RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXX 		BRANCH OF SERVICE: AIR FORCE
CASE NUMBER:  PD0900437		BOARD DATE: 20100302
SEPARATION DATE: 20090120
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SUMMARY OF CASE:  This covered individual (CI) was a Captain, Clinical Nurse, medically separated from the Air Force after more than four (4) years of active duty service.  The medical basis for the separation was Reflex Sympathetic Dystrophy (RSD).  The CI suffered a left ankle sprain in September 2007.  She became hypersensitive around left ankle and foot and in January 2008 she was diagnosed with RSD. 

The CI was referred to the Physical Evaluation Board (PEB), where she was found unfit for continued military service, and separated at 20% disability using the Veterans Affairs Schedule for Ratings Disabilities (VASRD) and applicable Air Force and Department of Defense regulations.
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CI CONTENTION:  “I am requesting this review because the final disability rating awarded by the Air Force for Reflex Sympathetic Dystrophy (RSD) was 20%, which was initially caused by left ankle tears that went undiagnosed for several months. The VA has awarded me 30% for RSD and 10% for left ankle sprain. RSD has no cure and I continue to have problems with my left lower extremity and request a review and reconsideration. Prior to this injury my earning potential as a registered nurse had no limitations. I was a registered nurse before I entered the Air Force and this injury has affected my earning potential and my career as a registered nurse. This condition has also contributed to adjustment disorder which the VA has awarded me 30% which I feel is primarily a result of chronic pain. Since this disease has no cure and the VA has found me to be entitled to a higher percentage, it is my hope that the Physical Disability Board Review (PDBR will reconsider the initial rating awarded by the Air Force.”
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RATING COMPARISON:

Service	VA (<2 Mo. after Separation)	
Unfitting Conditions	Code	Rating	Date	Condition	Code	Rating	Exam	Effective	
Reflex Sympathetic Dystrophy, Left Lower Extremity 	8799-8721	20%	20081124	Reflex Sympathetic Dystrophy, Left Leg	8599-8521	30%	20090317	20090121	
				Left Ankle Sprain	5271	10%	20090311	20090121	
No PEB Entry		Not in DES Package
STR: Assessment 20080515	Adjustment Disorder w/ Mixed Anxiety & Depression 	9400	30%

	20090317	20090121	
No PEB Entry		MEB Exam 20071219: Pain Scale Comments: hands, arms numb and foot and shin pain	Carpal Tunnel Syndrome With Tenosynovitis De
Quervain's, Right Upper	8599-8515	30%	20090311
20090317	20090121	
No PEB Entry		MEB Exam 20071219: Pain Scale Comments: hands, arms numb and foot and shin pain	Carpal Tunnel Syndrome W/ Tenosynovitis De
Quervain's, Left Upper	8599-8515	20%	20090311
20090317	20090121	
No PEB Entry		Not in DES Package	Lumbar Strain 	5237	10%	20090311	20090121	
No PEB Entry		Nephrolithiasis in MEB medical history
	Condition x 5
(Carpal Boss of the Left Wrist; Gastritis; Bilateral Nephrocalcinosis; Eczema; Dermatofibroma of the Left Lower Leg) 		0%
Each	20090311
20090317	20090121	
No PEB Entry		Not in DES Package
	Condition x 6
(Ganglion Cyst of the Left Wrist; Left Foot Strain; Astigmatism; Amblyopia; Fibroids; Bilateral Tubal Ligation)	NSC		20090311
20090317		
TOTAL Combined:  20%	TOTAL Combined (Includes Non-PEB Conditions): 
80% (Bilateral Factor of 4.4 percent for : 8515, 8515)	
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ANALYSIS SUMMARY:

Formal PEB (FPEB) 20081124: CI not present but sent a letter dated 20081118: She was not medically cleared for travel—she had a caesarean section and tubal ligation 20081013 and was at risk for Deep Vein Thrombosis (DVT).  CI requested increased rating for RSD left lower extremity and bilateral carpal tunnel syndrome.

