RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02792
BRANCH OF SERVICE:  Army  	BOARD DATE:  20150311
SEPARATION DATE:  20080706

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (OH-58 Helicopter Repairer) medically separated for a left foot condition.  The condition did not improve adequately to meet the physical requirements of his Military Occupational Specialty or satisfy physical fitness standards.  He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The “complex regional pain syndrome (CRPS), left foot” condition was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other condition was submitted by the MEB.  The Informal PEB adjudicated “complex regional pain syndrome of the left foot” as unfitting, rated 10% with application of the Veterans Affairs 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 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:  
					
Army IPEB – Dated 20080306	VA* – (~4 Mos. Pre-Separation) 	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Complex Regional Pain Syndrome, Left Foot	8799-8725	10%	Residuals, Left Foot Fracture, also claimed as Nerve Damage	5284-8521	20%	20080229	
Other x 0 (Not In Scope)	Other x 5	
RATING:  10%	RATING:  40%	
*Derived from VA Rating Decision (VARD) dated 20080716 (most proximate to date of separation [DOS])  

ANALYSIS SUMMARY:  

Left Foot Condition.  In October 2006, this CI injured his left foot during a road march.  He was diagnosed with fracture of the third metatarsal, and was placed in a cast for 25 days. When the cast was removed, he was placed in a Cam walker boot.  In spite of treatment, he continued to have significant pain in the left foot.  His podiatrist suspected that the CI was not fully complying with his profile.  In April 2007, he was diagnosed with CRPS.  Due to the chronic, persistent nature of his foot pain, MEB was initiated.  The MEB physical exam (PE) was on 27 December 2007.  The CI reported that he was not able to wear military footgear.  On PE, the left foot was discolored and slightly swollen.  The CI had difficulty putting full weight on the left foot, and his gait was antalgic.  Ankle range-of-motion (ROM) had been measured by physical therapy (PT) 2 weeks previously.  There was 0 degrees of dorsiflexion, and 25 degrees of plantar flexion.  The limitation of ROM was due to pain.  The diagnosis in the MEB narrative summary was: CRPS.   

On 29 February 2008, 4 months before separation, the CI had a VA Compensation and Pension (C&P) exam.   He reported pain, stiffness, numbness, and tingling of the left foot.  His gait was antalgic.  On PE of the left foot, it was discolored and cold to the touch.  There was tenderness to palpation (TTP) of the third metatarsal.  The dorsalis pedis and posterior tibialis pulses were absent.  Strength of toes against resistance was decreased at 3/5.  Ankle ROM was normal, but there was pain with ankle motion.  On 16 January 2009, 6 months after separation, the CI had another C&P exam.  He reported that he was still having pain in the left foot.  The pain severity level was 7/10.  Pain was elicited by physical activity, like standing or walking.  He was unable to jump or run.  On PE, his posture and gait were normal.  PE of the left foot revealed some TTP, but no edema (swelling), weakness, redness, muscle atrophy, or disturbed circulation.  Left ankle ROM was normal, but there was pain with ankle motion.  

The ROM evaluations which the Board weighed in arriving at its recommendation are summarized in the chart below.

Left Ankle ROM
(Degrees)	PT/MEB ~7 mos. Pre-Sep
(20071213)	VA C&P ~4 mos. Pre-Sep
(20080229)	VA C&P ~6 mos. Post-Sep
(20090116)	
Dorsiflexion (20 Normal)	0	20	20	
Plantar Flexion (45)	25	50	45	
Comment	Painful motion	Painful motion	Pain with motion	

The Board directed its attention to its rating recommendation based on the above evidence. The February 2008 C&P exam was only 18 weeks before his DOS, and therefore carried significant probative value.  At that exam, the CI reported that he was able to stand for 15-30 minutes.  He was able to walk more than 1/4 mile, but less than one mile.  He said that his symptoms affected his ability to do chores, and his ability to do sports and recreational activities.  At the January 2009 C&P exam, his condition had improved, but he was still having pain with standing and walking.  Based on a thorough review of the record, the Board determined that, at DOS, the CI’s level of disability was best described as “moderate.”  There was insufficient evidence to support a conclusion that his impairment was “severe.”    

As noted above, the PEB coded the condition 8799-8725 (analogous to neuralgia of the posterior tibial nerve), and assigned a disability rating of 10% (moderate impairment).  The Board determined that a more accurate code was 8799-8721 (analogous to neuralgia of the external popliteal nerve).  The evidence to support this was based on total loss of ankle dorsiflexion at the December 2007 MEB exam.  With time, the CI regained ankle dorsiflexion.  But, the total and temporary loss of dorsiflexion supports the conclusion that his external popliteal nerve was significantly involved in his unfitting left foot condition.

IAW the VASRD §4.124a, a rating of 20% is warranted for moderate impairment under diagnostic code 8799-8721 (analogous to neuralgia of the external popliteal nerve).  A rating of 20% is also in agreement with what the CI was granted by the VA.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt) and VASRD §4.7 (higher of two evaluations), the Board recommends a disability rating of 20% for the painful, unfitting 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 painful left foot condition, the Board unanimously recommends a disability rating of 20%, coded 8799-8721, IAW VASRD §4.7, and §4.124a.  There were no other conditions within the Board’s scope of review for consideration.    

RECOMMENDATION:  The Board, therefore, recommends that the CI’s prior determination be modified as follows, effective as of the date of his prior medical separation:  

CONDITION	VASRD CODE	RATING	
Complex regional pain syndrome of left foot, that began with a foot injury (metatarsal fracture) in October 2006 	8799-8721	20%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140606, 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, AR20150018798 (PD201402792)

1.  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 to modify the individual’s disability rating to 20% without recharacterization of the individual’s separation.  This decision is final.  

2.  I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum.   

3.  I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures.

 BY ORDER OF THE SECRETARY OF THE ARMY:

CF: 
(  ) DoD PDBR
(  ) DVA