RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2013-01882
BRANCH OF SERVICE:  MARINE CORPS	BOARD DATE:  20141016
SEPARATION DATE:  20060115

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty CPL/E-4 (6213/Fixed Aircraft Mechanic) medically separated for a pain syndrome condition.  This condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS) or satisfy physical fitness standards.  He was placed on limited duty and referred for a Medical Evaluation Board (MEB).  Unspecified reflex sympathetic dystrophy, causalgia of lower limb and lumbago were forwarded to the Physical Evaluation Board (PEB) IAW SECNAVINST 1850.4E.  The Informal PEB adjudicated reflex sympathetic dystrophy (RSD)/causaliga as Category I (unfitting), rated 20%, with application of the VA Schedule for Rating Disabilities (VASRD).  The remaining condition was determined to be Category II (contributes to the Category I condition).  The CI made no appeals and was medically separated.

CI CONTENTION:  “All medical conditions were not rated accurately.  1. Reflex Sympathetic Dystrophy Jet fuel exposure  1.1 Chronic Lumbago (continued) Only one medical issue was selected.  Not all.  Please review in accurate, and equally rate all medical conditions of SNM.”

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 Category I RSD/causalgia status post jet fuel exposure conditions and Category II chronic lumbago condition are addressed below.  Any other condition or contention not requested in this application, remain eligible for future consideration by the Board for Correction of Naval Records.  The Board also acknowledges the CI’s contention that suggests all medical conditions were not rated accurately and only one medical issue was selected.  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 IPEB – Dated 20050811	VA* - (4.3 Mos. Pre-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Reflex Sympathetic Dystrophy (RSD)/Causaliga…	8799-8720	20%	RSD Left Lower Extremity	8799-8720	10%	20050909	
			RSD Right Lower Extremity	8799-8720	10%	20050909	
Chronic Lumbago	Category II	Musculoskeletal Strain Lumbar Spine	5237	20%	20050909	
Other x 0 (Not in Scope)	Other x 9 (Not in Scope)	20050909	
Combined:  20%	Combined:  60%	
*Derived from VA Rating Decision (VARD) dated 20060210 (most proximate to date of separation (DOS))

ANALYSIS SUMMARY:  

Reflex Sympathetic Dystrophy/Causaliga status post Jet Fuel Exposure.  Treatment records provide evidence that the CI first presented with left lower extremity pain in February 2003 after jet fuel exposure.  He was diagnosed with contact dermatitis and early cellulitis.  He was treated with antibiotic and pain medications.  A month later he presented with increased pain and swelling with walking.  Physical examination demonstrated left leg swelling (edema), significant pus discharge, increased warmth, decreased foot sensation, paresthesias (a sensation of tingling, tickling, prickling, pricking, or burning of a person's skin) and dermatitis.  A diagnosis of abscess with questionable compartment involvement was rendered and the CI was referred to general surgery for evaluation.  The wound was drained and healed well.  The CI continued to report left shin and foot pain diagnosed as neuropathic pain intermittently relieved by local steroid injections.  A pain clinic evaluation dated 24 June 2003 noted that the pain was “not neuropathic in nature” and “possibly constrictive associated with the prior infection.”  A neurology consultation dated 26 August 2003 noted reports of pain between 4 to 6 on a scale of 10; not responding to pain medications.  The neurologist noted a possible diagnosis of RSD.  On 9 September 2003, the same neurologist documented a normal nerve conduction study and reiterated that RSD was part of his differential diagnosis.  A neurologic evaluation at the Portsmouth Naval Medical Center dated 21 June 2004 confirmed that the history and clinical symptoms were consistent with RSD of the left lower extremity.  In August 2004, the CI developed a right lower extremity cellulitis which was diagnosed as a right methicillin-resistant Staphylococcus aureus cellulitis.  The CI was treated with antibiotic medications and wound drainage with resolution of the cellulitis.  The CI continued to report left lower extremity pain and was referred for a MEB.  The MEB Medical Examination (DD Form 2808) dated 2 August 2005, approximately 5 months prior to separation, evidenced left lower extremity tenderness to palpation at the lateral portion of the leg up to the knee.  A diagnosis of RSD of the lower back and left lower extremity was documented.

