RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD1301198
BRANCH OF SERVICE:  Army	BOARD DATE:  20140401
SEPARATION DATE:  20080815

SUMMARY OF CASE:  The available evidence of record indicates this covered individual (CI) was an active duty SPC/E-4 (19D/Cavalry Scout) medically separated for testicular pain.  He initially developed pain in his left testicle during Airborne training in 2006 while wearing a parachute.  During a 2007 deployment, his pain returned after carrying a heavy rucksack.  Conservative treatment offered no relief and the pain could not be adequately rehabilitated to meet the requirements of his Military Occupational Specialty (MOS) or physical fitness standards, so he was issued a permanent P3 profile and referred for a Medical Evaluation Board (MEB).  The left testicular condition, characterized as “left orchalgia”, was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501, along with four other conditions (see rating chart below) for PEB adjudication.  The PEB adjudicated “chronic left testicular pain” as unfitting, rated 10%, citing criteria of the VA Schedule for Rating Disabilities (VASRD).  The remaining conditions were determined to be not unfitting.

CI CONTENTION:  The CI attached a single page statement to his application which is quoted in its entirety: “In response to your inquiry, regarding my disability rating, I submit that no changes should be made.  I am rated at 50 percent for PTSD, and although I seek continued treatment, I still struggle with the affects this has on my life, daily activities, and personal relationships.  I am rated 10 percent for chronic left groin and testicular pain syndrome.  This very painful condition has not subsided in any way.  Performing normal daily activities such as, mowing, playing with my son, and even standing to wash dishes are still almost impossible.
As for the Tinnitus, hearing loss, and Restless Leg Syndrome, these conditions have also not
yielded any relief and present difficulties with normal daily function and personal interactions.
I hope with continued treatment I can be afforded some relief from these conditions, however as of this point I am still plagued by the injuries and illnesses I suffered as a result of my service.
Please feel free to contact me if you have any other questions or concerns regarding this matter.” [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.  In addition, the CI was notified by the Army that his case may eligible for review of the military disability evaluation of any mental health (MH) condition in accordance with Secretary of Defense directive for a comprehensive review of cases referred to a disability evaluation process between 11 September 2001 and 30 April 2012 in which MH diagnoses were changed or eliminated during the process.  Since the CI responded to this mailing, it is presumed that he elected review of the MH condition.  In accordance with the Secretary of Defense directive, the applicant’s case file was reviewed regarding diagnosis change, fitness determination, and rating of unfitting MH diagnoses in accordance with VASRD §4.129 and §4.130.  The CI is also eligible for review of other conditions evaluated by the PEB.  The rating for the unfitting left testicular condition and any MH conditions are addressed below.  The contended hearing, tinnitus, insomnia, and restless leg syndrome (RLS) are also in scope and are likewise addressed below.  No additional conditions are 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 Board for Correction of Military Records.  

RATING COMPARISON:

Service PEB – Dated 20080430	VA - (7 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Left Testicular Pain…	8599-8530	10%	Chronic L Groin & Testicular Pain Syndrome…	8599-8530	10%	20090302	
Insomnia	Not Unfitting	Sleep Disorder	6899-6847	NSC		
Restless Leg Syndrome		Restless Leg Syndrome	8799-8721	0%		
Anxiety NOS…		PTSD	9411	50%		
Right High Frequency Hearing Loss		Hearing Loss, Right Ear	6100	0%		
		Tinnitus	6260	10%		
No Additional MEB/PEB Entries	Other x 2		
Combined:  10%	Combined:  60%	
Derived from VA Rating Decision (VARD) dated 20090410.

ANALYSIS SUMMARY:  The Board acknowledges the CI’s information regarding the significant impairment with which his service-connected condition continues to burden him, but must emphasize the Disability Evaluation System (DES) has neither the role nor authority to compensate members for later severity or complications of conditions for which they were medically separated.  That role and authority is granted by Congress to the Department of Veteran Affairs (DVA), which operates under a different set of laws.  The Board considers DVA evidence proximate to separation in arriving at its recommendations, and DoDI 6040.44 defines a 12-month interval for special consideration of post-separation evidence.  Post-separation evidence is probative to the Board’s recommendations only to the extent that it reasonably reflects the disability at the time of separation.

