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AF | PDBR | CY2012 | PD2012 01859
Original file (PD2012 01859.rtf) Auto-classification: Approved
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:    CASE: PD1201859
BRANCH OF SERVICE: Army  BOARD DATE: 20130516
SEPARATION DATE: 20061211


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SFC/E-7 (18E/Special Forces Communications NCO) medically separated for testicular pain and migraine headaches. The migraine condition began in 1994, and persisted with regularity. He developed post-vasectomy testicular pain in 1998, which worsened in 2004 during parachute training. Neither condition responded adequately to treatment to permit adequate performance of his Military Occupational Specialty (MOS) or meet physical fitness standards. He was issued a permanent P3/L3 profile and referred for a Medical Evaluation Board (MEB). Chronic bilateral testalgia; classical migraine with aura; right foot pain and right fourth finger digital cyst were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. The PEB adjudicated the testicular pain and migraine headache conditions as unfitting, rating each 0%, with application of the Veterans Affairs Schedule for Rating Disabilities (VASRD). The remaining conditions were determined to be not unfitting. The CI made no appeals and was medically separated.


CI CONTENTION: The application states: “Army Rating: 0% VA Rating: 50%.” The CI does not elaborate further or specify a request for Board consideration of any additional conditions.


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 ratings for the unfitting conditions are addressed below. The not unfitting right foot and finger conditions were encompassed within the combined VA rating cited in the application; the Board members agreed that these conditions were also within its purview. 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. The Board acknowledges the CI’s contention that suggests a higher rating should have been granted on the unfitting medical condition documented at the time of separation. IAW DoDI 6040.44, the Board’s authority is limited to making recommendations on correcting disability determinations. The Board’s role is thus confined to the review of medical records and all evidence at hand to assess the fairness of PEB rating determinations, compared to VASRD standards, based on ratable severity at the time of separation; and, to review those fitness determinations within its scope (as elaborated above) consistent with performance-based criteria in evidence at separation.



RATING COMPARISON:

Service PEB – Dated 20060912
 VA* - (1 Mo. Pre-Separation) VARD 20070326
Condition
 Code Rating Condition Code Rating Exam
Testicular Pain…
 8799-8730 0% Bilateral Testicular Pain 7599-7525 NSC** 20061107
Residual Scar S/P Vasectomy 7804 10% 20061107
Migraine Headaches…
 8100 0% Migraines 8100 0% 20061107
R Foot Pain…
 Not Unfitting S/P R Foot Internal Fixation... 5284-7804 10% 20061107
R 4th Finger Digital Cyst…
 Not Unfitting R Fourth Finger Cyst (Dominant) 7819 0% 20061107
No Additional MEB/PEB Entries
 Other x 5 20061107
Combined: 0%
 Combined: 50%
* Derived from VA Rating Decision, dated 20070326 (most proximate to date of separation)
* * 10% rating for Residual Scar S/P Vasectomy


ANALYSIS SUMMARY:

Testicular Pain Condition. The CI had elective sterilization (vasectomy) in 1998. He initially presented on 15 November 2004 with a 2-3 day history of bilateral testicular ‘cysts’ which were tender. An ultrasound performed on that same day was normal. The CI was to return to the clinic the next day; however, there was no follow-up in evidence until 9 April 2006 when he presented to the emergency room with a 2 day history of pain. An ultrasound performed that day revealed that the left testicle was “slightly larger” than the right. There was no active torsion of the left testicle; however, “intermittent torsion is not completely excluded.” The right testicle had microlithiasis (microcalcifications) present, which are typically are benign. There were small hydroceles in both testicles. The CI was referred to urology and evaluated on 11 April 2006 for a MEB consultation. The CI reported having bilateral scrotal/testicular pain since his vasectomy in 1998 which had acutely worsened over the previous few days. He stated at the MEB narrative summary (NARSUM) that his symptoms had worsened after free fall parachute training in 2004. He did note that the symptoms were worse after sexual intercourse and “work-related responsibilities.” The examination revealed no tenderness to palpation (TTP) bilaterally; however, there was a resolving ecchymosis originating near the external ring of the scrotum. The cremasteric reflexes were intact and there was evidence of Grade 1-2 bilateral varicoceles (left greater than the right). Both varicoceles reduced on examination. Bilateral vas granulomas were “exquisitely tender” with no appreciable scrotal swelling. A urinalysis was normal. The urologist diagnosed the condition “bilateral testalgia with scrotal ecchymosis of uncertain etiology (possible varicocele leak).” The urologist discussed treatment options with the CI, to include exploratory surgery with a possible epididymectomy or vasectomy reversal and treatment of the varicoceles (felt to be a benign finding) versus continued medical management. The CI wished to continue medical management, at that time. The CI was seen in the clinic requesting a refill of Percocet (a narcotic analgesic) about 2 weeks following the urology consultation. He was given the refill and told to follow up with urology. On 9 June 2006, he was seen in physical medicine for foot pain and also reported his testicular pain. The physical medicine doctor discussed the possibility of chronic epididymitis and recommended that the CI have sequential prostate massage for culture to rule that in or out. The CI expressed the desire to see a civilian urologist. The MEB NARSUM, dictated on 25 July 2006, 5 months prior to separation, noted that the CI was in good health following his vasectomy in 1998 and did not seek treatment for testicular pain until 2004. The NARSUM reported that a review of the service treatment record (STR) revealed a 3 day episode of scrotal pain in November 2004 and a sick call note in April 2006. The MEB examination performed on 1 June 2006 revealed ecchymosis on left side of the scrotum, TTP of scrotum on both sides, and a left varicocele. The NARSUM reported that the CI’s pain was 4 out of 10 that worsened with running, jumping, heavy lifting, and sexual intercourse. The pain improved with rest, ice, and analgesic medication. The examiner noted that surgical intervention was an option that could be considered in the future. The commander’s performance statement 7 June 2006, reported that the CI complained of testicular pain and tenderness over the past two years, almost daily. The pain limited the CI’s ability to perform his duties as a Special Forces soldier. The commander strongly recommended that the CI be separated from the military.

The VA Compensation and Pension (C&P) exam performed on 7 November 2006, a month prior to separation, reported that the CI was suffering from bilateral testicular pain that started in 1998. The CI reported urinating eight times day or about every 3 hours. He denied urinating frequently at night or urinary incontinence. The CI denied suffering from impotence. The CI reported that the pain limited his ability to run, jump, or ride a bicycle. The genital examination was normal, noting bilateral scars on the scrotum. The examination of the skin detailed that the scars measured about 1.5 cm by 0.2 cm and that there was “tenderness and disfigurement” present. The examiner reported “no ulceration, adherence, instability, tissue loss, keloid formation, hypopigmentation, hyperpigmentation, abnormal texture, inflammation, or edema” present. The examiner noted that there was no objective finding to support the subjective complaint of pain and, therefore, no diagnosis was given.

The Board directed attention to its rating recommendation based on the above evidence. The PEB analogously coded the bilateral testicular pain condition 8799-8730 (neuralgia involving the ilio-inguinal nerve) with a 0% disability rating. The VA found the bilateral testicular pain, code 7599-7525, not subject to compensation due to the inability to diagnose the condition based on the absence of objective data. The VA coded the residual scar status post vasectomy 7804 and assigned a 10% disability rating. The Board agreed with coding the bilateral testicular pain condition analogously, as there is no specific code for testicular pain and the PEB’s decision to rate the condition using a peripheral nerve code, given that the diagnosis of testicular testalgia. The Board members concurred that the evidence supported the 0% rating for mild to moderate neuralgia. The Board considered the code for chronic epididymo-orchitis (7525) which is rated IAW the VASRD criteria for urinary tract infection. The Board agreed that there was no evidence of follow-up studies to confirm or exclude the diagnosis of chronic epididymitis. The Board agreed rating the testicular pain condition analogous to 7525 would have been non-compensable. 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 adjudication for the bilateral testicular pain condition.

