RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD1300126
BRANCH OF SERVICE:  Army	BOARD DATE:  20140506
Separation Date:  20020501

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty PFC/E-3 (98J/Signal Analyst) medically separated for a left foot condition.  The CI sustained a spider bite on his left foot in 2001.  He was treated conservatively but developed persistent pain and eventually underwent a surgical procedure and spinal injections to relieve his pain.  Despite follow on attempts at rehabilitation, he was unable to meet the physical requirements of his Military Occupational Specialty or satisfy physical fitness standards.  He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The MEB forwarded the single condition of “regional pain syndrome, reflex sympathetic dystrophy (RSD)” to the Physical Evaluation Board (PEB) for adjudication.  The PEB adjudicated the CI’s “spider bite left foot…with development of RSD…” condition as unfitting and rated it analogously to “neuralgia of the sciatic nerve, moderate” at 20% with application of the VA Schedule for Rating Disabilities (VASRD).  The CI made no appeals and was medically separated.

CI CONTENTION:  “When medically discharged I received a twenty percent (20%) disability rating from the Army Medical Review Board.  I strongly believe that the level of disability awarded falls well below the actual level of my disability.  As the Veterans Administration has rated me at 50%.  My 20% rating from the Army and my 50% Veterans Administration rating are greatly different: one would expect the two ratings to be less disparate.  I have neurological damage to my nervous system (Reflex Sympathetic Dystrophy syndrome):  as a result I live with continuous pain.  I have received treatment from military and civilian neurology specialists at Brooks Army Hospital, University of Arizona Medical Center.  Munson Army Health Center at Fort Leavenworth.  And the University of Kansas Medical Center.  And their collective findings indicate that the damage is permanent.  The level of pain limits my physical capabilities and activity.  And has led to additional physical problems; as a result of a different walking gait.  I developed knee problems that required surgical correction, and during recovery suffered a fall that resulted in a broken ankle and torn ligaments.  The persistent physical pain and resultant physical limitations on my activities also has a detrimental effect on my active participation as a husband and father: because of my continuing pain.  I can't play with my son and daughter or even take a simple walk with my wife: every activity has to be planned in advance to take into account my limitations.  when I'll need a 'break', etc. I feel guilty about this and suffer depression.  Anxiety.  Insomnia and overall frustration with my situation.  I believe that my disability was under- evaluated at the time of my discharge and has caused and continues to cause me and my family inordinate physical.  Emotional.  And financial hardship.  I am confident that the PDBR will find that my Army-awarded disability rating should at least equal my VA disability rating.” [sic]

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, and 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 RSD rated analogous to neuralgia of the sciatic nerve as requested for consideration meets the criteria prescribed in DoDI 6040.44 for Board purview.  The requested knee, ankle, ligament, depression, anxiety and insomnia conditions were not mentioned by the MEB or PEB and are therefore not within the 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 IPEB – Dated 20020328	VA - (7 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Spider Bite Left Foot…w/ RSD	8799-8720	20%	Residuals, Left Foot Spider Bite with RSD of the Left Foot	8799-8720	40%	20031118	
No Additional MEB/PEB Entries	Other x0	20031118	
Combined:  20%	Combined:  40%	
VARD 20040315 (most proximate to Date of Separation)
NOTE:  VARD 20070712 awarded DC 5299-5262 (arthritis, right knee associated with residuals, left foot spider bite) 10% disabling from 20070209; VARD 20130415 awarded DC 9435 (mood and anxiety disorder due to reflex sympathetic dystrophy of the lower limb with major depressive episode and generalized anxiety associated with residuals, left foot spider bite) 50% disabling from 20121031.

ANALYSIS SUMMARY:  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.  The Board acknowledges the CI’s information regarding the significant impairment with which his service-connected condition continues to burden him; but must emphasize that the Disability Evaluation System has neither the role nor the authority to compensate members for anticipated future severity or potential complications of conditions resulting in medical separation.  That role and authority is granted by Congress to the Department of Veterans Affairs (DVA), operating 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 to 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.