Capt B--- requested her formal hearing proceed in her absence based on the recommendation she not travel while pregnant and her orthopedic surgeons concern of the potential for developing Deep Vein Thrombosis.  The board President approved the request. Capt B--- contends she is unfitting for Air Force service.  The member further contends her Reflex Sympathetic Dystrophy (RSD) of the left lower extremity is best rated at Severe, 30% under VASRD Code 8799-8721; to add bilateral Carpal Tunnel Syndrome under VASRD Code 8799-8712, best characterized as Mild as a Category I Unfitting Condition with a disability rating of 10%; and to place Capt B--- on the Temporary Disability Retired List with a combined compensable disability rating of 40%.  The board notes significant physical restrictions, no continuous bilateral lower extremity movement, no pushing or pulling with upper extremities, no forward bending or standing over 30 minutes.  These restrictions preclude the member from satisfactorily performing duties as a clinical nurse.  The board notes the member has missed significant period of time from work due both to her RSD as well as a high risk pregnancy which member carried to term.  The board notes most recent examinations of left lower extremity by Dr. R--- (4 Sep 08 and 6 Nov 08) show member's RSD persists.  Examination shows diminished sensation and brawny appearance of left lower extremity, minimal swelling, somewhat sensitive to touch, tenderness to palpation, fair range of motion, temperature differential, no gross instability of ankle.  The board finds this condition is unfitting for military service and best rated at 20% under VASRD code 8799-8721.  The board concludes this represents a moderate degree of impairment.  With regard to Bilateral Carpal Tunnel Syndrome, the board notes the member was not medically boarded for this condition.  The board reviewed the medical record and noted a June 08 visit where ganglion cysts were noted on the bilateral wrists.  Member saw Doctor S---, and the Hand Surgery and Rehabilitation Center, on 30 Jul 08 with follow-up l3 Aug 08 and 17 Nov 08.  Dr. S--- diagnosed Bilateral Carpal Tunnel Syndrome and carpal boss, left wrist.  The board concludes this condition is not unfitting for military service.  Based on the evidence, the board finds the member unfit for her RSD and recommends Discharge with Severance Pay at a compensable rating of 20% per the scheduled for rating disabilities in use by the Department of Veterans Affairs.

Condition 1. Reflex Sympathetic Dystrophy, Left Lower Extremity 
IPEB 20080626 RSD left lower extremity 8799-8721.
Your medical condition prevents you from reasonably performing the duties of your office, grade, rank, or rating. You have duty restrictions of no continuous bilateral lower extremity movement, no pushing/pulling with upper extremities, no forward bending, or standing over 30 minutes. The Informal PEB (IPEB) finds you unfit and recommends discharge with severance pay with a disability rating of 20% per the schedule for rating disabilities in use by the Department of Veterans Affairs IAW NDAA 2008.

Air Force:
The CI initially reported ankle pain in September 2007 after routine military training.  The patient stated that during a squatting exercise she pushed off the ground and felt a twinge in her left ankle.  Patient was unsure of the direction the ankle moved during this injury.  The patient was feeling fine on the day of the event, but reports that the next morning she woke up with ankle swelling and pain with weight bearing.  Patient was seen by McGuire AFB clinic provider and was treated for ankle sprain (brace and fitness restrictions).  Over the next few months, the patient did not notice an improvement in the pain and swelling. Patient used the brace, ice and nonsteroidal antiinflammatory drugs (NSAIDS).  A magnetic resonance imaging (MRI) was ordered in December as the patient had persistent symptoms. 

The patient was sent to orthopedics and patient was placed in a short cast in January 2008.  Patient had trouble wearing the cast and had to undergo multiple cast changes throughout the month of January and ultimately was placed in a cam walker boot in early February instead.  Around the time of the casting, patient had symptoms of hypersensitivity around her left ankle and foot.  Patient was given a presumptive diagnosis of RSD and was sent to physical therapy and was kept in the cam walker boot.  The patient was sent for a second opinion orthopedic consult at University of Pennsylvania and the surgeon there agreed with the first orthopedist that this patient in fact had signs of symptoms of RSD. 

At the time of the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI still had symptoms of hypersensitivity in her foot, ankle and calf and patient even reports pin and needles throughout her entire body.  Patient has completed six (6) weeks of physical therapy and has had little improvement at this time.  Patient still is in constant pain and cannot stand or sit for extended periods of time.  Her physical exam revealed tenderness to palpation of the left lower leg and dorsum of foot as well as an antalgic gait.  Her left calf measured one (1) cm smaller than her right calf.

The CI was followed by pain management clinic and was scheduled for a sympathetic nerve block.  However, she did not receive it prior to separation.  Her profile limited her to standing no more than 30 minutes without a break and no continuous bilateral lower extremity movement.