Chronic Left Testicular Condition.  The CI developed left testicular pain while wearing a parachute in 2006 which progressed in intensity and constant duration, thus prompting a medical evacuation from the deployed theater in July 2007.  Multiple scrotal ultrasounds revealed bilateral (left > right) epididymal benign cysts (a fluid-filled cyst).  An extensive urologic work-up failed to identify a surgically-correctable cause for the pain.  The service treatment record (STR) reflected a pain scale range from 6 to 8 out of 10 in intensity which increased with activity (such as sitting, standing or walking).  A clinical record from 29 August 2007 noted, “His pain affects his appetite, physical activity, concentration, mood, social relationships and sexual function.”  The CI failed all treatment levels in an attempt for complete pain relief to include medication, local and spinal nerve blocks, radio-frequency nerve destruction and surgical exploration.  The surgical exploration was both diagnostic and therapeutic and included a partial excision of the ilioinguinal (groin) nerve.  Eventually, the nerve excision brought a 70% reduction in his pain intensity.  There were no prolonged hospitalizations associated with this condition.

At the narrative summary (NARSUM) exam performed on 28 February 2008 (2 months prior to separation), the CI endorsed left testicular pain on a scale of 7/10 made “markedly worse” with any physical activity.  The examination revealed acute tenderness about the upper back portion of his left testicle, but scrotal swelling and palpable mass were both absent and there was no hernia present.  Urologic laboratory analyses were normal, so his diagnosis was left orchalgia (testicular pain; unknown etiology).  The examiner opined that the CI’s functional status was an inability to function as a soldier or perform the duties of his MOS due to the fact that his only real source for pain control was rest and inactivity.

At the VA Compensation and Pension (C&P) examination performed on 2 March 2009 (6 months after separation), the CI reported having testicular pain with almost any activity.  He endorsed sharp, “kicking in the groin” kind of pain associated with nausea.  Prolonged walking, intercourse and undergarments close to the skin caused pain.  “{He} cannot lift anything without testicular pain.”  The examiner noted the following:

“To get pain relief [the CI} mainly has to curl up in a ball and take medication.  That’s what would happen when in Afghanistan.  He could not perform his duty as a Scout because he had to curl up in a ball to get relief from his pain.  It was felt that this put the other military team members in his unit at risk because he was the team leader.”  

The VA examination reported a well healed, stable scar in the left inguinal area, slight scrotal tissue thickening and extreme tenderness of the left testicle (but not the right) and otherwise normal anatomical findings without evidence of hernia.  There was no comment or assessment of his functional abilities and the diagnosis remained left groin and testicular pain.

The commander’s letter did not identify any specific medical condition, but did indicate the CI’s inability to perform his duties were due to physical restrictions within his profile.  Though the commander was satisfied with his duty performance in a rear detachment, his limitations precluded him from “keeping up with the unit” in forward operations.  There was no commander’s comment regarding a recommendation for continued military service.

The Board directs attention to its rating recommendation based on the above evidence.  Both the PEB and VA assigned a 10% rating coded analogous to 8530 (paralysis of the ilioinguinal nerve) for severe to complete pain (the maximum allowable under this code IAW §4.124a; schedule of ratings, neurological conditions and convulsive disorders).  The Board agreed the evidence supports likely a neuropathic etiology (surgically identified), but also could clinically support code 7525 (epididymo-orchitis, chronic only), so considered evaluating the evidence for a higher rating under this code.  The Board considered both the 10% and 30% under the referenced urinary tract infection code and agreed that the evidence supported the 10% rating analogous to 7525 for use of long-term drug therapy, but does not meet the 30% criteria of “poor renal function or evidence that demonstrated recurrent symptomatic infection requiring drainage or hospitalization greater than two times per year, or continuous intensive management.”  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded there was insufficient cause to recommend a change in the PEB’s 10% adjudication of the left testicular condition.

Contended Psychiatric Condition.  The Board considered the appropriateness of changes in the MH diagnoses, PEB fitness determination and, if unfitting, whether the provisions of VASRD §4.129 were applicable, with a disability rating recommendation in accordance with VASRD §4.130 if appropriate.  The case file was reviewed for evidence of inappropriate changes in diagnosis of the MH condition during processing through the DES.  The available record indicates the diagnosis of anxiety disorder was the only MH diagnosis rendered during processing through the DES, so no MH diagnosis was changed to the applicant’s possible disadvantage.  The Board therefore determined the criteria for the Terms of Reference of the MH Review Project were not met.

