RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01422
BRANCH OF SERVICE:  Navy 	SEPARATION DATE:  20040813

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reserve E5, Culinary Specialist, medically separated for “reflex sympathetic dystrophy (RSD),” with a disability rating of 20%.

CI CONTENTION:  The CI contends his condition continues to worsen and negatively impacts his daily activities.  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 - 20040715	VARD - 20050419	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Type II RSD	8799-8720	20%	RSD, Left Foot with Scars	8521	10%	20041014	
Chronic Regional Pain Syndrome	Category II	Residuals, Fractures Left Tarsal Navicular and Calcaneus	5271	10%		
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Type II RSD (with Chronic Regional Pain Syndrome).  The Service treatment record (STR) and narrative summary (NARSUM) documented a broken left ankle (non-displaced navicular and cuboid fracture) after falling down the stairs in March 2003 (1 month after entry).  Surgical excision (of the left cuboid bone) was performed in August 2003 (12 months pre-separation), for pain, decreased range-of-motion (ROM) and nonunion.  A nerve resection was performed in February 2004 (6 months pre-separation) for “sural nerve entrapment.”  At an orthopedic visit in mid-April 2004 (4 months pre-separation), the examiner documented an antalgic gait (secondary to “pulling sensation behind heel”), with normal dorsiflexion, and plantar flexion of 30 degrees (normal 45).  At a pain consultation with anesthesia in May 2004 (3 months pre-separation), the CI reported 5-6/10 pain that increased with touch, activity and walking.  The examiner documented a “slow, steady” gait with use of a cane, an unspecified limitation of ROM, and “severe” hypersensitivity of the left lateral ankle (at the left inferior malleolus).  He diagnosed “chronic regional pain syndrome/ type 2 RSD.”  Two nerve blocks (lumbar sympathetic) were performed in June 2004 (2 months pre-separation) with “significant” relief of pain.  On the MEB DD Form 2697 Report of Medical Assessment and on the MEB DD Form 2807 Report of Medical History, both dated 15 June 2004 (2 months pre-separation), the CI reported walking with a cane.  

The MEB NARSUM examination was performed on 21 June 2004 (2 months pre-separation).  The CI reported “dysesthesia” along the lateral side of the foot.  The examiner documented a decreased sensation pattern along the sural nerve distribution (“consistent with the resection and burial”) with dysesthesia of the skin in the [lateral ankle] (“sinus tarsi area”).  Dorsiflexion was normal and plantar flexion was to 30 degrees.  The gait was “antalgic” and described as due to a “pulling sensation behind the heel,” which was consistent with the nerve resection surgery outcome.  

At a primary care visit in July 2004 (1 month pre-separation), the CI reported that the nerve blocks “did not help.”  He reported inability to stand more than 20 minutes, use of a cane, and denied foot drop.  The examiner documented use of a cane and a limp; and pain with ankle inversion and eversion and not with flexion or extension.  At an orthopedic visit in July 2004, the examiner documented “sensitivity” in the sural nerve distribution, “especially over [the] lateral surgical scar overlying [the] cuboid;” and “moderately limited” ankle dorsiflexion and subtalar motion.  At a visit with physical therapy in August 2004 (4 days pre-separation), the examiner documented antalgic ambulation with a cane, normal (5/5) strength during ankle dorsiflexion and plantar flexion, with range-of-motion “within functional limits.”  

At the VA Compensation and Pension (C&P) examination dated 14 October 2004 (2 months post-separation), the CI reported lateral superficial and deep ankle pain with anterior ankle pain with dorsiflexion as when going up hills.  There was fatigue and lack of endurance that resulted in inability to stand more than 20 minutes; a feeling of constant instability; and a description of one episode of giving way.  The CI avoided repetitive use and denied significant flare-ups.  The examiner documented an antalgic gait with use of a cane, and pain with full dorsiflexion of the ankle.  Radiographs documented no evidence of fracture, dislocation, or other bone or joint abnormalities.  At a next day visit with physical therapy for ROM, the examiner documented dorsiflexion of 15 degrees and plantar flexion of 20 degrees.  

The Board directed attention to the rating recommendation based on the above evidence.  The PEB adjudicated the “type II reflex sympathetic dystrophy [RSD]” as unfitting with a Category II diagnosis of “chronic regional pain syndrome” (those conditions that are contributing to the unfitting condition).  The RSD was rated at 20%, and analogously coded 8799-8720 (neuralgia).  The VA rated the RSD at 10%, coded 8521 (mild, incomplete paralysis of the common peroneal nerve), and also separately rated 10% for the residuals of fractures of the [ankle] bones based on painful and moderately limited motion.  It is first clarified that the PEB’s Category II diagnosis (“chronic regional pain syndrome”) is intrinsic to the rated condition and a separate rating cannot be supported without pyramiding (VASRD §4.14); thus, it is appropriately subsumed in the same rating.  The Board considered the evidence for a higher than 20% rating.  The PEB rated the ankle condition using the VASRD §4.124a schedule of ratings for neurologic conditions.  VASRD §4.124a states that “incomplete paralysis” indicates a degree of lost or impaired function “substantially less than” the type pictured for complete paralysis.  It further states that “when the involvement is wholly sensory, the rating should be for mild, or at most, the moderate degree.”  There was no STR or post-separation evidence documenting a complete paralysis or severe incomplete paralysis of the common peroneal nerve to support a higher rating.  There was no STR or post-separation evidence of weakness or repeated falls that could be considered “moderate,” however, in consideration of the severity of symptoms and disability in evidence (IAW §4.40 and §4.45), members agreed that the “incomplete moderate” 20% rating for the left RSD condition could be recommended.  

BOARD FINDINGS:  In the matter of the left RSD condition and IAW VASRD §4.124a, 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 20140312, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR DIRECTOR, SECRETARY OF THE NAVY COUNCIL OF REVIEW
               BOARDS 

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS
 
Ref:   (a) DoDI 6040.44
       (b) CORB ltr dtd 15 Apr 16

      In accordance with reference (a), I have reviewed the cases forwarded by reference (b), and, for the reasons provided in their forwarding memorandums, approve the recommendations of the PDBR that the following individual’s records not be corrected to reflect a change in either characterization of separation or in the disability rating previously assigned by the Department of the Navy’s Physical Evaluation Board:

		- XXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXX, former USN