A VARD dated 10 February 2006, most proximate to permanent separation, referenced a 9 September 2005 examination, which demonstrated tender postinfection scars in both legs with denial of any functional impairment due to the scars.  He reported loss of strength, fatigue, impairment of coordination and weakness in his left leg.  He could not stand for long periods, pick things up, walk long distances, run or keep up with normal work requirements.  “VA physical examination revealed the muscles involved were Group X on both lower extremities.  There was loss of muscle substance noted on palpation of each leg, but with no loss of deep fascia or impairment of muscle tone.”  There was also evidence of painful motion of the knee joints.

The Board directs attention to its rating recommendation based on the above evidence.  The PEB adjudicated the RSD/causalgia status-post jet fuel exposure as unfitting with a disability rating of 20%.  The PEB and VA coded the RSD condition 8799-8720, analogous to neuralgia of the sciatic nerve.  The VA rated each lower extremity at 10%; for a combined lower extremity disability rating of 20%.  The Board noted that the MEB forwarded unspecified RSD and causalgia of the lower limb.  The PEB combined the unspecified RSD and causalgia of the lower limb into a single unfitting condition.  RSD and causalgia are terms which reference post-traumatic pain.  Board members agreed that the PEB appropriately combined the RSD and causalgia conditions.  The Board noted that the anatomical location of the RSD/causalgia condition was not included in the PEB description of the unfitting condition.  The Board noted, however; that the preponderance of treatment notes, the narrative summary (NARSUM) and Joint Disability Evaluation Tracking System Findings and Recommended Disposition Work Card referenced the left lower extremity.  The Board deliberated whether there was evidence for a higher than 20% rating for the RSD/causalgia status-post jet fuel exposure.  IAW VASRD§ 4.124, the maximum rating for neuralgia is equal to moderate incomplete paralysis of the identified nerve.  Moderate incomplete paralysis of the sciatic nerve is rated 20%.  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 RSD/causalgia status-post jet fuel exposure condition.  

Contended PEB Conditions.  A chiropractic consultation request dated 4 November 2003 noted that the CI had a 2-week history of back pain.  The psychical examination was significant for T12-L5 tenderness to palpation with L5-S1 muscle spasms.  Radiographic evaluation of the lumbar spine demonstrated L5 posterior listhesis with left rotation.  Magnetic resonance imaging of the lumbar spine dated 14 November 2003 was unremarkable.  Despite chiropractic care, physical therapy and pain management, the CI continued to report 6 on a scale of 1 to 10 lower back pain with intermittent muscle spasms.  A pain management noted dated 11 July 2005 documented a diagnosis of musculoskeletal low back pain.  Multiple chiropractic and primary care treatment notes (from 2003-approximately 2 months prior to separation) documented normal lumbosacral spine painless motion, tenderness to palpation and intermittent muscle spasms.  At the NARSUM examination dated 18 July 2005, 6 months prior to separation, the documented a history of chronic lumbar back pain with bowel or bladder incontinence.  Radiographic evaluations were normal.  Lumbar range-of-motion (ROM) was documented as full without tenderness or deformity.  A VARD dated 10 February 2006, referenced a 9 September 2005 VA examination which revealed normal posture and gait, spasms present in the paraspinal muscles, and lumbar ROM was decreased with flexion limited to 60 degrees, extension to 20, right lateral flexion to 20, left lateral flexion to 30, right rotation to 20, and left rotation to 30 with pain during all maneuvers.  The VARD also referenced lumbar spine X-rays performed on the day of the examination which were considered normal.

