RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03403
BRANCH OF SERVICE:  Navy 	SEPARATION DATE:  20040401

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-1, Trainee, medically separated by the Informal Physical Disability Board for “complex regional pain syndrome [CRPS], type 1, left lower extremity [LLE]” with a disability rating of 10%. 

CI CONTENTION:  The CI contends for all of her conditions.  The applicant’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 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 - 20040212	VARD - 20040218	
Condition	Code	Rating	Condition	Code	Rating	Exam	
CRPS, Type I, LLE	8799-8723	10%	RSD Of The LLE	8799-5284	30%	20040218	
Posterior Tibial Tendinitis, LLE	Category II	No VA Placement	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Complex Regional Pain Syndrome, Type I, Lower Left Extremity with Posterior Tibial Tendinitis, LLE, as a Category 2 Condition.  The CI was evaluated in podiatry on 16 October 2003, 22 days after accession, for a 10-day history of pain in both feet and then again on 1 November 2003 for a 4-day history of left ankle pain.  She was treated with duty restrictions both visits and thought to have a posterior tibial tendonitis (a tendon on the inside of the ankle).  Her symptoms progressed and she was treated with a cast without benefit.  She was then referred to orthopedics and thought to have either a stress fracture or possible RSD (reflex sympathetic dystrophy, an old name for CRPS, a pain syndrome).  A bone scan 3 days later was thought to be consistent with RSD.  She was referred to physical therapy (PT) and placed on medications with some improvement in her symptoms.  However, it was not thought that she would improve sufficiently to return to training and she was referred for a Medical Evaluation Board.  The narrative summary was dated 5 December 2003, 4 months prior to separation, and noted that her hyperemia (redness, from increased blood flow) and swelling had decreased and the range-of-motion (ROM) of her ankle had increased.  On examination, her left foot and ankle showed warmth and swelling with increased sensation to touch as well as allodynia (pain with light touch).  Her skin was dry and mottled and the nail growth decreased compared to the right side.  She was noted to have some muscle atrophy.  She was diagnosed with CRPS Type I, LLE, and posterior tibial tendonitis, LLE.  At a follow up orthopedic examination on 6 January 2004, she was noted to have persistent hyperemia, warmth, and atrophy; the swelling, though, had decreased.  The 27 January 2004 PT evaluation documented a normal ROM and no swelling.  She could fully weight bear on the left and her gait was improved.  Hypersensitivity persisted.  At the VA Compensation and Pension (C&P) examination performed on 6 February 2004, 2 months before separation, the CI reported constant pain and swelling of the LLE.  She denied smoking.  On examination, her posture was erect and she had a slight limp on the left, using a cane.  The skin (of the foot) was normal to examination.  She was noted to have good pulses and sensory response (normal).  The orthopedic C&P was 2 weeks later on 18 February 2004.  She reported pain from her left hip to her toes.  She walked with a limp and had pain with motion.  She had marked tenderness of the left foot and ankle and moderate swelling of the left leg and foot.  However, the calf measurements were equal bilaterally.  She had pain with motion of the left ankle and foot.  Instability was not documented.  Redness of the left foot was documented, but no other skin changes were noted.  There are no further records proximate to separation.  A podiatry examination on 27 October 2006, 30 months after separation, documented that motion was pain free and that there was no swelling, tenderness, instability, weakness, or evidence of abnormal weight bearing.  There was no skin abnormality or muscle atrophy.  This examination is consistent with the improving trend noted the last few months prior to separation even though the CI did report progression of symptoms.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the CRPS condition at 10%, coded 8799-8723 (analogous to moderate neuralgia of the anterior tibial nerve).  The posterior tibial tendonitis was determined to be a Category II condition (contributing to the unfitting condition, but not separately unfitting).  The VA rated the condition at 30%, coded 8799-5284 (analogous to severe foot injuries).  The Board first considered if the posterior tibial tendonitis was separately unfitting.  It noted that this was an initial diagnosis and that it was not diagnosed at the final orthopedic note or the final clinical PT note in January 2004.  It was not noted by the orthopedist who accomplished the VA C&P 6 weeks prior to separation.  The evidence did not support the presence of a separately unfitting posterior tibial tendonitis condition at separation.  The Board then considered the rating for the CRPS condition.  This condition is thought to be a malfunction of the nervous system, typically after trauma.  The Board noted that there is no specific code for this condition in the VASRD, but determined that the PEB coding choice, 8799-8723, better described the pathology than the VA code.  The Board noted that the CI complained of pain in the entire LLE, not just the foot and ankle region.  The evidence shows that the condition was improving in the months leading up to separation and remote evidence indicates that she continued to improve after separation (although she reported increased symptoms).  The physical findings associated with CRPS were absent on this evaluation.  A finding of neuralgia (dull or intermittent pain) is limited to a disability rating of a moderate incomplete paralysis.  A higher rating is obtained for neuritis, but it entails loss of reflexes, muscle atrophy, sensory disturbances, and constant pain which is at time excruciating.  This level of disability is not supported by the two VA C&P examinations proximate to separation or the remote examination by podiatry.  A moderate level of severity supports a 10% 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 CRPS type I with posterior tibial tendinitis condition.  

BOARD FINDINGS:  In the matter of the CRPS condition and IAW VASRD §4.71a and 4.124a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended posterior tibial tendonitis condition, the Board unanimously recommends no change from the PEB determination as not unfitting.  There were no other conditions within the Board’s scope of review for consideration.  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 20140627, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

	MEMORANDUM FOR DIRECTOR, SECRETARY OF THE NAVY COUNCIL OF REVIEW
               BOARDS 

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS
 
Ref:   (a) DoDI 6040.44
       (b) CORB ltr dtd 16 Feb 16

      In accordance with reference (a), I have reviewed the cases forwarded by reference (b), and, for the reasons provided in their forwarding memorandums, approve the recommendations of the PDBR that the following individual’s records not be corrected to reflect a change in either characterization of separation or in the disability rating previously assigned by the Department of the Navy’s Physical Evaluation Board:

- XXXXXXXXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXXXXXXXX, former USMC 
- XXXXXXXXXXXXXXXXXXXX, former USMC
- XXXXXXXXXXXXXXXXXXXX, former USN   
- XXXXXXXXXXXXXXXXXXXX, former USN 

				XXXXXXXXXXXXXXXXXXXX	     				  	Assistant General Counsel
				(Manpower & Reserve Affairs)