At the VA examination on March 17, 2009 she reported pain along the outer margin of the left leg.  It is a severe pain and burning pain, at times swelling.  She was taking Neurontin 300 mgs with a minimal amount of relief.  The VA examination revealed hyperalgesia with mild to moderate touch starting below the knee and extending to the ankle joint.  She had diminished sensation and a brawny discoloration of the left lower extremity.  There was minimal swelling.  She sensitive to touch and there was a coolness with recurrent temperature.  Muscle atrophy was seen on that side compared to the right.  She continued to have pain that radiated down her left leg into her foot.  There was decreased pinprick sensation of the left lower extremity, anteriorly and posteriorly.  There was numbness and tingling throughout the entire lower extremity.  There was sensitivity to touch on the dorsal aspect of your foot.  She could walk heel to ball, but there was associated pain.  A bone scan of the leg showed a non-specific appearance.  The examiner assessed moderate to severe RSD of the left leg.  Her functional capacity was impaired with inability to walk prolonged distances.  Otherwise, ADL's were independent.  The VA considered this incomplete paralysis of foot movements with neuralgia which is severe and applied a 30% rating.

Left Ankle Sprain
FPEB 20081124: This condition was rated along with RSD and only one code was applied by the PEB.

An MRI performed in December 2007 demonstrated damage to the deep deltoid ligaments, distal tib-fib inteR---eous membrane, and anterior tib-fib ligament.  An X-ray of her left ankle 20071218 did not show any boney abnormality.  This injury was treated with a short leg cast and then a cam walker boot but it never completely healed and she continued to have an antalgic gait and used an ankle brace.

VA, civilian, and service provider examinations are shown below and they consistently showed decreased range of motion (ROM) secondary to pain.  The ROM did increase over time but remained less than normal prior to and two months after separation.  The CI also continued to have an antalgic gait.

An evaluation of 10 percent is assigned from January 21, 2009, the day after your discharge from service, as your claim was received within one year of service.  An evaluation of 10 percent is granted for moderate limited motion of the ankle.  A higher evaluation of 20 percent is not warranted unless the record shows marked limited motion of the ankle.

Left Ankle
ROM	Normal	VA C&P
20090311 (pain)	STR
20081124	Civilian 
PT
20080612	Civilian PT
20080523	Civilian PT 20080326	Military 
PT
20080205	
Dorsiflexion	20	20 (10)		5	5	0	0	
Plantar Flexion	45	45 (35)		52	52	47	35	
Inversion		30 (20)		25	30	25	5	
Eversion		40 (30)		15	15	12	5	
		Antalgic Gait; Still wearing brace;  Difficulty with prolonged standing and walking for more than 20 minutes; Had full ROM with pain at degrees shown; Not additionally limited by repeated motion	Pain elicited by motion of left ankle 	Pain 5/10 at rest, 9/10 with walking; tingling; burning sensation; working 4 hour shifts; Progress has plateaued due to multiple issues of pregnancy and RSD; d/c from PT to home exercises		Still in CAM walker; unable to squat, can stand 11-20 minutes	In Cam walker and using crutches; pain 6-7/10 w/crutches, 10/10 w/o;	

At civilian PT, left calf consistently 1 cm smaller than right

Carpal Tunnel Syndrome with Tenosynovitis De Quervain's, Right Upper (Dominate Hand) & Left Upper
FPEB 20081124: These conditions were not adjudicated by the PEB.

Analysis:
The CI’s bilateral carpal tunnel syndrome with De Quervain’s tenosynovitis and nephrocalcinosis don’t appear to have been unfitting at the time of separation.  While she did have physical limitations related to either the bilateral carpal tunnel syndrome or the De Quervain’s (no push or pull with upper extremities), neither these conditions nor a history of kidney stones is mentioned in the Commander’s letter as specifically interfering with performance of require duties.  There is not sufficient evidence to recommend categorizing these conditions as unfitting.  She was limited to desk duty but there is no mention of any limitations related to this duty such as inability to write or type.  She had complete relief of her De Quervain’s bilaterally with injections in December 2008 and she may have been able to get sustained relief with future treatments.
Other Conditions 
The other diagnoses rated by the VA (Adjustment Disorder w/ Mixed Anxiety & Depression; Gastritis; Lumbar Strain; Eczema; Dermatofibroma of the Left Lower Leg) were not mentioned in the Disability Evaluation System (DES) package and are therefore outside the scope of the Board.
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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.  After careful consideration of all available information, the Board unanimously determined by that the CI’s condition is most appropriately rated as a combined 30% with 20% for Reflex Sympathetic Dystrophy and 10% for Left Ankle Sprain.

The CI’s functional limitation began after she injured her ankle in September 2007. An MRI done in December 2007 demonstrated damage to the deep deltoid ligaments, distal tib-fib inteR---eous membrane, and anterior tib-fib ligament. This injury was treated with a short leg cast and then a cam walker boot but it never completely healed and she continued to have an antalgic gait.  Although her ankle range of motion (ROM) improved over time, she continued to have decreased ROM secondary to pain and used an ankle brace. The Board unanimously determined that her ROM limitations described above are considered moderate for rating purposes and therefore warrant a 10% rating for VASRD 5271.

