RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  pD-2016-00627
BRANCH OF SERVICE:  AMRY 	SEPARATION DATE:  20040922

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E6, Combat Engineer, medically separated for “mild to moderate orthostatic tachycardia” and “chronic right orchialgia following vasectomy,” rated 10% and 0%, respectively, with a combined disability rating of 10%.  

CI CONTENTION:  The CI contended his unfitting orchialgia and pain in his feet.  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 – 20040526	VARD - 20050225	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Mild to Moderate Orthostatic Tachycardia	8299-8210	10%	Postural Orthostatic Tachycardia Syndrome 	7011	10%	20040929	
Chronic Right Orchialgia	8799-8730	0%	Chronic Orchialgia, Right	7525	10%	STR	
Pes Planus	Not Unfitting	No VA Claim in evidence	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30% 	

ANALYSIS SUMMARY:  

Mild to Moderate Orthostatic Tachycardia.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI was evaluated in March 2003 for complaints of extreme lightheadedness with any type of physical exertion.  The CI underwent a comprehensive cardiopulmonary evaluation including pulmonary function testing, a graded exercise stress test, Holter monitor and brain MRI that did not reveal the source of his symptoms.  A tilt table test confirmed the diagnosis of postural orthostatic tachycardia syndrome.  After treatment with two different medications to control heart rate, the condition was not successfully treated to allow the CI to participate in full aerobic fitness conditioning.  

The 16 April 2003 echocardiogram (ECG), 17 months prior to separation, showed a normal left ventricular (LV) ejection fraction between 60-65%, normal LV wall motion and normal LV wall thickness.  No valve abnormalities were noted.  During the 2 June 2003 graded exercise stress test, 16 months prior to separation, the CI exercised 9 minutes on a full Bruce protocol, achieved a maximum heart rate of 197 beats per minute (102% of predicted), maximum blood pressure 158/92 and achieved 10 metabolic equivalents (METs) workload.  The baseline ECG, prior to exercise, was sinus tachycardia at a rate of 129 beats per minute.  An 8 July 2003 24-hour Holter monitor, 15 months prior to separation, reported that in a 24-hour recording time the CI was in a supraventricular tachycardia for 36% of the beats throughout various times of the day.  The diagnosis of supraventricular tachycardia, not associated with exercise was assigned.  

At the 8 September 2003 cardiology evaluation with tilt table test, 15 months prior to separation, the CI complained of near syncope (a feeling of going to pass out), nausea, dry heaves, vomiting and a rapid heart rate.  He stated that he was usually not aware of the rapid heart rate and attributed his symptoms to his pain, not a primary cardiac condition.  During the tilt table test he was given a medication which caused his blood pressure to drop 30 points and his pulse increase from 85 to 120-147 which duplicated his symptoms.  He was diagnosed with postural orthostatic tachycardia.  At that visit the CI was started on a medication to control heart rate and one month later in October 2003 the dose was increased.  After the October 2003 cardiology visit, there was only one visit that recorded an elevated heart rate (104 – normal 60-100) prior to separation.  

The 29 February 2004 MEB NARSUM examination, 7 months prior to separation, noted complaints of tachycardia associated with nausea, vomiting, shortness of breath and near syncope with any exertion more than just fast walking.  During the physical examination the cardiovascular system was not addressed.  The 25 February 2005 VA rating decision cites a 29 September 2004 VA Compensation and Pension (C&P) evaluation which is not in evidence.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the mild to moderate orthostatic tachycardia condition 10%, coded 8299-8210 (analogous to paralysis of the tenth (pneumogastric, vagus) cranial nerve).  The VA rated the postural orthostatic tachycardia syndrome condition 10%, coded 7011 (ventricular arrhythmias, sustained), based on the C&P examination 7 days after separation, citing workload greater than 7 METs resulting in dyspnea, fatigue, angina, dizziness, or syncope; or continuous medication is required.  There was no evidence of severe paralysis of the tenth cranial nerve characterized by difficulty swallowing, gastroparesis, or an abnormal gag reflex to support the next higher 30% rating under code 8210.  There was also no evidence of cardiac atherosclerosis or myocardial infraction to justify a rating using code 7005 or 7006.  Though there was evidence of supraventricular arrhythmia to evaluate under code 7010, the condition appeared to be somewhat controlled and in the year prior to separation there was no evidence of greater than 4 episodes documented by ECG or Holter to justify a 30% rating.  The panel concluded there was no evidence to support a rating higher than that adjudicated by the PEB.  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 orthostatic tachycardia condition.  

Chronic Right Orchialgia Following Vasectomy.  According to the STR and the MEB NARSUM, the CI underwent a routine vasectomy on 8 September 2000 without complications.  Several weeks later the CI developed acute pain and swelling in the scrotum.  After multiple treatments with antibiotics, two surgical procedures, the first in December 2000 where a spermatocele was incised and drained and a second in June 2002 when the CI underwent an epididymectomy, several types of pain medications, referral to the pain clinic where he was treated with a topical anesthetic cream as well as blocks to regional sensory nerves with little improvement, the CI’s condition could not be adequately rehabilitated to allow for unrestricted activity and full duty.  

The 29 February 2004 MEB NARSUM examination, 7 months prior to separation, noted complaints of constant pain in the right hemiscrotum that was aggravated by any physical exertion.  Physical examination showed decreased sensation of the right side of the scrotum and the right medial proximal thigh.  

The 29 March 2004 Urology MEB consult, 6 months prior to separation, the CI complained of an inability to perform strenuous activity or lift heavy weights due to those activities resulting in lightheadedness, dizziness and vomiting.  In addition, the CI stated he was unable to sleep on his stomach or side due to vomiting from the discomfort.  He stated he was no longer able to perform the tasks required for his MOS.  Physical examination revealed well-healed right inguinal and right scrotal surgical scars.  The right testicle and cord were very tender to palpation.  Bilateral cremasteric responses were intact and there was no evidence of an inguinal hernia.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic right orchialgia condition 0%, coded 8799-8730 (analogous to neuralgia, ilio-inguinal nerve), citing neuralgia, mild or moderate.  The VA rated the right orchialgia condition 10%, coded 7525 (epididymo-orchitis, chronic only), based on the STR, citing long-term drug therapy, one or two hospitalizations per year, or intermittent intensive management.  Panel members agreed there was no evidence of severe to complete paralysis of the ilio-inguinal nerve to validate a 10% rating using code 8730.  There was evidence of long-term drug therapy to satisfy the requirements for a 10% rating coded 7525.  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 right orchalgia condition, coded 7525.  

Contended PEB Condition:  Pes Planus.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended condition was not unfitting.  The contended condition was not profiled, implicated in the commander’s statement or judged to fail retention standards.  The 29 April 2004 Report of Medical Examination (DD Form 2808) noted mild, asymptomatic pes planus.  On the 22 April 2004 Report of Medical History (DD Form 2807-1), the CI did not indicate any problems with his feet.  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 the contended condition as unfitting and so no additional disability rating is recommended.  

BOARD FINDINGS:  In the matter of the orthostatic tachycardia condition and IAW VASRD §4.124a, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the right orchialgia condition, the panel unanimously recommends a disability rating of 10%, coded 7525 IAW VASRD §4.115a/b.  In the matter of the contended pes planus condition, the panel unanimously agrees that it cannot recommend it for additional disability rating.  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	
Mild to Moderate Orthostatic Tachycardia	8299-8210	10%	
Chronic Right Orchialgia following Vasectomy	7525	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160914, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record 

AR20170016323, 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.

Sincerely,	
Enclosure