RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2014-01969
BRANCH OF SERVICE:  Army	BOARD DATE:  20141218
SEPARATION DATE:  20040824

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Armor Crewman) medically separated for chronic left foot pain condition.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty.  He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The left foot pain, characterized as “complex regional pain syndrome (CRPS), left foot” was the only condition forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The PEB adjudicated “chronic left foot pain” as unfitting, rated 10% with likely application of the VA Schedule for Rating Disabilities (VASRD).  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 20040708	VA - (4 Mos. Post-Separation) 	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Left Foot Pain	8799-8722	10%	Paresthesias Left Foot and Extension Deformities Second Third and Fourth Toes of Left Foot	5284-8520	10%	20041208	
Other x 0  (Not in Scope)	Other x 3 	20041208	
Combined:  10%	Combined:  40%	
Derived from VA Rating Decision (VARD) dated 20050112 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Left Foot Pain Condition.  The treatment record documents that the CI initially sustained a forced dorsiflexion (upward flexion) injury of his left foot on 19 July 2003.  The CI presented to the emergency department that same day and a left ankle X-ray possibly showed a very small fracture, but a left foot X-ray was normal.  On 1 August 2003, a bone scan showed slight stress changes in the left foot.  Serial evaluations by podiatry subsequently diagnosed the persistent left foot pain as Achilles tendonitis (inflammation or irritation of the Achilles tendon) and plantar fasciitis (inflammation or irritation of the sole connective tissue).  Electro-diagnostic studies on 25 November 2003 were normal, indicating no neurological abnormality.  On 30 January 2004, a neurology evaluation listed the diagnosis of probable CRPS, a chronic pain syndrome following injury with pain out of proportion to severity of initial injury, and referred the CI to pain management for a trial of nerve blocks.  In the MEB narrative summary (NARSUM), by neurology, 5 months prior to separation, the CI complained of left foot pain since his forced dorsiflexion injury.  He complained of associated abnormal movements of the 2nd, 3rd and 4th toes ("they pop up"), paresthesias (abnormal sensations, tingling, burning, prickling), and pain on the dorsum of the foot.  Past surgical history was significant for a pre-service left knee arthroscopy.  The CI failed conservative treatment to include activity modification, toe taping, physical therapy, contrast baths, a transcutaneous electrical nerve stimulation (TENS) unit, gait training and medications.  He did not have significant improvement following a series of nerve blocks by pain management.  Physical exam showed the CI had an antalgic gait (assuming a posture or gait to lessen pain).  The left foot was slightly red and the 2nd, 3rd and 4th toes were hyperextended.  The feet were warm with normal pulses and no trophic changes (hair, nail, and skin changes associated with CRPS).  There was normal muscle bulk, tone and strength (5/5).  There were no involuntary movements and deep tendon reflexes were intact.  There was decreased light touch sensation with mild allodynia (pain from stimuli which are not normally painful) in the left foot.  No other sensory deficits were elicited.  The diagnosis was listed as CRPS of the left foot.

At the Compensation and Pension (C&P) exam, 4 months after separation, the CI recounted his history of left foot trauma.  He complained of left foot numbness, but denied pain.  The CI reported flare-ups 1-2 times a week that lasted a few hours.  The flare-ups were characterized by some swelling, but no pain.  It was unknown what precipitated the swelling and it was alleviated by elevating his legs and rest.  There was no worsening of functional impairment during flare-ups.  The CI used a cane to help with his left lower extremity (knee and foot) injuries, but was not using a brace or shoe inserts.  While working, he sat as needed due to left lower extremity weakness and pain.  He complained of difficulty with stairs, but denied difficulties with activities of daily living.  Physical exam showed an upright posture with a limping gait protecting his left lower extremity.  Visual exam of the foot was unremarkable other than the distal left forefoot, which was slightly red and cool.  Other findings associated with CRPS were not present.  The left foot had extension deformities of the 2nd, 3rd and 4th toes.  The toes were held at 10 degrees extension and were unable to flex or extend from that position.  Sensation was intact although 3-point discrimination was diminished.  There was good capillary refill and pulse.  There was no tenderness, pain with motion, weakness or instability.  The diagnoses were left foot paresthesias and extension deformities of the 2nd, 3rd and 4th toes.

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB rated the left foot pain condition at 10% coded 8799-8722 (analogy-musculocutaneous neuralgia; moderate) citing allodynia without trophic changes.  The VA rated the left foot pain condition at 10% coded 5284-8520 (foot injuries, other–incomplete paralysis of the sciatic nerve; mild) citing numbness without pain.  The left foot deformity was included in this condition because separately it would be non-compensable.  Neuralgia is usually characterized by dull and intermittent pain of the typical distribution of the identified peripheral nerve.  Peripheral neuralgia is to be rated on the identified nerve scale, with a maximum equal to moderate incomplete paralysis.  The PEB rating of 10% under code 8722 (moderate musculocutaneous neuralgia) was the maximum allowed.  The VA rating of 10% under code 8520 (mild incomplete paralysis of the sciatic nerve) was also appropriate because of the interval symptom improvement with resolution of pain and persistent numbness, although the Board observed that the PEB code was a better fit clinically.  The MEB NARSUM exam documented normal muscle bulk, tone, and strength (5/5) and intact deep tendon reflexes.  The C&P exam documented no weakness or instability.  Based upon objective findings for muscle bulk, tone and strength, the Board agreed there was no functional loss sufficient to warrant a rating higher than the 10% adjudicated by both the PEB and VA regardless of the code utilized.  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 foot pain 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.  In the matter of the left foot pain 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.

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 20140428, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

		
XXXXXXXXXXXXXXX
President
DoD Physical Disability Board of Review

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 XXXXXXXXXXXXXXX, AR20150009960 (PD201401969)

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			     XXXXXXXXXXXXXXX
			     Deputy Assistant Secretary of the Army
			          (Review Boards)
						         
CF: 
(  ) DoD PDBR
(  ) DVA