RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW NAME: XXXXXXXXXXXXXXXXXXX CASE: PD1200680 BRANCH OF SERVICE: ARMY BOARD DATE: 20130403 SEPARATION DATE: 20030819 SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SGT/E-5 (19D/Calvary Scout) medically separated for chronic bilateral groin pain. The CI had recurrent episodes of bilateral inguinal adenopathy. He underwent an extensive workup and multiple studies ruled out infectious or inflammatory etiology. The groin pain could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS). He was issued a permanent P3 profile and referred for a Medical Evaluation Board (MEB). The groin condition, characterized as “idiopathic inguinal lymphadenopathy,” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. No other conditions were submitted by the MEB. The PEB adjudicated the chronic bilateral groin pain as unfitting, rated 0% citing criteria of the US Army Physical Disability Agency (USAPDA) pain policy. The CI made no appeals, and was medically separated a 0% disability rating. CI CONTENTION: “feeling like people are shooting at me feelings the bullets but seeing no blood. Please help me! Problems has gotten a lot worse unable to work PTSD” [sic] SCOPE OF REVIEW: The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e. (2). It is limited to those conditions determined by the PEB to be unfitting for continued military service and those conditions identified but not determined to be unfitting by the PEB when specifically requested by the CI. The rating for the unfitting bilateral groin condition is addressed below; and, no additional conditions are within the DoDI 6040.44 defined purview of the Board. The contended posttraumatic stress disorder (PTSD) condition was not identified by the MEB or PEB and thus is not within the DoDI 6040.44 defined purview of the Board. Any conditions or contention not requested in this application, or otherwise outside the Board’s defined scope of review, remain eligible for future consideration by the respective Army Board for Correction of Military Records. RATING COMPARISON: Service PEB – Dated 20030617 VA - (5 Mos. Post-Separation) Condition Code Rating Condition Code Rating Exam Bilateral Groin Pain 5099-5003 0% Idiopathic Inguinal Lymphadenopathy 7799-7710 0% 20040113 No Additional MEB/PEB Entries Other x 11 20040113 20040106 Combined: 0% Combined: 40% ANALYSIS SUMMARY: The Board acknowledges the CI's contention suggesting that ratings should have been conferred for other conditions documented at the time of separation and for conditions not diagnosed while in the service (but later determined to be service-connected by the VA). While the Disability Evaluation System considers all of the member's medical conditions, compensation can only be offered for those medical conditions that cut short a member’s career, and then only to the degree of severity present at the time of final disposition. The Department of Veterans Affairs, however, is empowered to compensate all service-connected conditions and to periodically re-evaluate said conditions for the purpose of adjusting the veteran’s disability rating should the degree of impairment vary over time. Bilateral Groin Pain. The CI sought care for a 4 to 5 year history of recurrent bilateral inguinal pain associated with adenopathy that worsened with any strenuous activity. He underwent an exhaustive evaluation from 1997-2000 by multiple specialists to include infectious disease, allergy immunology, internal medicine, pain management, general surgery, and gastroenterology. These evaluations included physical exams, special laboratory and radiographic studies and even biopsies of the right axilla and right inguinal lymph nodes. The biopsies revealed nonspecific changes and lymphoma was not identified. The remainder of the studies did not identify a clear cause for his symptoms, to include an infectious, inflammatory, gastrointestinal, or vaccine etiology. In April 2000 he was issued a permanent profile for adenopathy and fevers of unknown origin with the following limitations, run at own pace and distance, march up to two miles, and no jumping activities. He could do unlimited walking, biking, and swimming, push-ups and sit-ups and any of the alternate events for the Army Physical Fitness Tests (APFT). The profile further recommended a MOS/Medical Review Board (MMRB). The service treatment record documented that CI returned back to his unit in Germany from his evaluations at WRAMC in April 2000 and that his unit would be recommending an MMRB. The CI however left the service in May 2001 and reenlisted in November 2001. The July 2001 reenlistment physical exam form did not document any adenopathy. In July 2002 he began experiencing the same symptoms. This led to more evaluations for which no cause was identified. Another permanent profile was written in March 2003 which was the same as before but additionally added able to lift up to 25 pounds and recommended an MMRB. The commander’s statement corroborated the medical condition, limitations and further documented, while he was non deployable he