RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01796
BRANCH OF SERVICE:  NAVY	BOARD DATE:  20150130
Separation Date:  20050802

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (AEGIS Console Operator) medically separated for left ankle complex regional pain syndrome (CRPS) status post (s/p) left ankle sprain.  The condition could not be adequately rehabilitated to meet the physical requirements of her Rating or satisfy physical fitness standards.  She was placed on limited duty (LIMDU) and referred for a Medical Evaluation Board (MEB).  The left ankle CRPS s/p left ankle sprain condition(s), characterized as “pain in joint, ankle and foot” was forwarded to the Physical Evaluation Board (PEB) IAW SECNAVINST 1850.4E.  No other conditions were submitted by the MEB.  The Informal PEB adjudicated “left ankle CRPS s/p left ankle sprain” as unfitting, rated 10%.  The CI made no appeals and was medically separated.

CI CONTENTION:  “Please consider all conditions.”

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 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/Naval 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 IPEB – Dated 20050510	VA - (2 Mos. Pre-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Ankle CRPS s/p Left Ankle Sprain	8799-8720	10%	Left Ankle Strain with Complex Pain Syndrome	5271	20%	20050610	
Other x0	Other x1	20050610	
Combined:  10%	Combined:  30%	
Derived from VA Rating Decision (VARD) dated 20051212 (most proximate to date of separation [DOS])

ANALYSIS SUMMARY:  

Left Ankle CRPS S/P Left Ankle Sprain Condition.  The CI was a passenger on a bus that was involved in a motor vehicle crash and she sustained multiple contusions which included a left ankle injury.  The CI was evaluated by Orthopedics for leg contusions.  The examiner documented a normal ankle X-ray series; and physical exam findings of left ankle edema, tenderness to palpation (TTP) and decreased sensation to light touch.  The examiner diagnosed left ankle sprain and prescribed a left ankle splint.  A week later, the Orthopedist noted left ankle diffuse bruising and ordered a walking boot for 4 weeks, physical therapy (PT) and a non-steroidal anti-inflammatory drug.  The Orthopedist noted throbbing left ankle pain, worse at night; and pain with walking.  There were physical findings of mild left ankle edema, hypersensitivity of the lateral left ankle, mild redness of the dorsal foot and peroneal muscle weakness of 4/5.  The examiner ordered supervised PT, a lace up ankle brace and LIMDU.  The PT noted nightly sharp throbbing foot pain rated 8/10, with poor balance on the left foot limited from 5 to 10 seconds.  The examiner diagnosed left ankle sprain with mild, early reflex sympathetic dystrophy (now known as CRPS).  There were physical exam findings of TTP of the anterior and lateral areas, mild edema and dysesthesia with light touch.  A Pain Management Specialist documented non-radiating left ankle pain at 7/10, with a sharp hyperesthestic quality, which also caused disturbed sleep, and was dependent on positioning and standing.  The physical findings were TTP, and hyperesthesia to lateral ankle.  The examiner did not order nerve blocks.  The physical therapist noted that the CI had pain throughout the day and that prolonged standing for more than 10 minutes, running and squatting aggravated the left ankle pain.  There were physical exam findings of mildly unstable left foot proprioception and that light touch and palpation caused increased sensitivity and pain.  The Orthopedic exam, approximately 6 months prior to separation, showed no improvement in left ankle symptoms.  The Orthopedic physical exam findings are summarized in the chart below.  The MEB narrative summary (NARSUM) exam approximately 4 months prior to separation documented persistent left ankle pain which failed to improve with PT, an inability to run, climb ladders without significant difficulty or stand for prolonged periods of time.  The MEB NARSUM physical exam findings are summarized in the chart below.  The VA Compensation and Pension (C&P) exam, approximately a month prior to separation, documented that the CI continued to have left ankle pain on an intermittent basis with weakness, stiffness and swelling, redness and instability.  She would have weekly left ankle flares which would last for 1-to-2 days and were precipitated by prolonged standing.  During these flares, the CI would have decreased range-of-motion (ROM) and decreased function.  She would wear a brace when in pain. The VA C&P physical exam findings are also summarized below.

There were three ROM evaluations in evidence, with documentation of additional ratable criteria, which the Board weighed in arriving at its rating recommendation; as summarized in the chart below.