The STR is scant on service-related MH documentation.  The evidence indicates the CI deployed to Afghanistan 17 January - 27 July 2007.  The psychiatric NARSUM addendum of 28 February 2008 (7 months post deployment, 6 months prior to separation) noted a prior visit to a MH provider 3 months earlier (in November 2007) for anxiety-type symptoms.  At that time, the CI was “…given Celexa (antidepressant) to address anxiety primarily and Atarax (antihistamine) for sleep.”  Background information noted the CI’s anxiety symptoms began prior to deployment and increased upon returning home.  He described symptoms as “difficult breathing, heavy chest, numbness in arms and legs, and sensitivity to light…occurs 4-6 times per week lasting 20 minutes.”  Since his November 2007 visit, the CI reported, “significant improvements of his anxiety, less irritable, general improvement of symptoms.”  He denied suicidal or homicidal (S/H) ideations or hallucinations.  The examination was normal and mood was not specifically described.  At non-MH clinical encounters, though, his mood was sequentially described as depressed, unchanged, and adequate up through January 2008.  His Global Assessment of Functioning (GAF) was assessed at 70 (connoting ‘mild’ impairment).  There was consideration for one of two possible diagnoses, and the examiner’s comments are excerpted below:

Anxiety d/o (NOS) vs Mood d/o due to general medical condition (GMC) were both considered given issues regarding pre-existing symptoms with worsening following deployment and medical/pain issues.  Anxiety d/o (NOS) seems most appropriate given that mood-related symptoms did not necessarily appear to be solely attributable to his medical/pain issues due to positive response and improvement of his symptoms, his psychiatric condition is not medically disqualifying.

The MEB psychiatrist’s Axis I final diagnosis was anxiety disorder not otherwise specified (NOS), with no differential comments regarding posttraumatic stress disorder (PTSD).  The commander’s statement was absent any comment referencing a MH condition, and the permanent profile remained “S-1” under the P-U-L-H-E-S (Physical capacity/stamina, Upper extremities, Lower extremities, Hearing/ear, Eyes, Psychiatric) classification system.  In April 2008, there were two STR encounters listed, “No issues pertaining to alcohol or depression” and “[The CI] is irritable, but feels this will improve when the pain (referring to testicle pain) is gone.”

At the VA psychiatric C&P evaluation of 17 March 2009 (7 months post-separation), the examiner first noted the CI had no active medical records in the VA system to review, that he was a recipient of the combat action badge per the DD Form 214 and provided reasoning for the present claim.  Specifically, the examiner noted “The [CI] reported that his traditional care expires in May and he is extremely concerned about being able to maintain health care, which is what prompted his filing this claim.”  CI endorsed being “frustrated” with unsuccessful attempts to control his physical pain, inability to play with his kids, and with his spouse contemplating going back in military service.  He reported problems with anger and “major paranoia.”  “…He is always mad, angry, and yelling and finds numbness to emotions.”  He also reported problems with nightmares, hot flashes and flashbacks.  He reported high levels of stress over his “lack of competence, lack of self-esteem, and fears of losing his marriage.”  “He dislikes crowds or people in general.  Prefers to keep by himself and just sits in the corner.”  “He avoids movies and the mall.”  He also described himself as “…on guard and hypervigilant since his return.”  He reported, “…he avoids watching the news because he is aware that it makes his paranoia worse.” His reported deployment experience is excerpted from the VA examination as noted below.

“He indicated experiencing occasional firefight and frequently would knock down doors.  He describes significant conflict within his platoon who was out in the field for 2 or 3 months at a time on the border where there was no water and no air support.  He stated they were truly on their own.” 

The [CI] stated, “I wasn’t like this when I got back,” and further described himself as “self-confident” and believed he was going back to Afghanistan.  His mental status examination revealed thought content that reflected paranoia and perceived persecution with racing thoughts and distorted thinking.  His affect was calm and controlled and speech was normal.  He denied current hallucinations but did note previous hallucinations as a side effect from taking sleep medication.  There was no historical indication of psychiatric hospitalizations.  Psychological testing produced an “invalid profile” and suggested “exaggerated symptom reporting.”  The examiner specifically stated, “The [CI] did not endorse or express symptoms consistent with a depressive d/o”, but rather “…met full criteria for PTSD” and opined the CI “…reports clear onset of symptoms to have occurred during his time in service overseas.”  The Axis I diagnosis was PTSD with a GAF assessed as 45 (connoting between major and serious impairment).  The examiner indicated “total” impairment in social and occupational functionality.

