RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03420
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20061226

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E5, Telecommunications Operator, medically separated for “chronic low back pain (LBP)” and “idiopathic left lower extremity (LLE) complex regional pain syndrome (CRPS) without any history of trauma/injury” rated at 10% and 0% respectively, with a combined disability rating of 10%.  

CI CONTENTION:  The CI requests the Board 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 - 20060919	VARD – 20070123	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic LBP	5237	10%	Spondyloarthropathy Lumbar Spine	5239	10%	20060830	
Idiopathic LLE CRPS	8799-8720	0%	Bilateral Pes Planus	5276	10%	20060830	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Chronic LBP.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s atraumatic LBP condition began in July 2002 and gradually worsened.  Magnetic resonance imaging (MRI) studies done 18 December 2002 of the lumbosacral spine showed mild lumbar spondyloarthropathy (vertebral joint disease).  
A repeat lumbosacral spine MRI done 16 August 2005 showed mild lumbar spondyloarthropathy and a mild disc bulge at L4-5.  Despite treatment, the back condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for an MEB.  The MEB forwarded “lumbar degenerative disc disease with mild disc protrusion at L4-5” for PEB adjudication.  At the MEB examination recorded on DD Form 280 dated 6 June 2006, approximately 6 months prior to separation, the CI reported arthritis in his lower back.  There was no back physical examination conducted.  On 19 July 2006, physical therapy (PT) performed a range of motion (ROM) measurements for the MEB NARSUM.  The physical examination findings are summarized in the chart below.  At the VA Compensation and Pension (C&P) examination in August 2006, 4 months before separation, the CI reported that she had sharp intermittent pain in her lower back rated at 9/10.  She was limited to lifting between 15 and 20 pounds and standing was limited to less than 10 minutes.  She was also unable to bend over without pain.  The physical examination findings are likewise summarized in the chart below.  

The range of motion (ROM) examinations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.  

Thoracolumbar ROM
(Degrees)	PT ~5 Mos. Pre-Sep	VA ~4 Mos. Pre-Sep	
Flexion (90 Normal)	60 (60,60,65)	70	
Combined (240)	175/180	205	
Comments	Painful motion	Painful motion , antalgic gait 	
§4.71a Rating	10-20% (PEB 10%)	10%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating under the 5237 code (lumbosacral strain), citing ROM limited by pain.  The VA assigned a 10% rating using the 5239 code (spondylolisthesis or segmental instability) based on the VA C&P examination, 4 months before separation, citing forward flexion of 70 degrees.  The PT examiner noted that the thoracolumbar measurements were obtained using both a goniometer and an inclinometer rather than the goniometric thoracolumbar ROM specified by the VASRD.  The VA examiner did not specify what measurement tool was used for the ROM’s.  The Board agreed that the VA C&P examination was more proximate to the time of separation and therefore had the higher probative value.  The Board agreed that a 10% rating, but no higher, was justified for limitation of flexion (greater than 60 degrees but not greater than 85 degrees) reported on the VA exam.  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 chronic LBP condition.  

