MEMORANDUM FOR THE DIRECTOR, AIR FORCE REVIEW BOARDS AGENCY

SUBJECT:  Physical Disability Board of Review Recommendation on XXXXXXXXXXXXX
	Case Number PD-2017-06150 

	In accordance with Title 10 § 1554a and in compliance with DoDI 6040.44, the Physical Disability Board of Review (PDBR) adjudicated the disability rating accompanying the medical separation of the covered individual from the United States Air Force.  After carefully reviewing the application and medical separation case file, the PDBR recommended modification of the disability rating previously assigned to reflect a combined rating of 20% rather than 10%, without re-characterization of the separation.

I have reviewed the application and Record of Proceedings and I recommend you accept this proposed decision.

	Sincerely,

RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX 	CASE:  PD-2017-06150
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20050314

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Manned Aerospace Maintenance F-16 Avionic Systems Journeyman, medically separated for “right groin/back pain associated with depression” with a disability rating of 10%. 

CI CONTENTION:  “I was rated 10% for my back but 100% for depression/anxiety and paranoia by the VA.”  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 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 - 20050121	VARD - 20050616	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Groin/Back Pain Associated with Depression	

8730	

10%	Dysthymic Disorder, Adjustment Disorder with Anxiety and Depression	9433	100%	20050412	
			Disc Protrusion (L5-S1) Lumbar Spine	5242	10%	STR	
			Bilateral Epididymitis (Claimed as ... Right Groin Nerve Damage/Pain)	7525	0%	STR	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  100%	

ANALYSIS SUMMARY:  

Right Groin/Back Pain Associated with Depression.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI first presented with a complaint of right testicular pain in June 2003.  The initial evaluation, including a testicular ultrasound, failed to confirm an etiology, but the working diagnosis was epididymitis.  A confusing array of symptoms followed, which included alternating left and right flank pain that was temporally associated with bilateral kidney stones.  Serial imaging demonstrated transient mild obstruction on the left, although the concurrent complaint was lateralized to the right.  Intermittent right flank pain persisted after resolution of the stones on follow-up imaging.  Subsequently, the CI complained of persistent pain that was variably localized on the right side to the low back, groin, hip, and pelvic areas.  The symptoms waxed and waned, but did not resolve with multiple medication trials and other treatment modalities.  Comprehensive work-ups with specialty consultations failed to identify any pathology except for a lumbar MRI in December 2003 that revealed mild degenerative disc disease with protrusion at L5/S1, but no nerve root impingement. A week after the MRI, the CI began to complain of intermittent right lower extremity (RLE) pain radiation, diffuse sensory complaints, and subjective weakness with reports of giving way and falls.  Multiple motor and reflex examinations of both lower extremities was normal as was sensory testing, except for sporadic deficits that were inconsistent and non-dermatomal.  Electro-diagnostic testing of the RLE was normal (left not tested), and neurosurgery/neurology consultants opined that there was no objective evidence of a spinal radiculopathy or peripheral neuropathy.  Urology and general surgery consultants found no etiology related to their specialties, and the CI’s primary care physician speculated that there might still be an occult neuralgia of the inguinal or pudendal nerve.

The physical findings documented in multiple STR provider notes were variable, and there was a general paucity of objective findings.  There was no documentation of any range of motion (ROM) limitation of the joints or spine except for a neurosurgery note on 19 July 2004 that stated, “Back [ROM] is slightly decreased in forward flexion.”  Painful motion of the lumbar spine was implied in some treatment notes, although it was not specifically addressed or labeled as such.  There was STR evidence of a normal gait and spinal contour, except for a transient period of a mildly antalgic gait with expressed uncertainty in provider notes as to whether it was genuine.  There was no record of incapacitating episodes.

With regard to associated mental health (MH) symptoms, there was no documentation of any issues until an initial voluntary presentation to behavioral health in April 2004, 10 months before separation.  At a preventative health assessment in August 2003, the CI had specifically denied depression, anxiety or other MH symptoms, although he did acknowledge work and domestic stressors.  The reported symptoms at the initial and subsequent MH evaluations were not in evidence, but the Axis I diagnosis remained “major depressive disorder, single episode, moderate,” and there was an Axis III listing of multiple medical conditions (most related to above).  There was no recorded mental status examination (MSE) or Global Assessment of Functioning (GAF) score, and no STR evidence for suicidal ideation or other acute features or psychiatric hospitalizations.  There were no treatment entries that documented any mental status or cognitive abnormalities, active MH symptoms (except for occasional mention of depression), or behavioral issues.
	