The Board directs attention to its rating recommendation based on the above evidence.  The service found the anxiety disorder as not unfitting and the VA originally assigned a 50% rating coded 9411 (PTSD), which later was changed to 100% under an “unmistakable error” from the original rating decision.  The Board first considered whether the MH condition, regardless of specific diagnosis, was unfitting for continued military service.  The Board’s main charge is to assess the fairness of the PEB’s determination that the MH condition was not unfitting.  The Board’s threshold for countering service fitness determinations is higher than the VASRD §4.3 (reasonable doubt) standard used for its rating recommendations but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  An established principle for fitness determinations is that they are performance based.  The Board is confronted in this case with a wide disparity of examination information as it relates to the severity, type, and onset of MH symptoms.  The two STRs within 4 months of service separation noted no issues with depression, along with anxiety-like symptoms being clearly linked to his physical pain condition.  The Board concluded the above cited evidence supports assigning a higher probative value to the MEB examination and the STR encounters, vice the VA C&P exam, as an accurate reflection of the CI’s condition near the time of Service separation.  The NARSUM clearly noted that the MH symptoms were present prior to deployment as well as after, indicating the CI was “fit” to deploy.  Despite having ‘increased symptoms’ after deployment, it is noted that outpatient treatment provided the CI significant relief.  No MH condition was implicated in the commander’s letter or listed on the permanent profile.  The Board concluded there was insufficient evidence within the STR of objective performance-based criteria that any MH condition was independently unfitting near the time of separation.

Other Contended PEB Conditions.  Similarly, the Board’s main charge regarding these contended conditions is to assess the fairness of the PEB’s determination that the restless leg syndrome, insomnia, tinnitus, and right-sided high frequency hearing loss were not unfitting.

Insomnia and Restless Leg Syndrome:  A sleep study performed in February 2008 as part of a diagnostic work-up to help in the diagnosis of RLS or periodic limb movement disorder and to assess complaints of daytime fatigue.  The CI endorsed the “creepy, crawly” feeling as well as pain in his legs, all the time.  The study revealed no periodic leg movements and noted that neurologic sleep patterns may be related to the CI’s current use of medication as reasoning for fatigue.  Neither of these conditions was part of the commander’s letter nor profiled.

Right-sided High Frequency Hearing Loss and Tinnitus:  A screening audiogram on 14 January 2008 indicated a significant threshold shift in the CI’s right hear as compared to baseline hearing from September 2006.  He endorsed decreased hearing on the right following loud weapons exposure and constant tinnitus (ringing in the ear) on the right.  Radiology studies of the brain and internal auditory canals were normal.  A follow-up pure tone audiogram performed on 27 February 2008 revealed normalization (20 decibels or less) of his hearing in all speech-related frequencies.  Speech discrimination tests revealed excellent word recognition and tympanometry indicated normal eardrum mobility.   There is no link to fitness in the available evidence for either condition.

These conditions were judged to be within military standards, were not a cause of any limitations or profiled restrictions, and were not identified as causing impairments in the commander’s letter.  All were reviewed by the action officer and considered by the Board.  There was no performance-based evidence in the record any of these conditions significantly interfered with satisfactory duty performance.  After due deliberation in consideration of the preponderance of the evidence, the Board concluded there was insufficient cause to recommend a change in the PEB fitness determination for any of the contended conditions, so no additional disability ratings are recommended.

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 surmised from the record or PEB ruling that no prerogatives outside the VASRD were exercised.  In the matter of the chronic left testicular pain condition and IAW VASRD §4.124a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended anxiety disorder/PTSD, RLS, insomnia and right-sided high frequency hearing loss conditions, the Board unanimously recommends no change from the PEB determinations as not unfitting.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  The Board recommends no recharacterization of disability and separation determination.

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20130905, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

				
XXXXXXXXXXXXXXXXXX, DAF
President
Physical Disability Board of Review

SAMR-RB									
MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXXX, AR20140013581 (PD201301198)

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						     XXXXXXXXXXXXXXXXXX
						     Deputy Assistant Secretary
						         (Army Review Boards)

CF: 
(  ) DoD PDBR
(  ) DVA