The CI subsequently developed a reflex sympathetic dystrophy (RSD) in her left lower leg. Her signs and symptoms included severe and burning type pain, hypersensitivity, decreased pinprick sensation, mild swelling, a brawny skin appearance, and muscle atrophy with the left calf consistently measuring one (1) cm smaller than the right.

She had 5/10 pain at rest that increased to 9/10 with walking or standing for prolonged (more than 20 minutes) periods. Both the residuals of her ankle sprain and the RSD contributed to her functional limitations and it is not possible to determine how much each condition contributed to her limitation. All of her functional limitations cannot be attributed to her either the RSD or the ankle sprain residuals (pain-limited ROM) alone and both should be rated. 

The board determined the RSD is appropriately rated as moderate. While the CI appears to have significant pain, there is no evidence of a severe level of hypersensitivity. The CI did not complain that clothing, shoes, or air movement were intolerable and was able to wear an ankle brace without problem. Based on the ROM limitations, the ankle sprain warrants a 10% rating for moderate limited motion.

The Board unanimously determined by that the CI’s bilateral carpal tunnel syndrome with De Quervain’s tenosynovitis and nephrocalcinosis were not unfitting at the time of separation.  While she did have physical limitations related to either the bilateral carpal tunnel syndrome or the De Quervain’s (no push or pull with upper extremities), neither these conditions nor a history of kidney stones is mentioned in the Commander’s letter as specifically interfering with performance of require duties.  There is not sufficient evidence to recommend categorizing these conditions were unfitting.

The other diagnoses rated by the VA (Adjustment Disorder w/ Mixed Anxiety & Depression; Gastritis; Lumbar Strain; Eczema; Dermatofibroma of the Left Lower Leg) were not mentioned in the Disability Evaluation System (DES) package and are therefore outside the scope of the Board.  The CI retains the right to request her service Board of Correction for Military Records (BCMR) to consider adding these conditions as unfitting.
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RECOMMENDATION: The Board recommends that the CI’s prior determination be modified as follows and that the discharge with severance pay be recharacterized to reflect permanent disability retirement, effective as of the date of her prior medical separation.

UNFITTING CONDITION	VASRD CODE	RATING	
Reflex Sympathetic Dystrophy, Left Leg	8599-8521	20%	
Left Ankle Sprain	5271	10%	
COMBINED	30%	
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The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20090714, w/atchs.
Exhibit B.  Service Treatment Record.
Exhibit C.  Department of Veterans' Affairs Treatment Record.

SAF/MRB
1535 Command Drive, Suite E-302
Andrews AFB, MD  20762-7002

	Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2009-00437.

	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 Administration Schedule for Rating Disabilities.  Accordingly, the Board recommended your separation be re-characterized to reflect disability retirement, rather than 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 determined that your records should be corrected accordingly.  The office responsible for making the correction will inform you when your records have been changed.

	As a result of the aforementioned correction, you are entitled by law to elect coverage under the Survivor Benefit Plan (SBP).  Upon receipt of this letter, you must contact the Air Force Personnel Center at 1-800-531-7502 to make arrangements to obtain an SBP briefing prior to rendering an election.  If a valid election is not received within 30 days from the date of this letter, you will not be enrolled in the SBP program unless at the time of your separation, you were married or had an eligible dependent child, in such a case, failure to render an election will result in automatic enrollment.  

PDBR PD-2009-00437

MEMORANDUM FOR THE CHIEF OF STAFF

	Having received and considered the recommendation of the Physical Disability Board of Review and under the authority of Section 1554, Title 10, United States Code (122 Stat. 466) and Section 1552, Title 10, United States Code (70A Stat. 116) it is directed that:

	The pertinent military records of the Department of the Air Force relating to XXXXX are corrected to show that:

		a.  The diagnosis in her finding of unfitness was Reflex Sympathetic Dystrophy, Left Leg, VASRD code 8599-8521, rated at 20% and Left Ankle Sprain, VASRD code 5271, rated at 10% rather than Reflex Sympathetic Dystrophy, Left Lower Extremity, VASRD code 8799-8721, rated at 20%.

		b.  On 19 January 2009, she elected Child Only coverage under the Survivor Benefit Plan (SBP) based on full retired pay.

		c.  She was not discharged on 20 January 2009 with entitlement to disability severance pay; rather, on that date she was relieved from active duty and on 21 January 2009 her name was placed on the Permanent Disability Retired List.