RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02708
BRANCH OF SERVICE:  Navy 	SEPARATION DATE:  20021122

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E4, Boatswain’s Mate, medically separated for “crushing injury, left foot and ankle, status post multiple irrigations and debridements and skin grafts,” and “superficial peroneal nerve neuroma, left foot, status post-surgical excision” as unfitting, rated 10% and 10%, with a combined disability rating of 20%.

CI CONTENTION:  “Please consider all conditions.”  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 - 20020821	VARD - 20030409	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Crushing Injury, Left Foot and Ankle, Status Post Multiple Irrigations and Debridements and Skin Grafts	7803	10%	Status Post Left Ankle Crush Injury Residual Scarring	7801	20%	20030310	
			Status Post Donor Site Scar	7805	0%		
Superficial Peroneal Nerve Neuroma, Left Foot, Status Post-Surgical Excision	8622	10%	Status Post Crushing Injury. Left Ankle with Peroneal Nerve Neuroma	8622	10%		
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Crushing Injury, Left Foot and Ankle.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s crush injury of the left foot and ankle began in October 2000 when his foot was caught between two boats.  The injury caused de-gloving of the skin of the left foot was treated with multiple split thickness skin grafts on 1 November 2000.  In choosing this method of wound treatment, the plastic surgeon anticipated that the CI would continue to have chronic pain and intermittent drainage of the skin graft, but it was thought this provided the best chance of regaining mobility.  The CI also eventually underwent superficial peroneal nerve (SPN) resection (further discussed below) due to nerve pain.  At a plastic surgery follow-up visit in March 2001, the surgeon noted no skin breakdown and at both an orthopedic visit in August and physical therapy visit in December 2001 left ankle ROM was dorsiflexion (DF) 5 degrees (normal 20 degrees).  At an orthopedic visit in March 2002 the examiner noted “the skin graft site looks good” and the CI was ready to proceed with a MEB.  The MEB forwarded “crushing injury left foot and ankle, status post multiple debridements and skin grafts” for PEB adjudication.  

At the MEB NARSUM on 18 March 2002, 8 months prior to separation, physical examination showed absent sensation in the left SPN distribution.  Sensation of the medial, lateral and plantar aspects of the foot was intact.  The skin grafts were intact but “some areas of breakdown” were noted.  The MEB NARSUM examiner indicated the CI was unable to run, unable to wear most shoes due to graft irritation, and had constant pain of the graft site, aggravated by pressure, with periods of drainage.  

At the time of the primary care clinic appointment on 7 August 2002, 4 months prior to separation, the CI reported shooting pain of the left foot and leg with every step.  The examination noted no signs or symptoms of infection and bilateral lower extremity reflexes, strength, and ROM were noted as “+”.  The CI was started on anti-inflammatory medication for two weeks with a plan for referral to pain medicine if no improvement.

At the 10 March 2003 VA Compensation and Pension (C&P) examination, 4 months after separation, the CI reported severe pain of his foot and some skin breakdowns.  One nerve under the skin graft was very painful.  He reported severe pain with walking approximately 100 yards.  He was wearing an extra wide shoe.  The CI was employed in a sedentary position.  Physical examination showed an antalgic gait.  Three skin grafts were noted, with a small area of breakdown on the most anterior skin graft.  The scar from the SPN surgery was noted on the lateral aspect of the leg.  There was eczematous-type dermatitis of the leg.  Ankle ROM was documented as “-18 degrees” (normal 20 degrees), with the examiner noting normal DF of 10 degrees. (Please note: the unaffected right ankle ROM was reported as “-5 degrees” DF).  Plantar flexion was 40 degrees (normal 45 degrees).  There was mild tenderness of the lateral knee, but knee examination was otherwise unremarkable.  Reflexes were normal, sensation of the foot was altered and increased sensitivity of the posterior and lateral foot was noted.  

Left ankle X-rays noted surgical staples and no other abnormalities of the bones, joints, or soft tissues.  The VA Rating Decision dated 9 April 2003 noted the sizes of three skin grafts – one was 7 cm wide by 15 cm long, the second was 5 cm by 4 cm, and the third was 5 cm by 5 cm in size. 