Left Ankle ROM (Degrees)	Ortho ~7 Mos. Pre-Sep	MEB ~4 Mos. Pre-Sep	VA C&P ~2 Mos. Pre-Sep	
Dorsiflexion (20 Normal)	15	15	10	
Plantar Flexion (45)	45	45	45	
Comment	No skin changes; Pos. hyperesthesia; poor balance; No atrophy	Pos. hyperesthesia; Normal pulses; Decreased strength calf muscle, otherwise normal; No skin changes	Normal gait; Pos. Laxity; No swelling or tenderness	
§4.124a/§4.71a Rating	20%	20% (PEB10%)	20% (VA 20%)	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB coded the left ankle CRPS s/p left ankle sprain condition as 8799 analogous to 8720 (Neuralgia), and rated at 10% consistent with mild.  The VA coded the left ankle strain with complex pain syndrome condition as 5271 (limitation of ankle motion) and rated at 20%, consistent with marked.  The Board reviewed the VA’s 20% rating based on limitation of ankle ROM and members agreed that based on the CI’s normal gait, full plantar flexion and 50% loss of ankle dorsiflexion, the 5271 based rating is more consistent with the moderate, 10% rating.  All evidence is consistent with the diagnosis of CRPS which is appropriately rated under the peripheral nerve VASRD codes based on the nerve involved.  The area of the lateral left foot and ankle was primarily involved with the main disability being abnormal sensation, with minimal to no decrease in strength, which is best attributed to the external popliteal nerve (common peroneal) nerve.  The Board reviewed the tenants of VASRD §4124a (Neuralgia, cranial or peripheral, characterized usually by a dull and intermittent pain, of typical distribution so as to identify the nerve, is to be rated on the same scale, with a maximum equal to moderate incomplete paralysis).  The Board members agree that the degree of hyperesthesia, pain, and poor balance was most consistent with the moderate 20% rating, the maximum available under VASRD rating guidelines.  After due deliberation, considering all of the evidence and mindful of VASRD§4.3 (reasonable doubt) and §4.7 (higher of two evaluations), the Board recommends a disability rating of 20% for the left ankle CRPS s/p left ankle sprain 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 left ankle CRPS s/p left ankle sprain condition, the Board unanimously recommends a disability rating of 20%, coded 5271-8721 IAW VASRD §4.71a and §4.124a, respectively.  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, effective as of the date of her prior medical separation:

UNFITTING CONDITION	VASRD CODE	RATING	
Left Ankle CRPS s/p Left Ankle Sprain	5271-8721	20%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140421, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

			XXXXXXXXXXXXXXXXXXXX
President
DoD Physical Disability Board of Review

MEMORANDUM FOR COMMANDER, NAVY PERSONNEL COMMAND
DEPUTY COMMANDANT, MANPOWER & RESERVE AFFAIRS

Subj: PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS

Ref: (a) DoD I 6040.44

(b) PDBR ltr dtd 1 Jun 15 ICO XXXXXXXXXXXXXXXXXX
(c) PDBR ltr dtd 1 Jun 15 ICO XXXXXXXXXXXXXXXXXX
(d) PDBR ltr dtd 8 Jun 15 ICO XXXXXXXXXXXXXXXXXX
(e) PDBR ltr dtd 19 May 15 ICO XXXXXXXXXXXXXXXXXX
 
1. Pursuant to reference (a} I approve the recommendations of the Physical
Disability Board of Review set forth in references (b) through (d).

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

a. XXXXXXXXXXXXXXXXXX former USN: Entitlement to disability
severance pay with a disability rating of 10 percent (increased from 0 (zero)
percent) effective date of discharge.

b. XXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability
severance pay with a disability rating of 20 percent (increased from 10
percent) effective date of discharge.

c. XXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability
severance pay with a disability rating of 20 percent (increased from 0 (zero)
percent) effective date of discharge.

d. XXXXXXXXXXXXXXXXXX, former USN: Placement on the Permanent
Disability Retired List with a 50 percent disability rating (increased from
20 percent) 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. 

XXXXXXXXXXXXXXXXXX
Assistant General Counsel
(Manpower & Reserve Affairs)