RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-01297
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20070302

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Chemical Operations Specialist, medically separated for “chronic right inguinal pain status post repairs of 3 inguinal hernias and resection of his ilioinguinal nerve” with a disability rating of 0%.  

CI CONTENTION:  He requested review of the inguinal hernia and additional conditions not identified by the Medical Evaluation Board (MEB) and Physical Evaluation Board (PEB).  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 MEB, but determined by the PEB 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.  The panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections when appropriate.  The panel’s assessment of the PEB rating determination is based on review of medical records and all available evidence relevant to application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards for 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, which operates 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 disability at the time of separation.  

RATING COMPARISON:  

SERVICE PEB - 20070209	VARD - 20071001	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Right Inguinal Pain… 	8799-8730	0%	Inguinal Hernia	7338-7804	10%	20070828	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Chronic Right Inguinal Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s right inguinal pain began in April 2004 after lifting heavy boxes.  At an emergency room (ER) visit on 21 April 2004, he was found to have a probable right inguinal hernia.  A treatment note on 8 March 2005 indicated the CI had “triple hernia surgery” (two small direct defects in addition to a questionable indirect defect) and continued pain with physical training.  On 27 May 2005, while deployed, the CI reported having a hernia repair with mesh in August 2004, and experiencing intermittent pain when bending and straining since the surgery.  Examination revealed right groin focal tenderness over the incision and at the external inguinal ring, but no definite hernia identified with and without a valsalva (forceful exhalation against a closed airway) maneuver.  Because the CI could not perform his duties he was returned from deployment.  He was treated with a narcotic/acetaminophen pain reliever and nonsteroidal anti-inflammatory drug (NSAID), and referred for pain management.  Abdominal wall sonography on 16 July 2005 revealed no evidence of an inguinal hernia.  Over the ensuing weeks, the CI continued medications for pain relief and attended physical therapy sessions.  

At a general surgery clinic visit on 13 September 2005, the provider felt the CI’s pain was likely due to nerve entrapment or scarring, and prescribed Percocet (combination of oxycodone, a narcotic, and acetaminophen).  At a physical medicine appointment on 19 October 2005, the CI was prescribed gabapentin and nortriptyline for nerve pain, as well as acetaminophen. He had a right iliohypogastric diagnostic and therapeutic nerve block with an anesthetic/steroid combination on 1 November 2005, but due to continued pain, he underwent a right groin exploration and iliohypogastric and ilioinguinal nerve resections on 21 April 2006.  There was no evidence of a recurrent inguinal hernia, but there was an extensive fibrotic reaction to the area of the previous hernia repair.  The CI was seen in the ER on 28 April 2006 for drainage of a ruptured seroma (clear fluid without blood) from the surgical site.  At a follow-up visit on 20 June 2006, the CI reported continued pain and was started on another NSAID; right hip X-rays dated 16 January 2007 were normal.  

During the 3 January 2007 MEB examination (recorded on DD Forms 2807-1 and 2808), 2 months prior to separation, the CI reported a triple hernia in August 2004 and nerve resections in April 2006; physical examination was deferred to the VA.  The 19 January 2007 MEB NARSUM examination noted complaints of chronic groin pain, and the examiner documented significant tenderness of the right inguinal area and a 6 cm x 0.5 cm surgical scar. 

At the 19 January 2007 VA Compensation and Pension (C&P) examination, less than 2 months before separation, the CI reported pain exacerbated by exercise, prolonged standing and pulling. Physical examination revealed a soft abdomen with significant right inguinal area tenderness but no hernia or mass; bowel sounds were present and normal in all quadrants.  During the 28 August 2007 VA C&P examination, 5 months after separation, the CI reported discomfort and slight tenderness and tingling in the inguinal area.  On examination, there was a well-healed scar, slight right lower quadrant tenderness, no palpable masses or hernia of the right groin area, and no testicular atrophy. 

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right inguinal pain condition 0%, analogously coded 8799-8730 (ilioinguinal nerve neuralgia-mild).  The VA rated the right inguinal pain condition 10%, dual coded 7338-7804 (hernia, inguinal- scar(s), unstable or painful), based on the C&P examination, citing a “superficial scar that is painful on examination.”  Panel members agreed that the NARSUM and 19 January 2007 C&P examinations, which were most proximate to separation, held the greatest probative value for rating.  Both examinations found the inguinal area to be significantly tender without any mass or hernia.  The panel noted the PEB used code 8799-8730 for neuralgia, which is defined in the VASRD as “characterized usually by a dull and intermittent pain,” and is limited to a moderate rating, whereas neuritis, using code 8630, is “characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating.”   However, the use of code 8799-8630 (ilioinguinal neuritis-severe), which more closely represents the CI’s pain prior to and as a result of the two nerve resections, warrants a 10% rating since the condition post resections is equivalent to “severe to complete paralysis” of the ilioinguinal nerve (code 8530-paralysis of the ilioinguinal nerve), albeit VASRD §4.123 (neuritis, cranial or peripheral) indicates the maximum rating is equal to severe, incomplete paralysis, which is not an option for the ilioinguinal nerve.  Therefore, a 10% rating code is more applicable using code 8599-8530 (paralysis of the ilioinguinal nerve-severe to complete).  A 30% rating is not available using a nerve code; however, use of code 7338 does have a 30% rating option, but it is not warranted unless there is a small, postoperative recurrent hernia, or an unoperated irremediable hernia, which is not well supported by truss or readily reducible.  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 inguinal pain condition, coded 8599-8530.  

BOARD FINDINGS:  In the matter of the chronic right inguinal pain condition, the panel recommends a disability rating of 10%, coded 8599-8530 IAW VASRD §4.124a.  There are no other conditions within the panel’s scope of review for consideration.  

The panel recommends the CI’s prior determination be modified as follows, effective the date of medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic Right Inguinal Pain 	8599-8530	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170315, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20180010276, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX

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