RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	    CASE:  PD-2014-02058
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20051015

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (Financial Management Technician) medically separated for a foot condition.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS).  He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The “chronic regional pain syndrome left foot” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.   No other condition was submitted by the MEB.  The Informal PEB adjudicated “chronic regional pain syndrome, left foot” as unfitting, rated 20%.  The CI made no appeals and was medically separated.  

CI CONTENTION:  He was not evaluated for any other condition by the MEB or PEB.  His complete submission is at Exhibit A.

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 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:  

 IPEB - Dated 20050920	VA* - (~3 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Regional Pain Syndrome, Left Foot	8720	20%	Left Foot Internal Fixation…	5284	10%	20060105	
Other Conditions x 0 (Not In Scope)	Other x 5	
RATING:  20%	RATING:  20%	
*Derived from VA Rating Decision (VARD) dated 20060227 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY: 

Chronic Regional Pain Syndrome (CRPS).  Absent known direct trauma, the CI developed left foot pain after a physical training run in July 2003.  Progressively, his pain became worse and was associated with swelling, induration, and altered sensation.  Initial X-rays were normal and a magnetic resonance image (MRI) revealed evidence of bone marrow edema.  A bone scan was inconsistent in providing a definitive diagnosis, but did note a consistency with Regional Sympathetic Dystrophy (RSD), (another name for CRPS) as a possible diagnosis.  On 17 December 2004, the CI underwent a surgical fusion of the left 1st metatarsal to the adjacent bone.  He experienced some post-operative improvement, but within a brief period of time, his painful symptoms returned; and, continued efforts at rehabilitation (to include sympathetic spinal nerve blocks) did not fully restore his abilities to fulfill his MOS duties.  In July 2005 (5 months pre-separation), Neurology definitively diagnosed the CI’s condition as RSD of the left foot.  CRPS is a fairly uncommon, but well recognized, peripheral nerve dysfunction following (often minor) trauma.  It is characterized by hypersensitivity of the involved nerve and results in severe persistent pain out of proportion to that expected from the original injury.  In these cases, there usually are no ancillary or physical examination findings which are expected to be abnormal and or diagnostic.  This particular case was quite typical, and the diagnosis was considered and or corroborated by multiple medical providers.  The CI underwent many specialized imaging and ancillary studies without clear evidence of any alternate biologic etiology.  

The Board concurred with the diagnosis and opined that the variety and severity of symptoms evidenced in this case was consistent with CRPS or RSD as the sole etiology; and, the Board found no probative value concerns relative to the stated severity and associated disabilities.  The CI was permanently profiled in May 2005 and referred to an MEB.  His profile included a maximum of 15 minutes standing as well as a 4-hour workday.  The commander’s letter noted that the CI has performed at an ‘excellent’ level, but his physical condition limits the performance of most duties associated with his position.  At the MEB and VA Compensation and Pension (C&P) examinations (1 month pre-separation and 3 months post-separation), the CI endorsed similar symptoms of constant pain, weakness, stiffness, and swelling of the left foot.  The MEB physical examination (PE) revealed brawny colored edema, tenderness, and diminished sensation to the medial aspect of the left foot.  His pain was assessed (per American Medical Association (AMA) guidelines) as ‘constant’ and ‘slight’.  The examiner noted the CI’s condition as stable with a guarded prognosis.  The DD Form 2808, Report of Medical Examination, also noted “no limitation of movement” of the left foot.  The VA C&P examination addressed bilateral ankle findings without a clear description of the left foot.  His gait was normal.  The VA’s final diagnosis and objective findings were listed as left foot internal fixation with screws and screws on X-ray, respectively.    

The Board directed attention to its rating recommendation based on the above evidence.  The PEB applied the VASRD nerve code 8720 (neuralgia, sciatic nerve) and arrived at a 20% rating, for moderate impairment under §4.124a criteria.  The VA did not code under §4.124a, but rather §4.71a, 5284 (other, foot injury) at 10% for moderate impairment.  The other impairment levels under this code include 20% (moderately severe) and 30% (severe).  All Board members agreed that absent an actual known mechanism of injury, the best approach and most beneficial to the CI was to apply a peripheral nerve code.  The most clinically appropriate code in this case is 8621 (neuritis; common peroneal nerve) for it is a specific fit for the evidenced condition.  Members first agreed that there were no ratable ROM impairments, fractures, ankylosis, or other features in evidence which would achieve a more favorable or additional rating under any alternate coding scheme.  Therefore, members deliberated on whether a higher rating could be justified under code 8621; which offers 40% for complete paralysis (clearly not present) and 30% for severe impairment.        
 
Clearly, the CRPS condition had an occupational impact on the CI in that it prevented him from doing any occupation that would require prolonged walking and or standing.  During service, the CI’s activity was limited by constant sharp pain and paresthesia in his left foot, as noted in the MEB, as well as his inability to perform most normal daily activities.  Board members deliberated and agreed that a condition assessed as slight pain that preserves the ability of full foot motion coupled with a normal gait would not support a severe level of disability, but rather that of moderate impairment.  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 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 CRPS condition and IAW VASRD §4.123, 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 20140423 w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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 XXXXXXXXXXXXXXXXXX, AR20160000137 (PD201402058)

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