There was a total of three MH evaluations in the STR, but there was no psychiatric addendum to the NARSUM in evidence.  The MH entries documented a trial of an antidepressant (Zoloft) that was discontinued due to lack of results and side effects.  A trial of a different antidepressant (Lexapro) was recommended in lieu of Zoloft, but there was no evidence that it was ever taken.  The final MH note on 6 January 2005, 2 months before separation, recommended a trial of Cymbalta (for both neuropathic pain and depression), and the provider released the CI from psychiatric care.  He had been on a temporary S4 profile from the second visit, and a permanent S3 was recommended on the final visit.  The final permanent profile issued 2 weeks later, however, designated an S1 profile without note of weapons restriction or geographic limitations.  The 2 December 2004 commander’s performance statement addressed only the CI’s “medical condition,” noting that it restricted him from performing all tasks but that he was still performing within his specialty.  There was no indication from the commander of unsatisfactory performance or of any MH issues or diagnoses.

The 30 November 2004 MEB NARSUM examination, 3 months prior to separation, detailed the above history of complaints and clinical evolution, but did not elaborate on current symptoms or pain severity.  Functional limitations were also not specified, but the profile recommended administrative duties only and prohibited running, lifting, and some fitness testing events.  The physical examination recorded normal abdominal and musculoskeletal findings, neurological testing, and gait, with no note of tenderness, spasm, or joint/spine ROM limitation.  The NARSUM examiner (the CI’s primary care physician) listed diagnoses of “chronic pain syndrome,” “major depressive episode,” and “bilateral nephrolithiasis.”  

The CI underwent a mental disorders Compensation and Pension (C&P) examination on 12 April 2005, a month after separation.  The VA psychologist noted that there was no active treatment for a MH disease, although the CI remained on Cymbalta (the only psychoactive medication).  The examiner listed numerous somatic complaints related to the above, and additional conditions outside the panel’s scope of review; but, the only MH-related complaints specified were “chronic, but relatively mild” depression, insomnia improved with pain medication, “emotional unavailability,” “low motivation”, and “poor concentration and short term memory.”  The presence of marital stressors and difficulty with civilian adjustment were also noted.  The MSE was positive for an “anxious” mood, “blunted” affect, and “minimal” insight, but no suicidal/homicidal ideation or other acute features.  The Axis I diagnoses were “dysthymic disorder,” “adjustment disorder with anxiety and depression,” and “somatization disorder.”  Axis III listed “multiple somatic symptoms and multiple pain symptoms.”  The GAF assignment was 35 (major impairment in multiple areas), stating that the CI’s “combined diagnoses have affected his functioning in numerous areas.”  Occupational-specific limitations were not elaborated.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB combined the right groin pain, back pain, and the associated depression as a single unfitting condition rated 10%, coded 8730 (neuralgia, ilio-inguinal nerve), referencing Department of Defense and Veterans Administration Schedule for Rating Disabilities (VASRD) guidelines.  The VA rated the lumbar condition, right groin pain, and MH condition separately, based on the STR evidence for the lumbar and groin conditions, and on the post-separation C&P for the MH condition.  The lumbar condition was rated 10%, coded 5242 (degenerative arthritis of the spine), citing the applicable VASRD §4.71a spine criterion (thoracolumbar flexion greater than 60 degrees but not greater than 85 degrees).  The right groin condition was rated 0% as a component of epididymitis under code 7525 (epididymo-orchitis), citing a failure to satisfy the VASRD §4.115b minimum 10% criteria of long term drug therapy, hospitalizations, and intensive management.  The MH condition was rated 100% under code 9433 (dysthymic disorder), citing the applicable VASRD §4.130 criteria for “total occupational and social impairment” referencing the C&P examiner’s opinion.