could do routine garrison duties and was a quality NCO. There were two APFTs in evidence, one in 2000 and one in May 2002, both of which reflected the maximum passing score of 300 in spite of his ongoing symptomatology. The MMRB convened March 2003 and recommended a MEB. The MEB physical exam focused on the genitourinary and inguinal regions. The exam demonstrated no hernias or swollen lymph nodes, bilateral tenderness at the inguinal ring and otherwise normal genitourinary male findings. At the VA Compensation and Pension (C&P) exam performed 5 months after separation, the CI additionally reported 3 months after receiving the anthrax vaccine and after his return from the war in the Balkan Mountains he developed intermittent fevers, night sweats, frontal headaches, pain in the joints (knees, wrists, back and shoulders), muscular pain, atypical chest pain, abdominal pain, nausea and diarrhea with weight loss of 10 pounds. He was evaluated and found to have multiple painful lymph nodes and otherwise his extensive workup did not reveal an etiology for his symptoms. The C&P exam demonstrated the inguinal regions revealed "shotty" palpable inguinal lymph nodes and proximal femoral lymph nodes. The most painful on the right and left measured approximately 0.5 cm diameter with pain radiating into the right and left testicle respectively. The examiner documented the CI had an undiagnosed illness which had resulted in the symptoms referenced and opined as likely as not secondary to anthrax injections. In support of this opinion he referenced “the dictation by Dr. xxxxx citing an article in the Journal of the American Medical Association of December 8th, 1999, describing post anthrax immunization syndrome.” The Board directs attention to its rating recommendation based on the above evidence. The PEB and VA chose different coding options for the condition, but this did not bear on rating. The PEB’s DA Form 199 reflected application of the USAPDA pain policy for rating, and its coding choice, 5003 (arthritis, degenerative) was inconsistent with the pain pathology in this case. The Board discussed likely his bilateral groin pain was due to systemic lymph node adenitis, inflammation of the lymph node without a clear etiology. The VA assigned a 0% rating coded analogous to 7710 (Adenitis, non-pulmonary tuberculous) which is IAW VASRD §4.88c which states “rate residuals under the specific body system or systems affected. The Board considered the VA’s chosen code and agreed this diagnostic code is the most clinically appropriate code as the disability is not specifically listed in the rating schedule, but the anatomical localization and symptoms, are closely related.” There is no evidence of documentation of incapacitating episodes or ratable peripheral nerve impairment which would provide for additional or higher rating. The Board prefers the 7799-7710 coding route as this clinically captures the bilateral groin adenitis pathology even though rating is unaffected. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB rating adjudication for the bilateral groin condition. BOARD FINDINGS: IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication. The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised. As discussed above, PEB reliance on the USAPDA pain policy for rating the bilateral groin pain was operant in this case and the condition was adjudicated independently of that policy by the Board. In the matter of bilateral groin pain condition and IAW VASRD §4.88c, the Board unanimously recommends no change in the PEB rating of 0% but a change in VASRD code to 7799-7710. There were no other conditions within the Board’s scope of review for consideration. RECOMMENDATION: The Board recommends that the CI’s prior VASRD code be modified as follows, effective as of the date of his prior medical separation: UNFITTING CONDITION VASRD CODE RATING Bilateral Groin Pain 7799-7710 0% RATING 0% The following documentary evidence was considered: Exhibit A. DD Form 294, dated 20120605, w/atchs Exhibit B. Service Treatment Record Exhibit C. Department of Veterans’ Affairs Treatment Record xxxxxxxxxxxxxxxxxxxxxxx, DAF Director of Operations Physical Disability Board of Review SFMR-RB MEMORANDUM FOR Commander, US Army Physical Disability Agency (TAPD-ZB / xxxxxxxxxxxxxx), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557 SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for xxxxxxxxxxxxxxxxxxxxxxx, AR20130009622 (PD201200680) I have reviewed the enclosed Department of Defense Physical Disability Board of Review (DoD PDBR) recommendation and record of proceedings pertaining to the subject individual. Under the authority of Title 10, United States Code, section 1554a, I accept the Board’s recommendation and hereby deny the individual’s application. This decision is final. The individual concerned, counsel (if any), and any Members of Congress who have shown interest in this application have been notified of this decision by mail. BY ORDER OF THE SECRETARY OF THE ARMY: Encl xxxxxxxxxxxxxxxxxxxxx Deputy Assistant Secretary (Army Review Boards)