RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX		CASE:  PD-2014-02499
BRANCH OF SERVICE:  ARMY	SEPARATION DATE:  20080325

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-3 (Construction Equipment Repairer) medically separated for left foot pain.  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 “reflex sympathetic dystrophy,” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded six other conditions (see rating chart below) for PEB adjudication.  The Informal PEB adjudicated the left foot pain condition as unfitting, rated 20%, with application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The remaining conditions were determined to be not unfitting.  The CI made no appeals and was medically separated.  

CI CONTENTION:  The applicant has asked for consideration of all his conditions.  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/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 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 20080214	VA* - (~7 Mos. and 10 Mos. Post-Separation) 	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Foot Reflex Sympathetic Dystrophy…	8799-8720	20%	Left Ankle Strain	5271	10%	20081107	
			Reflex Sympathetic Dystrophy, Left	8599-8522	0%	20081107	
Migraines	Not Unfitting	Migraines	8100	30%	20081107	
Hypertension	Not Unfitting	Hypertension	7101	0%	20081107	
Astigmatism	Not Unfitting	No VA Placement	
Myopia	Not Unfitting	No VA Placement	
Esophageal Reflux	Not Unfitting	Gastroesophageal Reflux Disease	7346
	30%	20081107	
Major Depression	Not Unfitting	Post Traumatic Stress Disorder (also Claimed, asDepression)	9411	70%	20090225	
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 3	
RATING:  20%	RATING:  90%	
*Derived from VA Rating Decision (VARD) dated 20090722 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY:   

Left Foot Pain Condition.  The narrative summary (NARSUM) documented that the CI’s history of left ankle pain begun with a sprain in February 2007.  The sprain was treated with a splint and he was provided crutches.  Since his condition was not improving, he was sent to physical therapy in March 2007 and to podiatry in May 2007.  He reported no improvement.  He was diagnosed with chronic regional pain syndrome.  Podiatry entry of 25 July 2007 documented tenderness on palpation over the course of the superficial peroneal nerve, and pain elicited by motion in the subtalar joint.  The physician noted a bone scan was negative for stress fracture, and radiographs demonstrated normal calcaneus.  In August 2007, primary care entry noted a 2-day history of swelling and blue discoloration with associated tingling of the left foot after removal of his foot cast.  The CI noted he has swelling when the leg is not elevated.  Orthopedic examination of the left foot/ankle, August 2007, recorded touching of the left foot over the lateral ankle/heel area elicits painful sensation,  The skin was slightly shiny; however, temperature to touch was normal, pulses were palpable and there was absence of evidence of inflammation or infection.  The physician referred him to pain specialist.  In September 2007, he returned to the orthopedic clinic where he was given another trial of physical therapy with TENS and ultrasound without noted benefit.  Orthopedic exam dated 26 October 2007 recorded left ankle tenderness on palpation of the lateral aspect, range-of-motion (ROM) in all planes was “decreased by 50%.”  Pain was elicited in all planes on ROM testing.  Mild weakness (4/5) was noted with all movement.  The ankle was not warm, erythematous, or swollen.  The examiner noted left ankle was not tender on palpation of the anterior, medial, and posterior aspects, and the ankle had no deformity.  The left foot demonstrated tenderness but was otherwise normal.  The examiner noted that the CI ambulated with a limp and used a cane.  It was determined that he had reached maximum medical improvement after several medication trials, series of steroid injections, sympathetic ganglion block and ultrasound therapy.  The CI was given a permanent L3 profile and referred for MEB.  Treatment record documented primary complaint of left ankle/foot pain that worsens as the day progresses.  At the NARSUM exam on 3 February 2008, 6 weeks prior to separation, the CI reported his pain is tolerable with medication unless exacerbated by activity or light touch.  The pain often made it hard for him to fall asleep but his medication for sleep helped.  Focused examination of the ankle and foot was accomplished one month prior and that exam documented left foot sensitivity to touching the hairs on the foot; touching the actual foot causes intense pain.  Passive movement at the ankle causes pain, and the examiner noted that his foot turned “bright red” during course of exam.  ROM was not recorded but it was noted limitation of motion appeared due to pain.  ROM measurements documented in January 2008 noted left ankle dorsiflexion of zero (20), opined to be limited by pain and right ankle dorsiflexion to 7 degrees without pain.  Plantar flexion left ankle was to 50 degrees (45), compared to 60 degrees in the right ankle.  The VA Compensation and Pension (C&P) exam was accomplished 7 months post-separation and that exam recorded ROM dorsiflexion of the left ankle to 10 degrees, and plantar flexion to 35 degrees.  The left ankle shows no signs of edema, effusion, redness, heat or guarding of movement.  Foot examination did not reveal any signs of abnormal weight bearing or breakdown, callouses, and he required the use of a cane, but did not require a brace, crutches, corrective shoes or a walker.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB and VA chose different coding options for the condition.  The PEB adjudicated the condition as reflex sympathetic dystrophy, coded 8799-8720 (analogous for neuralgia, incomplete paralysis), with a 20% rating for moderate incomplete paralysis.  The VA adjudicated the condition as reflex sympathetic dystrophy coded 8599-8522 (analogous for paralysis of lower radicular group); and assigned a 0% rating, and cited the absence of documentation regarding claudication or the presence of tropic changes or cold sensitivity.  Of note both the coding option of the VA and PEB requires meeting the same criteria for the higher rating of 30%; demonstrating incomplete paralysis of ankle movements consistent with severe degree of impairment.  Pain was present during each examination (NARSUM and C&P); however, evidence of other ankle pathology was absent, except ROM was decreased in both exams.  The Board concluded there was insufficient evidence to support a higher rating under either code.  The Board next considered ankle ROM code; however, there was no benefit to the CI under this code (5271) since there are no rating higher than 20% (marked limitation of motion).  The Board, after due diligence, found no additional route to any higher disability rating.  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 ankle condition.  

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the conditions of migraine headaches, hypertension, astigmatism, myopia, esophageal reflux and major depression were not unfitting.  The Board’s threshold for countering fitness determinations requires a preponderance of evidence, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  The Board reviewed the available treatment record and noted that the CI had headaches since the age of 14.  His headaches became more frequently since his return from deployment.  In May 2007, he was prescribed abortive and preventive medication and reported some benefit.  The NARSUM examiner opined his condition met retention standards.  The record also noted he received treatment for hypertension, and was prescribed corrective lenses to address his conditions of astigmatism and myopia.  The CI was prescribed Prilosec for his reflux condition and reported good response.  The Board next reviewed the record for the condition diagnosed as major depression and noted the psychiatrist indicated his condition did not render him unfit for duty.  The Board reviewed the CI’s profile and noted the conditions of migraine headache, hypertension, astigmatism, myopia, esophageal reflux and major depression were not profiled or implicated in the commander’s statement and were not judged to fail retention standards.  All were reviewed and considered by the Board.   There was no performance based evidence from the record that any of these conditions significantly interfered with satisfactory duty performance.  After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the any of the contended conditions and so no additional disability ratings are recommended.

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 Foot Reflex Sympathetic Dystrophy condition and IAW VASRD §4.124a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended migraine headaches, hypertension, astigmatism, myopia, esophageal reflux and major depression conditions, the Board unanimously recommends no change from the PEB determinations as not unfitting.  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 20140519, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB

28 JUL 2016

MEMORANDUM FOR Commander

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation
for XXXXXXXXXXXXXXXXXXXX, AR20160004559 (PD201402499)

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