RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01377
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20081012

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Motor Transport Operator, medically separated for “chronic post traumatic lymphedema of the left foot and ankle,” with a disability rating of 20%.  

CI CONTENTION:  The condition continues to worsen and negatively impacts daily living.  The CI’s complete submission is at Exhibit A.

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44.  It is limited to those conditions determined by the Physical Evaluation Board (PEB) to be unfitting for continued military service and when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting.  Any conditions outside the Board’s defined scope of review and any contention not requested in this application may remain eligible for future consideration by the Board for Correction of Military Records.  Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards to the unfitting medical condition at the time of separation.  The Board has neither the role nor the authority to compensate for post-separation progression or complications of service-connected conditions.  That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws.  The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation.   

RATING COMPARISON:  

 SERVICE PEB - 20080701	VARD - 20090513	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Post Traumatic Lymphedema of the Left Foot and Ankle	7121	20%	Lymphadenoma, Left Lower Extremity	7199-7121	20%	STR	
RATING:  20%	RATING:  20%	

ANALYSIS SUMMARY: 

Left Lower Extremity Lymphedema Condition.  According to the service treatment records (STR) and the Medical Evaluation board (MEB) narrative summary (NARSUM), the left lower extremity condition began approximately 8 months prior to referral for MEB.  An 85-pound tow bar fell off the back of the Humvee and struck the CI’s left anterior ankle.  A bilateral lower extremity ultrasound (US) was normal and showed no evidence of deep vein thrombosis (DVT).  A bilateral lower extremity bone scan showed moderately severe bilateral shin splints and a right foot inflammatory soft tissue process.  A left lower extremity lymphoscintigraphy (radioisotope imaging of lymphatics) study showed absence of lymphatic (low pressure vessels with unidirectional valves that return lymph [pale tissue fluid with white blood cells] to heart) drainage consistent with lymphatic obstruction and lymphedema (abnormal lymph accumulation from lymphatic system overload).  Left foot magnetic resonance imaging (MRI) showed mild swelling of the dorsal foot without other significant abnormality.  Computed tomography (CT) of the abdomen and pelvis was unremarkable and showed no mass, adenopathy (enlarged lymph nodes), or fluid collection.  A vascular surgery physical examination revealed a small area of peri-ankle tenderness on the left with edema.  The bilateral lower extremities had intact pulses and the skin was normal.  The vascular surgeon recounted the findings of the, bone scan, lymphoscintigraphy, MRI, and CT.  The assessment listed left ankle/foot lymphedema, likely secondary to injury while deployed, and he recommended compression stockings.  In the NARSUM, 5 months before separation, the CI recounted the history of injury with a tow bar.  She complained of persistent left ankle and foot swelling with throbbing ankle pain.  Symptoms were exacerbated by weather changes, prolonged sitting, prolonged standing, walking, running, stairs, jumping, climbing, bicycling, swimming, or load bearing and relieved by rest, elevation, heat, and Epsom salts.  The CI reported painful flares of severe, throbbing, tense, tight, pain.  Flares were associated with pain radiating to the heel, marked mid-tibial region swelling, and decreased ROM.  She had failed conservative management which included activity modification, crutches, controlled ankle motion (CAM) boot, cane, physical therapy (PT), massage, and compression garments.  She used a CAM boot daily and a cane occasionally.  The physical examination documented a minimally antalgic (assuming a gait or posture to lessen pain) gait with no voluntary guarding or muscle atrophy.  There was a depressed and scarred area of soft tissue on the midfoot dorsum that was adherent to the deep tissues.  There were no skin changes over the lower extremities.  The left ankle (L=27 cm, R=20.5 cm) and midfoot (L=26 cm, R=20 cm) were edematous and enlarged compared with the right.  Except for minimal ankle weakness, and decreased heel light touch, strength, sensation, pulses, and deep tendon reflexes (DTRs) were normal.  Left ankle repetitive (X3) active ROM was dorsiflexion of 18/16/12 (20 normal) and plantarflexion of 30/32/30 (45) degrees.  The examiner recounted the findings of the US, bone scan, lymphoscintigraphy, MRI, and CT.  The diagnosis listed chronic post traumatic lymphedema.

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB assigned a 20% rating under the 7121 code (post-phlebitic syndrome of any etiology) citing a blunt injury to the left foot and ankle, chronic post traumatic lymphedema, chronic pain, soft tissue had remained swollen despite conservative measures including compressive stockings, and no evidence of fracture, thrombophlebitis, or other vascular abnormalities.  The VA assigned a 20% rating under an analogous 7121 code (post-phlebitic syndrome of any etiology) based on the STR as the CI did not show for the scheduled Compensation and Pension (C&P) examination.  The VA cited chronic pain, absence of left lower extremity lymphatic drainage consistent with lymphatic obstruction/lymphedema, soft tissue swelling despite use of compression stockings, and no indication of thrombophlebitis or other vascular abnormalities.  There was no deformity for consideration under 5270 (ankle, ankylosis), 5272 (subastragalar or tarsal joint, ankylosis of), or 5273 (os calcis or astragalus, malunion of).  There was no excision of the astragalus for consideration under 5274 (astragalectomy).  The NARSUM examination documented dorsiflexion of 18/16/12 (20) and plantarflexion of 30/32/30 (45) degrees.  Board members agreed that the ROM values more closely approximated the moderate (10%) than the marked (20%) rating under 5271 (ankle, limited motion of).  The Board agreed a 10% rating was supported based on VASRD §4.40 (functional loss) or §4.59 (painful motion).  The Board agree the constellation of findings more closely approximated the 20% rating; persistent edema, incompletely relieved by elevation of extremity, with or without beginning stasis pigmentation or eczema.  The 40% rating would require; persistent edema and stasis pigmentation or eczema, with or without intermittent ulceration.  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 left lower extremity lymphedema condition.

BOARD FINDINGS:  In the matter of the left lower extremity lymphedema condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  There were no other conditions within the Board’s scope of review for consideration.  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 20140225, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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 XXXXXXXXXXXXXXXXXXXXXXX AR20160010056 (PD201401377)

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:

Enclosure

CF:
( ) DoD PDBR
( ) DVA