The Board directs attention to its rating recommendation based on the above evidence.  The PEB adjudicated the chronic lumbago condition as Category II; contributing to the unfitting condition.  The VA rated the chronic lumbago condition at 20% for forward flexion limited to 60 degrees, coded 5237, lumbosacral strain.  The chronic lumbago was implicated in the commander’s statement, but was noted that it did not hinder his ability to perform as a Tower NCO which was not his primary fixed aircraft mechanic MOS.  The Board noted that despite approximately 2 years of chiropractic care, a course of physical therapy, multiple pain medications, and the administration of nerve blocks, the CI continued to report low back pain.  The Board agreed that the chronic lumbago condition could reasonably be determined to be separately unfitting and recommended for disability rating.  Although the VA examination most proximate to separation document limitation of forward flexion to 60 degrees, over 2 years of chiropractic care notes, including a note 2 months prior to separation, documented full lumbosacral and thoracolumbar ROM with localized tenderness.  Gait and spinal contour were consistently documented as normal.  Considering the totality of the evidence and mindful of VASRD §4.3 (reasonable doubt), members determined that the evidence best supports a 10% disability rating for the chronic lumbago 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.  In the matter of the RSD/causalgia status-post jet fuel exposure condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended chronic lumbago condition, the Board unanimously agrees that it was unfitting and unanimously recommends a disability rating of 10%, coded 5237 IAW VASRD §4.71a.  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; and, that the discharge with severance pay be recharacterized to reflect permanent disability retirement, effective as of the date of his prior medical separation:

UNFITTING CONDITION	VASRD CODE	RATING	
Reflex Sympathetic Dystrophy/Causalgia status-post Jet Fuel Exposure	8799-8720	20%	
Chronic Lumbago	5237	10%	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20130923, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

MEMORANDUM FOR COMMANDER, NAVY PERSONNEL COMMAND
		   DEPUTY COMMANDANT, MANPOWER & RESERVE AFFAIRS
	                          
Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS          

Ref:   (a) DoDI 6040.44
       (b) PDBR ltr dtd 8 Dec 14 ICO XXXXXXXXXXXXXXX
	 (c) PDBR ltr dtd 15 Dec 14 ICO XXXXXXXXXXXXXXX 
	 (d) PDBR ltr dtd 10 Dec 14 ICO XXXXXXXXXXXXXXX
	 (e) PDBR ltr dtd 24 Dec 14 ICO XXXXXXXXXXXXXXX
       (f) PDBR ltr dtd 18 Dec 14 ICO XXXXXXXXXXXXXXX
       (f) PDBR ltr dtd 18 Dec 14 ICO XXXXXXXXXXXXXXX
	 (h) PDBR ltr dtd 12 Feb 15 ICO XXXXXXXXXXXXXXX
          
1.  Pursuant to reference (a) I approve the recommendations of the Physical Disability Board of Review set forth in references (b) through (h).

2.  The official records of the following individuals are to be corrected to reflect the stated disposition:

     a. XXXXXXXXXXXXXXX, former USMC: Placement on the Permanent Disability Retired List with a 40 percent disability rating effective date of discharge.

     b. XXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 30 percent disability rating effective date of discharge.

     c. XXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 40 percent disability rating effective date of discharge.

     d. XXXXXXXXXXXXXXX, former USMC:  Placement on the Permanent Disability Retired List with a 30 percent disability rating effective date of discharge. 

     e. XXXXXXXXXXXXXXX, former USMC: Placement on the Permanent Disability Retired List with a disability rating of 40 percent effective date of discharge.

     f. XXXXXXXXXXXXXXX, former USMC: Placement on the Permanent Disability Retired List with a disability rating of 40 percent effective date of discharge.

     f. XXXXXXXXXXXXXXX, former USMC: Disability separation with final disability rating of 20 percent (increased from 10%) effective date of discharge.

3.  Please ensure all necessary actions are taken to implement these decisions, including the recoupment of disability severance pay, if warranted, and notification to the subject members once those actions are completed.