Migraine Headaches Condition. The C&P examination documented that the CI first had headaches at the age of 12-13, but that they increased and were nearly incapacitating while he was in basic training. The Board noted that the CI denied frequent or severe headaches on the accession history and on subsequent history forms in 2000 and 2004. He did not disclose these on a history form until the MEB history on 23 May 2006. However, the STR documents that the CI was seen for acute treatment of a migraine headache on 14 August 1996. He reported seeing spots, feeling dizzy, and vomiting with his headache. He was treated with IM Phenergan (for nausea) and hydrated with lactated ringers through an IV drip. The CI was next seen on 4 November 1997 and refused IV rehydration. He was apparently treated with Midrin for headaches; the note indicated that the CI had also been seen on 31 August 1997 for a headache, but this record is not in evidence. He returned on 08 December 1997 reporting that there was no significant relief with Midrin. He was given Tylenol 3 in addition to the Midrin and it was recommended that he return to neurology for follow-up. The CI was ordered bed rest for 24 hours. The CI was instructed to return the following day for re-evaluation and neurology consultation; however, the next treatment note in the STR was in 2002. The CI was seen in the health clinic on 9 July 2002 to obtain treatment for his headaches. He reported having 4-5 headaches that month, but he was not in pain on that day. He was prescribed a trial of Imitrex and a head CT was recommended. The CI was seen in the emergency room on 17 December 2005 and a head CT performed. The CT was limited due to motion artifact, but was otherwise normal. The Board noted that there were five clinical visits recorded in the STR for headaches from accession until the MEB directed neurology evaluation performed on 7 June 2006. At that visit, the CI reported headaches twice a month to four times a week, but that he could also go 2-3 months without a headache. The CI said an aura preceded the headaches by 4-8 hours, which may last up to 20 hours. The CI reported that he would have to leave work to go home and rest. He reported to the examiner that the headaches were sometimes accompanied by upper extremity numbness (left greater than the right). He also reported uncontrollable vomiting. The CI reported missing 11 days from duty over the prior 6 months. He also reported that he was seen in the emergency department March 2006; this report was not in evidence. The CI reported smoking one pack of cigarettes per day and drinking 2-3 double shot espressos per day. The CI was counseled regarding decreasing caffeine consumption and smoking cessation. He was prescribed Amitryptiline (antidepressant used for migraine/pain). There is no evidence that he had been placed on a medication for migraine prophylaxis prior to this session. The prognosis was considered good. The commander’s statement, 7 June 2006 reported that the CI’s migraine headaches limited his ability to perform his duties as a Special Services soldier. The commander reported that the CI was having headaches about twice a month which would “render him useless for about 24 hours.” The CI reported on 14 July 2006, during a psychophysiology clinic appointment that his headaches had become less frequent due to the Amitriptyline. He was still drinking coffee and smoking cigarettes despite recommendations to decrease the former and discontinue the latter. The MEB NARSUM, 25 July 2006 reported that the CI was having headaches about twice a month in which had resulted in 3-4 lost duty days per month. The CI reported that his pain was 10 out of 10 and required him to leave work to rest in a dark room for about 12 hours. He reported that it took him 24 hours to recover from his headaches. He reported that he had been on Toradol, Midrin, Imitrex, Fiorinal, Tylenol, aspirin, and Motrin for the headaches. He reported that he had been taking Amitriptyline which had been helpful with sleep. He felt that the Imitrex, Tylenol, and Motrin did not totally resolve the headaches. He reported no change in the frequency of his headaches over the past 12 years.

The C&P examination performed on 7 November 2006, a month prior to separation, reported that the CI started having headaches in 1994 and they were occurring 1-2 times a month. The CI reported that the headaches would last about 24 hours and he was unable to do anything other than stay in bed.

The Board directed attention to its rating recommendation based on the above evidence. The PEB coded the headaches 8100 and assigned a 0% disability, citing that the last documentation of an emergency room visit was December 2005 and that the CI reported improvement since starting Amitriptyline. The VA also coded the migraine headache condition 8100 and assigned a 0% disability rating due to the absence of prostrating attacks. The Board observed that there was a significant discrepancy between the reported severity of the headaches and the amount of treatment sought. The Board agreed that there was evidence that the headaches probably occurred 1-2 times per month on average, but did not adjudge that the evidence supported that they were prostrating. Although the CI and commander indicated that the CI had headaches 1-2 times a month which rendered him unable to work for 24 hours, the remainder of the record does not support these statements. The Board noted that the CI denied ‘frequent or severe’ headaches on every periodic physical, including accession, until he had been entered into the Disability Evaluation System process. The Board also noted the CI’s report of no change in the frequency of his headaches over the last 12 years, during which time he had been on active duty. The evidence did not reflect that the migraine headache condition was severe enough to require regular medical treatment, changes in aggravating habits, or frequent emergent care. The Board evaluated the CI’s history for prostrating attacks and adjudged that having to rest for 24 hours in a quiet and darkened room constituted sufficient severity to meet the threshold as prostrating. Mindful of VASRD §4.3 (reasonable doubt), the Board agreed that the evidence supported that the CI was having headaches 1-2 times per month and that the prostrating attacks were averaging one in 2 months. After due deliberation and considering all of the evidence, the Board recommends a disability rating of 10% for the migraine headache condition.