At an orthopedic evaluation on 15 May 2003, 6 months after separation, the CI reported daily pain with difficulty walking and wearing shoes.  The physical examination showed an antalgic gait with diffuse foot pain.  There was pain over the top of the ankle with “dysesthetic pain” over the top of the foot.  The medial plantar nerve was “exquisitely tender” with a positive Tinels’ sign and there was “some” tenderness of the sural nerve laterally.  There was some decreased sensation in the distribution of the SPN, but “significant residual dysesthesias over the SPN” were noted.  The scars were well healed and there was no evidence of drainage.  The surgeon’s assessment was that the CI had “several different problems” including generalized neuritis and the biggest problem was that the tibial nerve was scarred down under the medial aspect of the heel skin graft.  The CI was started on a trial of medication for nerve related pain (Neurontin) with discussion of multiple possible surgical interventions for future consideration.  

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB rated the left ankle/foot crush injury condition 10%, coded 7803 (Scars, superficial, unstable).  The VA rated the left ankle/foot condition characterized as “status post left ankle crush injury residual scarring” 20%, coded 7801 (Scars…that are deep or cause limited motion).  The Board noted that both the PEB and VA rated the CI’s residual disability due to the crush injury according to VASRD 4.118 (skin).  The VASRD skin codes were updated in August 2002 and the VA coding choice was the most appropriate skin code in effect in November 2002 and the Board is required to make its rating recommendation based on VASRD rules in effect on the date of separation.  Members agreed that IAW VASRD §4.118, the CI’s disability met the 20% rating, coded as 7801 for deep scars that measured a total area of 150 sq. cm, exceeding 12 square inches (77sq. cm) but less than 72 sq. inches (465 Sq. cm) that caused limited motion.  The Board’s contention that a 20% rating was appropriate at separation is further supported by noting that a 20% rating can be supported coded as 5271 (limited ankle motion) IAW VASRD §4.71a (musculoskeletal conditions), with severe pain noted with ambulation and ankle DF limited to 5 degrees documented in the STR after the grafting procedures.  At the C&P examination after separation the documentation of the ankle ROM was unclear and the Board determined it could not be construed from the description provided. However, the orthopedic evaluation in May 2003 re-iterated that the CI had severe pain, an antalgic gait, and limited ankle ROM, without quantification of the ROM in degrees.  However, the Board agreed the total evidence in record was sufficient basis for describing the limitation of ankle motion as “marked” as opposed to “moderate”  VASRD §4.71a code 5284 (other foot injury) could also be utilized and members unanimously agreed that the CI’s foot injury could be described as “moderately severe” for 20% rating with 5284 as well.  Finally, the Board noted that proximate to separation the CI’s disability was predominately due to nerve related pain and considered the pain related to the scarring causing tibial nerve compression could be coded 8624 IAW VASRD §4.124a (neurological disorders) for neuritis of the tibial nerve.  According to VASRD 4.123 (neuritis), neuritis characterized by constant pain and sensory disturbances, but without loss of reflexes or muscle atrophy may be rated as maximally as “moderate” incomplete paralysis, in this case also 20%.  The Board deliberated if the next higher evaluation of 5284 of 30% was warranted for severe foot injury, however, there was no bony deformity of the foot and the skin grafts remained intact at separation.  These considerations as well as the multiple different coding approaches that supported a 20% rating led the Board to recommending 20% rating, coded 7801.  

Superficial Peroneal Nerve Neuroma, Left Foot.  According to STR and the MEB NARSUM, the CI’s left foot SPN neuroma began in approximately August 2001 after the foot crush injury noted above.  The orthopedic visit on 1 August 2001 noted increased sensitivity and paresthesia over the SPN and a positive Tinel’s sign.  The orthopedic surgeon noted the CI would ultimately need a MEB and injected the nerve, which provided complete temporary relief of the CI’s pain.  The CI underwent left SPN resection in December 2001.  At orthopedic follow-up visits after the SPN resection the CI reported all the SPN related pain was gone, he was full weight bearing, and was very happy with the result.  The MEB forwarded “superficial peroneal neuroma, left foot, status post-surgical excision” for PEB adjudication.  

At the MEB NARSUM on 18 March 2002, 8 months prior to separation, physical examination showed absent sensation in the left SPN distribution, with a negative’s Tinel’s sign over the SPN and otherwise normal sensation of the foot.  The scar over the lateral aspect of the left leg was well healed

At the 10 March 2003 VA Compensation and Pension (C&P) examination, 4 months after separation, the CI reported left leg and foot symptoms as noted under the crush injury discussion above.  The physical examination noted a scar of the left leg from the middle third to the lower third in the area of the SPN surgery.  Altered sensation of the left lateral and posterior foot was noted.

The physical examination at the orthopedic examination on 15 May 2003, 6 months after separation, showed decreased sensation in the distribution of the SPN and “significant residual dysesthesias over the SPN.”  The scars were well healed and there was no evidence of drainage.  