Left Lower Extremity Condition.  According to STR and the MEB NARSUM, the CI complained of atraumatic left leg, ankle, and foot swelling approximately 2 years prior to referral for MEB.  Left ankle diagnostic imaging (X-ray) studies were normal.  Lower extremity diagnostic imaging (Doppler ultrasound) was negative for deep vein thrombosis ([DVT] blood clot [thrombus] in large vein).  A subsequent left ankle MRI showed moderately prominent soft tissue ankle edema (excess tissue fluid swelling) suggesting possible cellulitis (subcutaneous connective tissue inflammation) or inflammation, rather than venous insufficiency or trauma.  The CI was treated with an antibiotic for a possible early left medial ankle cellulitis.  Diagnostic imaging (bone scan) revealed mild bilateral mid-foot and right ankle, stress changes attributed to gait alterations from pain.  At a rheumatology evaluation the CI complained of 6 months of bilateral foot swelling and left foot 6/10 pain.  Swelling and pain was exacerbated by activity and relieved with elevation, rest, and medication.  
The rheumatologist documented the MRI was negative for reflex sympathetic dystrophy ([RSD] or complex regional pain syndrome [CRPS] chronic extremity pain, swelling, limited ROM, vasomotor instability, skin changes, and patchy bone demineralization following injury) and the workup was negative for RSD and rheumatoid arthritis (RA).  The physical examination documented a limping gait and full ROM of all joints.  The lower extremity examination revealed skin patches of scales, normal foot temperature and hair distribution, and no edema or lesions.  Strength, deep tendon reflexes (DTRs), pulses, and sensation were normal except for extreme sensitivity to touch of the feet diffusely.  A lumbosacral spine MRI revealed L4-5 spondyloarthropathy, a mild disc bulge, and a mild to moderate degree of left foraminal (nerve root opening) stenosis (narrowing).  Physical medicine and rehabilitation (PM&R) performed an L5 nerve root block.  A repeat bone scan suggested mild stress changes, possible mild left plantar fasciitis, no evidence of focal stress fracture, and no findings to suggest CRPS/RSD.  The NARSUM documented the CI experienced limited benefit with various modalities and treatment measures (PM&R, PT, chiropractic care, podiatry, L5 nerve root block, Unna boot, and gradient pressure compressive device) and was not a surgical candidate.  She pursued multiple medication trials with no to limited benefit.  The author did not perform a physical examination and referred to the 19 June 2006 DD 2807-1 and DD 2808 and the 19 July 2006 PT summary.  The extensive multispecialty evaluations, treatments, and interventions could not identify an etiology for the left lower extremity pain and swelling, or provide benefit to date.  The diagnosis listed idiopathic left lower extremity CRPS.  In the C&P examination the CI complained of acute onset of left foot pain and swelling without trauma.  The symptoms were characterized as constant, stable, sharp, 9/10 pain which "felt like someone putting needles into foot."  She denied stiffness, instability, or flare-ups.  The physical examination documented an antalgic (assuming a gait or posture to lessen pain) gait with use of a cane on her right side.  Left ankle ROM was dorsiflexion of 20 (20 normal) and plantarflexion of 45 (45) degrees.  There was increased pain (9/10) with repetitive motion but no change in ROM from pain, incoordination, instability, fatigue, or weakness.  There was pain and tenderness with manipulation but it was not consistent with allodynia (pain from stimuli which are not normally painful).  The left foot examination revealed non-pitting edema with mild pes planus.  There was no abnormal color, abnormal temperature, abnormal Achilles tendon alignment, vascular changes, tissue breakdown, callosities, atrophy, deformity, claw foot, or hammertoes.  Strength, sensation, and DTRs were normal and pathologic reflexes were absent.  The examiner documented that the CI had no known injury to the left foot, no skin changes, no radiologic changes, a normal bone scan, normal ROM, was able to exercise regularly on a treadmill, and the examination was not consistent with RSD.  The diagnosis listed left foot mild pes planus and lymphedema (abnormal lymph accumulation from lymphatic system overload) with a diagnosis of RSD in 2004.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 0% rating for the left lower extremity under an analogous 8720 code (sciatic nerve neuralgia) citing idiopathic left lower extremity CRPS, no history of trauma/injury, no etiology was identified after extensive evaluation, pain limited ankle ROM, ankle swelling with non-pitting edema, grossly normal musculoskeletal examination, no evidence of atrophy, skin changes, or hypersensitivity, and not currently using any pain medications.  The VA assigned a 10% rating for the bilateral feet under the 5276 code (flatfoot, acquired) based on the VA C&P examination 4 months before separation, citing left lower extremity swelling and pain, diagnosed with CRPS, underwent several diagnostic tests all of which were negative, full ankle ROM, pain and tenderness with manipulation, not consistent with allodynia, left foot pain, swelling, and non-pitting edema and no abnormal color, abnormal temperature, abnormal Achilles tendon alignment, vascular changes, tissue breakdown, callosities, atrophy, deformity, claw foot, or hammertoes.  There was no ankle limitations in motion for consideration under 5271 (ankle, limited motion of).  There was no excision of the astragalus for consideration under 5274 (Astragalectomy).  There was no weakness for consideration under 5277 (weak foot).  While there were sensory disturbances, they were not consistent with typical sensory pathology for consideration under 5279 (metatarsalgia).  
There was no deformity for consideration under 5270 (ankle, ankylosis), 5272 (subastragalar or tarsal joint, ankylosis of), 5273 (os calcis [calcaneus], malunion of), 5275 (lower extremity bone shortening of), 5278 (claw foot), 5280 (hallux valgus), 5281 (hallux rigidus), 5282 (hammer toe), or 5283 (metatarsal bones malunion/nonunion of).  Because of pain on manipulation and use of the feet, Board members agreed the EPTS pes planus was consistent with the moderate (10%) rating under 5276 (flatfoot, acquired).  Board members agreed that there was sufficient evidence of pain with use to support a 10% rating considering VASRD §4.40 (functional loss) and §4.59 (painful motion).  Peripheral neuralgia are usually characterized by dull and intermittent pain, of typical distribution so as to identify the nerve.  The neuralgia codes rate based on an assessment of functional impairment expressed in terms of severity of paralysis.  The neuralgia code (8720) is limited to a maximum of moderate incomplete paralysis (§4.124) which is a 20% rating.  The rheumatologist documented that diagnostic imaging and lab evaluations were negative for RSD.  While the sensory disturbances were characterized as “extreme sensitivity to touch” and “not consistent with allodynia,” serial exams showed no evidence of associated loss of reflexes, motor loss, or muscle atrophy.  Members agreed that findings were concordant with mild incomplete paralysis, consistent with a 10% rating under 8720 (sciatic nerve, paralysis of).  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the left lower extremity condition.  

BOARD FINDINGS:  In the matter of the chronic LBP condition and IAW VASRD §4.71a, the Board unanimously or majority recommends no change in the PEB adjudication.  In the matter of the left lower extremity condition, the Board unanimously or majority recommends a disability rating of 10%, coded 8799-8720 IAW VASRD §4.124.  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, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Chronic LBP	5237	10%	
Idiopathic LLE CRPS	8799-8720	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140501, with attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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 XXXXXXXXXXXXXXXXXXXXX AR20160017185  (PD201403420)

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, accept the Board’s recommendation to modify the individual’s disability rating to 20% without re-characterization 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