective date of discharge.
     
3.  Please take action to implement these decisions and provide notification to the above individuals once those actions are complete.

	XXXXXXXXXXXXXXXXXXX
	Acting