RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX 	CASE:  PD-2017-02348
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20061130

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E2, Basic Airman trainee, medically separated for “persistent perineal pain status post [s/p] external hemorrhoidectomy and gluteal abscess” with a disability rating of 0%.   

CI CONTENTION:  The condition, and residuals experienced during active duty, should have resulted in a higher rating.  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 Medical Evaluation Board (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 - 20061122	VARD - 20070508	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Persistent Perineal Pain, S/P External Hemorrhoidectomy and Gluteal Abscess	8599-8530	0%	S/P Hemorrhoidectomy with Left Gluteal Abscess and Scar	7804	10%	20070110	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Persistent Perineal Pain, S/P External Hemorrhoidectomy and Gluteal Abscess.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI underwent an uncomplicated hemorrhoidectomy of the external hemorrhoids on 1 September 2006.  The CI continued to have persistent perianal pain.  A 12 October 2006 CT scan with contrast, of the abdomen and pelvis, demonstrated thickening of the rectal wall with inflammatory changes adjacent to the rectum, and with abscess identified.  On 6 September 2006, he reported extreme pain 10/10 and difficulty standing.  On 15 September 2006, the CI had a colon-rectal surgical consultation, which noted on examination that the CI had minimal rectal erythema, some granulating tissue, and no purulent drainage consistent with a normal postoperative examination.  The surgeon recommended convalescent leave.  

In the emergency room (ER) on 15 September 2006, the CI reported increased rectal pain after walking.  Treatment was with morphine.  On 18 September 2006, the operative site was healing well.  After convalescent leave, a left gluteal abscess was noted, which was incised and drained on 5 October 2006.  Thereafter, he had packing and dressing changes with evidence of slow healing.  By 16 October 2006, the abscess was resolving and the packing changes were discontinued.  On 20 October 2006, the CI was seen in the ER with rectal pain.  The operative sites were healing well and treatment consisted of a stool softener.  The 7 November 2006 MEB NARSUM examination, less than one month prior to separation, noted the complaint of persistent perianal pain.  

At the 10 January 2007 VA Compensation and Pension (C&P) examination, one month after separation, the CI reported significant pain with any substantial bowel movement.  He was using Motrin (ibuprofen, a nonsteroidal anti-inflammatory drug) for pain along with docusate and Tucks pads.  Narcotic pain medications caused constipation and were not being used.  Physical examination showed a scar on the left buttock adjacent to the anal sphincter with pain on palpation and adherence to underlying tissue.  The CI deferred examination of the internal anus.  There was no evidence of fecal leakages and the size of the lumen at the sphincter appeared normal.  There were no fissures, no external hemorrhoids and no evidence of bleeding.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the persistent perineal pain s/p hemorrhoidectomy and gluteal abscess 0%, analogously coded 8599-8530 (ilioinguinal nerve paralysis: mild or moderate).  The VA rated the s/p hemorrhoidectomy with left gluteal abscess 10%, coded 7804 (scar(s) unstable or painful), based on the C&P examination, citing “superficial scar that is painful on examination.”

The panel noted the PEB rated the CI’s condition using an analogous code for the ilioinguinal nerve.  However, that nerve does not innervate the perianal area or the anal sphincter, both of which are innervated by the inferior anal [or rectal, or hemorrhoidal] nerve, a branch of the pudendal nerve which is derived from the sacral nerve roots S2, S3, and S4 of the sacral plexus.  Therefore, use of an analogous code 8599-8620 (sciatic nerve neuritis) IAW VASRD §4.123 (neuritis, cranial or peripheral) is reasonable and a mild disability warrants a 10% rating, whereas a moderate disability merits a 20% rating.  Because the CI had pain, but did not have sphincter abnormalities or soiling, a moderately severe disability rating is precluded.  Since the CI’s pain was predominantly in the anal area innervated by the inferior anal nerve and there was no indication that the sciatic nerve nor the pudendal nerve per se were injured, a 10% rating, and no higher, is reasonable.  

The panel then considered whether code 7336 (hemorrhoids, external or internal) offered a higher rating.  Mild or moderate hemorrhoids warranted a 0% rating, while large or thrombotic, irreducible, with excessive redundant tissue, evidencing frequent recurrences provides a 10% rating, and persistent bleeding with secondary anemia, or with fissures provides a 20% rating.  However, at examinations proximate to separation, there was no evidence of external hemorrhoids, large or thrombotic hemorrhoids or persistent bleeding with secondary bleeding or with fissures.  No NARSUM examination was available to answer whether there were internal hemorrhoids and the CI deferred examination of the anus internally.  Therefore, use of code 7336 does not afford a rating higher than 0%.  Code 7333 (rectum and anus, stricture) requires moderate reduction of lumen, or moderate constant leakage, neither of which were documented in the STR or at the C&P examination and there was no evidence of impairment of sphincter control of either the rectum or anus (code 7332) to offer a higher rating.  However, although the colon-rectal surgeon indicated the etiology of the pain was unclear, nevertheless, at the VA C&P examination the CI had a painful scar adjacent to the anal sphincter.  Therefore, use of code 7804 does support a 10% rating.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the persistent perianal pain, dual-coded 7366-7804.  

BOARD FINDINGS:  In the matter of the persistent perianal pain, the panel recommends a disability rating of 10%, coded 7366-7804 IAW VASRD §§4.114 and 4.118.  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	
Persistent Perianal Pain	7366-7804	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170228, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

SAF/MRB
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD 20762

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

		Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2017-02348.

After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was not appropriate under the guidelines of the Veterans Affairs Schedule for Rating Disabilities.  Accordingly, the Board recommended modification of your assigned disability rating without re-characterization of your separation with severance pay. 

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding, accept their recommendation and direct that your records be corrected as set forth in the attached copy of a Memorandum for the Chief of Staff, United States Air Force.  This will not result in any change to your separation documents or the amount of severance pay you are entitled to.  Disability severance pay is computed the same regardless of a rating of 0, 10 or 20 percent.

						Sincerely,

		

								

Attachments:
1.  Directive 
2.  Record of Proceedings