RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00211
BRANCH OF SERVICE:  Navy	SEPARATION DATE:  20050801

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an E5, Quartermaster medically separated for “chronic pain in the back, lumbar region, lower abdomen and bilateral testicles with no definitive etiology” and “previous left inguinal hernia, surgery without recurrence or other problems” rated as overall effect with a disability rating of 0%. 

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 - 20050609	VARD - NA	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Pain in the Back…Abdomen…and Bilateral Testicles with no Definitive Etiology…	Overall Effect	0%	No VA Exam in Evidence	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  NA	

ANALYSIS SUMMARY:

Chronic Pain.  The PEB determined that the CI was unfit due to the “overall effect” of multiple conditions.  In an “overall effect” case, each condition has been determined by the PEB to be separately not-unfit, but the “overall effect” considered together creates a condition of unfitness.  Such cases are identified by the PEB explicitly stating the conditions were combined under the provisions of “Overall Effect” and citing the SECNAVINST 1850.4E.  The panel noted that this is also IAW DoDI 1332.38 E3.P3.4.4.  In these cases, the panel evaluates each condition separately for fitness, but does not recommend a rating unless a preponderance of evidence demonstrates that a specific condition was separately unfitting at separation.

According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI first presented with groin pain in early December 2003 which was aggravated by activity.  He denied specific trauma, but was in BUDS (initial training to become a USN SEAL).  He was given light duty and medications, but had persistent pain.  He had a past history of a left inguinal hernia repair at age 16, over 6 years earlier.  An X-ray of the hip was normal.  An ultrasound of the groin was negative for a hernia.  Microlithiasis of the testicles (deposits of multiple tiny calcifications through the testes) was noted.  This was an incidental finding of unknown etiology and unknown significance, but not typically associated with pain.  The CI was referred to urology.  A CT scan of the abdomen and pelvis was normal as were tumor markers (laboratory tests).  No etiology for the pain was discovered and the CI was referred to pain management.  Coincident with the urology evaluation, the CI was also evaluated for the groin pain for a hip etiology.  A bone scan was unremarkable other than mild stress changes of both tibia (mild shin splints) without uptake in the hips or spine.  An evaluation by general surgery for a possible recurrence of the left inguinal hernia was also negative.  It was noted that the CI had difficulty with the demands of training, but did well with the activities of daily living.  An MRI of the thoracolumbar spine (not in evidence) was normal other than mild spondylosis (early degenerative changes from “wear and tear”) at L4-5.  Due to ongoing pain in multiple areas of pain (back, abdomen, and bilateral testicles) which prevented full duty and the completion of SEAL training, the CI was referred for an MEB.

At the 3 November 2004 MEB NARSUM evaluation (report of medical board), 9 months prior to separation, the CI reported constant pain which varied with activity.  He had chronic pain of the back (lumbar region), lower abdomen, and bilateral testicles without a definitive etiology which was refractory to treatment.  He was evaluated by neurology, urology, and surgery specialists with no plans for further studies or treatment recommended.  He was evaluated by the pain clinic and underwent several trails of medical management without improvement, and was duty-limited by pain and discomfort.  Physical examination showed a normal gait.  Mild tenderness of the lumbar spine muscles and abdominal lower quadrants was present.  The examination was unremarkable otherwise as was examination of the left groin and testes.  During the 30 November 2004 MEB examination (recorded on DD Forms 2807-1 and 2808 and dated), 8 months prior to separation, the CI reported chronic back, lower abdominal, and testicular pain which precluded standing for any length of time.  The examination was remarkable for bilateral painful testicles, but otherwise unremarkable.  

The Informal PEB (31 January 2005) determined that the CI was fit for duty.  The CI non-concurred and a Formal PEB was performed.

On 15 February 2005 the CI was seen in primary care and reported that the back pain was now debilitating 3 times a month.  Physical examination revealed a limp (antalgic gait) and bilateral groin and back tenderness.  The back range of motion (ROM) was full, but severe pain was present with full flexion.  His condition was thought to have progressed, but no etiology was determined.  

The CI was next seen by physical therapy on 11 April 2005 and requested documentation (of his limitations) for the PEB process.  He reported progressive pain.  The physical examination revealed cervical spine to lumbar tenderness.  Cervical spine ROM showed flexion to 35 degrees (normal 45) and combined ROM was 240 (normal 340); painful motion was not addressed.  Thoracolumbar ROM showed flexion to 65 degrees (normal 90) and combined ROM was 195 (normal 240); painful motion was not addressed.  No etiology was determined and he was released to activity as tolerated.  During a 27 April 2005, primary care visit, the CI was noted to have a limping stiff gait.  He reported an increase in the pain in his neck and shoulders as well as the testicular pain.  Neck ROM was “reduced” and tenderness in the neck, thorax, and lumbar paraspinal muscles.  The examiner opined that the CI had an exacerbation of a chronic pain syndrome.  There was no VA examination for this panel to review.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic pain conditions at 0% citing overall effect.  The panel considered the evidence.  It showed that the CI was initially seen for left groin pain and over time, also developed bilateral testicular pain, lower abdominal pain, low back pain, neck pain, and shoulder pain.  The CI was evaluated by multiple specialties and by multiple modalities.  No etiology determined nor was significant pathology discovered.  The onset of pain was without specific trauma and no explanation for the progression was found in the evidence available for review.  The panel noted that pain is a symptom rather than a diagnosis.  The panel did not find a preponderance of evidence to determine that a specific diagnosis was unfitting and noted that, in fact, no specific diagnosis was made during the PEB process.  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 pain condition.

BOARD FINDINGS:  In the matter of the “chronic pain in the back, lumbar region, lower abdomen, and bilateral testicles with no definitive etiology and (history of) previous left inguinal hernia surgery without recurrence or other problems” condition and IAW DoDI 1332.38 E3.P3.4.4., 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 modification or re-characterization of the CI’s disability and separation determination.

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160411, w/atchs
Exhibit B.  Service Treatment Record

MEMORANDUM FOR DIRECTOR, SECRETARY OF THE NAVY COUNCIL OF REVIEW
               BOARDS 

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS
 
Ref:   (a) DoDI 6040.44

      In accordance with reference (a), I have reviewed the cases listed below and approve the recommendations of the PDBR that the following individual’s records not be corrected to reflect a change in either characterization of separation or in the disability rating previously assigned by the Department of the Navy’s Physical Evaluation Board:

		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN

		
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