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB and VA both rated the status post excision of the left SPN neuroma condition 10%, coded 8622(SPN).  The Board agreed that the residual sensory disturbances noted after the SPN resection (with the anticipated and desired loss of sensation distal to the resection) could be rated at 10% for “mild” neuritis of the SPN, but did not rise to the threshold of “moderate.”  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 S/P left neuroma condition

BOARD FINDINGS:  In the matter of the “crush injury, left foot and ankle, status post multiple irrigations and debridements and skin grafts” condition, the Board unanimously recommends a disability rating of 20%, coded 7801 IAW VASRD §4.118.  In the matter of the “superficial peroneal nerve neuroma, left foot, status post-surgical excision” 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 recommends that the CI’s prior determination be modified as follows; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	RATING	
Crushing Injury, Left Foot and Ankle	7801	20%	
Superficial Peroneal Nerve Neuroma, Left Foot	8622	10%	
COMBINED	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140515, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR COMMANDER, NAVY PERSONNEL COMMAND
	         DEPUTY COMMANDANT, MANPOWER & RESERVE AFFAIRS	
	                          
Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS          

Ref:  (a) DoDI 6040.44
	(b) PDBR ltr dtd 29 Aug 16 ICO XXXXXXXXXXXXXXXXXXXX  
	(c) PDBR ltr dtd 29 Aug 16 ICO XXXXXXXXXXXXXXXXXXXX
	(d) PDBR ltr dtd 29 Aug 16 ICO XXXXXXXXXXXXXXXXXXXX
	(e) PDBR ltr dtd 29 Jul 16 ICO XXXXXXXXXXXXXXXXXXXX
	(f) PDBR ltr dtd 12 Sep 16 ICO XXXXXXXXXXXXXXXXXXXX
	(g) PDBR ltr dtd 28 Aug 16 ICO XXXXXXXXXXXXXXXXXXXX
	(h) PDBR ltr dtd 29 Aug 16 ICO XXXXXXXXXXXXXXXXXXXX
	(i) PDBR ltr dtd 29 Aug 16 ICO XXXXXXXXXXXXXXXXXXXX
	(j) PDBR ltr dtd 12 Sep 16 ICO XXXXXXXXXXXXXXXXXXXX
	(k) PDBR ltr dtd 12 Sep 16 ICO XXXXXXXXXXXXXXXXXXXX

1.  Pursuant to reference (a), the recommendations of the Physical Disability Board of Review set forth in references (b) through (k) are approved.

2.  The official records of the following individuals are to be corrected to reflect the stated disposition:
     
     a. XXXXXXXXXXXXXXXXXXXX, former USMC: Retroactive placement on the Permanent Disability Retired List with a 30 percent disability rating (increased from 20 percent) effective date of discharge.  

     b. XXXXXXXXXXXXXXXXXXXX, former USN: Retroactive placement on the Permanent Disability Retired List with a 30 percent disability rating (increased from 20 percent) effective date of discharge.  

     c. XXXXXXXXXXXXXXXXXXXX, former USMC: Retroactive placement on the Permanent Disability Retired List with a 50 percent disability rating (increased from 10 percent) effective date of discharge.  

     c. XXXXXXXXXXXXXXXXXXXX, former USMC: Placement on the Temporary Disability Retired List for six months with a 50 percent disability rating effective date of discharge followed by transfer to the Permanent Disability Retired List with a final disability rating of 30 percent. 

     d. XXXXXXXXXXXXXXXXXXXX, former USMC: Retroactive placement on the Permanent Disability Retired List with a 30 percent disability rating (increased from 10 percent) effective date of discharge. 

     e. XXXXXXXXXXXXXXXXXXXX, former USMC: Placement on the Temporary Disability Retired List for six months with a 50 percent disability rating effective date of discharge followed by transfer to the Permanent Disability Retired List with a final disability rating of 30 percent.
Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS          

     f. XXXXXXXXXXXXXXXXXXXX, former USN: Retroactive placement on the Permanent Disability Retired List with a 30 percent disability rating (increased from 10 percent) effective date of discharge.  

     g. XXXXXXXXXXXXXXXXXXXX, former USN: Retroactive placement on the Permanent Disability Retired List with a 50 percent disability rating (increased from 10 percent) effective date of discharge.

     h. XXXXXXXXXXXXXXXXXXXX, former USMC: Retroactive placement on the Permanent Disability Retired List with a 30 percent disability rating (increased from 10 percent) effective date of discharge.

     i. XXXXXXXXXXXXXXXXXXXX, former USMC: Retroactive placement on the Permanent Disability Retired List with a 30 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 complete.