Spider Bite Left Foot with RSD Condition.  The CI’s condition is well documented in the numerous notes in the service treatment record (STR).  The initial injury occurred as a result of a spider bite on 9 May 2001 and was treated with warm soaks, elevation and oral antibiotics.  Five days later, the CI underwent an incision and drainage for a left foot abscess.  The CI was evaluated the next day and reported foot pain with physical exam findings of tenderness to palpation over the incisional area and resolving erythema.  The CI was evaluated for a left foot cellulitis and admitted for intravenous (IV) medication therapy, with physical exam findings of swelling in the dorsum of the left foot with ecchymosis surrounding the area of swelling and marked tenderness.  The CI was seen by a civilian orthopedist who documented that a bone scan showed osteomyelitis of the left ankle and foot.  The CI reported that he could not even stand to have sheets rest on his skin with pain that radiated up to his ankle.  The CI continued to be followed by primary care, orthopedics, physical therapy and surgery for the continuous left foot pain and was prescribed a narcotic for pain control of the RSD.  The CI was seen in follow-up for chronic burning pain at the left foot, which felt like it was on fire.  He was unable to run, unable to perform push-ups or sit-ups, unable to wear a back pack and could not get into a comfortable position to fire a weapon.  There were physical findings of mild swelling of the dorsum of the left foot, a blue-reddish discoloration over the dorsum, reduced hair growth at left foot with a distinct hypersensitivity to the entire dorsum of the left foot.  There was a distinct hypersensitivity to the entire dorsum and when the skin was touched, the CI reported pain over the dorsum of the left foot with range-of-motion (ROM) limited to 0 degrees on dorsiflexion; however, 50 degrees on plantar flexion.  The CI was given a permanent L3 profile for RSD (dystrophy) of the left foot with specific additional restrictions related to this condition.  The CI was started on a narcotic patch and an oral narcotic for breakthrough pain for the left foot RSD.  The CI was seen by the orthopedist approximately 15 months prior to separation who documented that the CI had burning pain on the left foot and in his toes which was unimproved.  The commander’s statement noted that the CI was on convalescent leave and could not report to duty due to severe foot pain.  The MEB narrative summary exam completed 14 months prior to separation indicated that the CI received no benefits from epidural nerve blocks that were administered 20 September 2001 to 26 December 2001.  The CI reported pain in the dorsum of the left foot and that his toes remained significantly tender to light touch.  The pertinent physical exam findings were hypersensitivity to touch and swelling on the top of the foot with decreased strength due to pain.  There was a lack of hair growth on the dorsum of the left foot with a left ankle ROM of 20 degrees.  A month after separation, a neurology consultant noted that pain interfered with the strength assessment, there was an abnormal exaggerated response to painful stimuli on the dorsum of the foot, the CI was unable to heel or toe walk due to left foot pain and there were normal reflexes.  The VA Compensation and Pension exam performed approximately 6 months after separation documented constant hypersensitivity to the dorsal aspect of the left foot, a sharp fire-like pain, stiffness and swelling.  If the CI walked for more than a quarter of a mile, he experienced localized heat and redness to the left ankle.  The CI was able to work as a forklift operator using hand controls.  The physical exam findings were a left ankle ROM of 8 degrees dorsiflexion (20 degrees normal) with 38 degrees of plantar flexion (45 degrees normal).  There was hypersensitivity, decreased strength and foot motion due to pain.  Subsequent notes in the STR remote from separation continued to document RSD symptomatology.

The Board directs attention to its rating recommendation based on the above evidence.  The PEB coded the spider bite left foot as 8799-8720 (sciatic nerve neuralgia) and rated it 20% for moderate.  The VA used the same analogous code 8799-8720; however, they rated the residuals, left foot spider bite with RSD, at 40% which is consistent with the moderately severe incomplete paralysis of the sciatic code.  That coding and rating scheme does not follow VASRD rating guidelines in that the maximum rating allowable under VASRD code 8720 is 20% for moderate as applied by the PEB.  The 40% rating level is available for application under code 8620 (neuritis, for a moderate severe, incomplete paralysis of the sciatic nerve).  There is ample evidence in the STR supporting the CI’s diagnosis of RSD and its failure to respond to all treatment modalities tried.  The Board reviewed the tenants of VASRD §4.123 (neuritis, cranial or peripheral, characterized by loss of reflexes, muscle atrophy, sensory disturbances and constant pain, at times excruciating) and those of §4.124 (neuralgia, cranial or peripheral, characterized usually by a dull and intermittent pain, of typical distribution so as to identify the nerve).  The Board also discussed the possible use of VASRD code 5284 (other foot injuries); however, the Board agreed that the CI’s condition was primarily a nerve injury.  The Board agreed that the sciatic nerve was the nerve impacted by this disease.  The Board determined that neuritis more accurately depicted the CI’s condition rather than neuralgia and use of the neuritis code 8620 would allow for a maximum, 40%, rating consistent with a moderately severe, incomplete, paralysis, if the CI’s disability met that rating level.  Board deliberations focused on a 20% vs. 40% rating recommendation.  As noted above, findings consistent with neuritis are the constant, excruciating pain and sensory disturbances as manifested by the CI; along with loss of reflexes and muscle atrophy which were physical findings not manifested by the CI.  Because the CI lacked two of the physical finding associated with a severe neuritis, the Board determined that his condition could not receive the maximum allowable rating under that code and was more accurately described as moderate.  This would support a 20% disability rating under 8620 and confer no benefit to the CI.  Considering the totality of the evidence and mindful of VASRD §4.3 (reasonable doubt) and VASRD §4.7 (higher of two evaluations), members agreed was that a disability rating of 20% for the spider bite left foot condition was appropriately recommended in this case.
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 spider bite left foot condition and IAW VASRD §4.124a, the Board unanimously recommends no change in the PEB adjudication.

RECOMMENDATION:  The Board, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination.

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20130227, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

			

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, AR20140018956 (PD201300126)

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						     
						         
CF: 
(  ) DoD PDBR
(  ) DVA