Contended PEB Conditions. The Board’s main charge is to assess the fairness of the PEB’s determination that the right foot pain and right 4th finger cyst were not unfitting. The Board’s threshold for countering 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.

Right Foot Pain Condition. The CI injured his right foot in 2001 and underwent an open reduction and internal fixation of the right 3rd metatarsal (long bone of the foot). The right foot condition was profiled, at that time. A podiatry telephone consultation note on 23 January 2002 reported that the CI had come in the day before to update his profile. The provider noted that the CI had recent X-rays that showed “good progression of the fracture healing.” There were no follow-up notes in the STRs or evidence of a subsequent injury to the right foot. There was no indication that the right foot condition was profiled following recovery after the surgery. An X-ray of the right foot on 6 June 2006 revealed a fracture that was “completely healed with anatomic alignment with plate and screw fixation still in place.” The commander’s statement, 7 June 2006 reported that the CI injured his foot in Special Forces Assessment and Selection, which led to him having a plate implanted. The commander reported that the CI complained of right foot pain, almost daily. However, the Board noted that the CI had remained on airborne status, despite his right foot pain. The CI was seen by Physical Medicine and Rehabilitation on 9 June 2006 and reported numbness and tingling in the right foot intermittently. The examination was without palpable pain and was considered “unremarkable.” The CI was seen in the podiatry clinic on 28 June 2006 for an MEB/PEB consult. The CI reported that his right foot pain was aggravated by prolonged standing, running, and rucking. He described it as a sharp shooting pain out of his middle three toes. He also reported feeling numbness in the same toes. The CI reported having to take a couple of days off because the pain interfered with his duties. The examination of the right foot revealed mild TTP on the dorsal metatarsals of the 2nd, 3rd, and 4th digits. No other abnormalities were noted. The examiner concluded that the CI met retention standards. The evidence was reviewed by the action officer and considered by the Board. After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the right foot pain condition and so no additional disability rating is recommended.

Right Fourth Finger Cyst Condition. The right 4th finger cyst was never profiled or implicated in the commander’s statement and was not judged to fail retention standards. The evidence was reviewed by the action officer and considered by the Board. There was no performance based evidence from the record that the right 4th finger condition significantly interfered with satisfactory duty performance. After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the right 4th finger cyst condition and so no additional disability rating is 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 did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised. In the matter of the testicular pain condition and IAW VASRD §4.124a, the Board unanimously recommends no change in the PEB adjudication. In the matter of the migraine headache condition and IAW VASRD §4.124a, the Board unanimously recommends a rating of 10%, coded 8100. In the matter of the contended right foot pain and right 4th finger cyst conditions, the Board unanimously agreed that it cannot recommend them for additional disability ratings. There were no other conditions within the Board’s scope of review for consideration.


RECOMMENDATION: The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of his prior medical separation:

UNFITTING CONDITION
 VASRD CODE RATING
Testicular Pain Condition
 8799-8730 0%
Migraine Headache Condition
 8100 10%
COMBINED
 10%


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20120524, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans’ Affairs Treatment Record




         Physical Disability Board of Review


 SFMR-RB                                                                         


MEMORANDUM FOR Commander, US Army Physical Disability Agency
(TAPD-ZB),


SUBJECT: Department of Defense Physical Disability Board of Review Recommendation
for AR20130012151 (PD201201859)
1. 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 to modify the individual’s disability rating to 10% without recharacterization of the individual’s separation. This decision is final.

2. I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum.

3. I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures.

BY ORDER OF THE SECRETARY OF THE ARMY:




Encl                                                 
                                                      (Army Review Boards)

CF:
( ) DoD PDBR
( ) DVA

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