Panel members first considered the right groin and lumbar conditions.  As the evidence makes clear, there was a significant overlap, if not actual merger, of these two complaints.  The functional limitations could not be separated, although separate VASRD rating criteria could be distinguished without violation of VASRD §4.14 (avoidance of pyramiding).  It could conversely be argued that all of the physical symptoms were primarily a manifestation of a single unfitting MH condition, with only the latter being subject to rating.  The panel does not have the authority, however, to substitute a speculative hypothesis such as this for the PEB adjudication, since there was no service diagnosis or opinion to that effect before the PEB. With regard to the right groin and lumbar conditions, there were distinguishable pain complaints for both the right groin/pelvis/hip and the back.  The two complaints were not always concurrent, or characterized as the same pain with radiation.  There was also a possible distinct and separate etiology (disc disease) for the lumbar component. The RLE complaints could be associated with either condition, and panel members agreed that the RLE component could not be justified as separately unfitting in itself, given the lack of evidence for any objective impairment.  Although separate clinical features of the right groin and lumbar conditions could be distinguished, undue speculation would be required to assign unfitting functional limitations to one that would not be equally applicable to the other.  Therefore separate fitness implications were not discernible, and the panel ultimately agreed that it was fair to concede that the right groin and lumbar conditions were reasonably justified as separately unfitting.  

Having so concluded, the panel turned to deliberation of the appropriate rating recommendation for each condition.  Since no certain etiology was identified for the groin pain, there was no clinical foundation for any specific VASRD code, therefore any code would essentially be analogously applied.  Since pain (and possibly the RLE neurological symptoms) was the only manifestation, a VASRD §4.124a neuralgia code was the logical choice.  There were no alternative analogous codes under other VASRD systems that were applicable and favorable.  Given the neurological evidence (including normal EMG) that there was no more distal (and higher rated) nerve involved, panel members agreed that the ilio-inguinal nerve (code 8730) as applied for the combined rating by the PEB was appropriate.  The maximum rating under that code is 10% for severe impairment.  After due deliberation, considering all the evidence and conceding VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the right groin pain, coded 8799-8730. 

The panel then deliberated the appropriate rating recommendation for the lumbar condition.  It was subject to rating under separate VASRD spine criteria, and panel members agreed that it could not be more favorably coded.  There was no specific ROM evidence, but it was reasonably conceded that the flexion and combined ROM were not completely normal as would be requisite for a 0% rating.  Furthermore reasonable doubt favored concession of painful motion in support of a minimum 10% rating IAW VASRD §4.59.  The panel agreed that it was more likely present than not, and, although not specifically addressed, it was not refuted by the available service evidence.  There was insufficient evidence for an abnormal gait and no evidence for abnormal spinal contour to support a 20% rating.  There was no documentation of incapacitating episodes which would provide for a higher rating under that formula.  After due deliberation, considering all the evidence and with deference to reasonable doubt, the panel recommends a disability rating of 10% for the lumbar condition, coded 5242.  

The panel next deliberated whether the MH condition was reasonably justified as separately unfitting for additional service rating.  With regard to the psychiatric severity, members agreed that there was a significant disparity between the findings and opinions in the post-separation VA C&P examination and that reflected by the service evidence.  Although there were certainly psychiatric symptoms, and logically some associated impairment, in evidence at separation, the panel’s fitness assessment must be premised on performance-based service evidence.  Panel members ultimately agreed that the latter was insufficient to support a conclusion that the psychiatric symptoms alone (divested from the Axis III conditions rated as above, or outside the scope of review) would have rendered the CI unfit for his specialty duties.  Although a P3 profile was recommended, and may not have been implemented due to an oversight (speculative), there were no profile restrictions imposed other than those for the physical limitations.  Both the profile and the commander’s statement indicated that the CI was fully capable of his administrative duties, and it may be reasonably surmised that any significant psychiatric functional impairment would have been captured in the commander’s statement and/or multiple provider notes.  The panel therefore agreed that the preponderance of evidence indicated that the CI’s depression (or other mood or adjustment disorder) would not have caused him to be referred into the DES and found unfit.

BOARD FINDINGS:  In the matter of the PEB-combined right groin, lumbar, and associated depression conditions, the panel recommends that it be re-adjudicated for separate conditions as follows: an unfitting right groin condition coded 8799-8730 with a disability rating of 10% IAW VASRD §4.124a; an unfitting lumbar condition coded 5242 with a disability rating of 10% IAW VASRD §4.71a; and, a depressive disorder determined to be not unfitting and not subject to service 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	
Chronic Right Groin Pain of Uncertain Etiology	8799-8730	10% 	
Chronic Back Pain of Uncertain Etiology	5242	10%	
Depressive Disorder 	Not Unfitting	
COMBINED	20%