RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-04146
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20090101

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Food Service Specialist, medically separated for “complex regional pain syndrome (CRPS), left foot and ankle,” with a 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 based on 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 - 20081030	VARD - 20090227	
Condition	Code	Rating	Condition	Code	Rating	Exam	
CRPS, Left Foot and Ankle ….With Ankle Sprains	8799-8720	20%	CRPS, Left Lower Extremity	8799-8720	20%	20090113	
			Degenerative Joint Disease, Left Ankle	5003-5271	10%	20090113	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

CRPS (Left Foot and Ankle).  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s left ankle condition began in 2005 after several injuries during physical training.  Recurrent ankle sprains and pain were not relieved by conservative therapy.  Radiographic studies showed a cyst in the distal fibula and pes planus (flat foot) on weight bearing; a bone scan in 2008 showed “findings suggesting reflex sympathetic dystrophy of the left lower extremity [LLE] around the ankle and foot.”  There was no surgical indication.  Despite treatment, the CI’s ankle/foot condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and he was referred for a MEB.  The MEB forwarded “complex regional pain syndrome, left lower extremity” for PEB adjudication.

At an orthopedic visit on 5 June 2008, the CI reported marked LLE pain interfering with functioning and sleep.  On examination, there was tenderness to light touch in a non-anatomic distribution and left ankle and foot dependent rubor (red color change to the skin).  Upon bone scan analysis, the rendered diagnosis was “reflex sympathetic dystrophy lower limb ankle.”  At a neurology clinic appointment on 9 September 2009, the CI reported severe (9/10) pain in the lower left leg.  Examination revealed normal gait, motor function and reflexes.  There was hyper-sensitivity to light touch/pinprick in the LLE below the knee in all dermatomes and allodynia (pain which occurs in response to a stimulus which is usually not painful).  There were no color changes or swelling.  There was no decreased response to pain, temperature and tactile stimulation.  

At the MEB examination (recorded on DD Form 2807 and 2808) dated 18 September 2008, 3 months prior to separation, the CI reported chronic LLE pain from below the knee to the foot.  Pain was constant and varied “from a hot burning sensation to a feeling of ‘bones being crushed and muscles being ripped’ rated 8-10/10.”  Symptoms were aggravated by prolonged standing, walking, activities and cold weather.  The CI was unable to stand for over 30 minutes, lift/carry heavy equipment, or mount/dismount tactical vehicles.  The examiner stated that “All of the treatment modalities were of little help, although the gabapentin and the narcotic analgesics decreased the symptoms.”  Physical examination showed normal heel-toe walk, LLE strength, reflexes and pulses.  There was hypersensitivity “along the left lower extremity.”  Left ankle range of motion (ROM) was dorsiflexion of 20 degrees (normal) and plantar flexion of 40 degrees (normal 45) limited by pain.  With repetition, there was an increase in pain, weakness, fatigue and lack of endurance but no LLE instability/incoordination or further decrease in ankle ROM.  The left knee was stable with “full” ROM and no tenderness.  The examiner referenced the June orthopedic and September neurology examinations summarized above.  

At the VA Compensation and Pension (C&P) evaluation performed the same month as separation, the CI reported constant pain without flare-ups.  Physical examination showed normal gait and station.  Ankle ROM was dorsiflexion of 25 degrees and plantar flexion of 45 degrees without pain on repetitive testing.  The examiner stated that “Touching his foot, heel or lower extremity up to his knee” caused “lancinating pain in the left lower leg and ankle” that was hard for the CI to describe.  Peripheral nerve examination documented “no deformities and intact symmetrical neurological system.”  Radiographs indicated mild osteoarthritis.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the left lower leg condition 20% using the  analogous code 8799-8720 (sciatic nerve neuralgia), citing chronic pain, paresthesias and temperature changes of the foot, rubor of the foot with dysesthesia and full ankle motion as equivalent to moderate incomplete paralysis.  The VA also assigned the left leg condition a 20% using the same code.  The VARD narrative indicated that the VA examination warranted a 10% (mild) rating, but that the MEB findings were more probative for awarding a 20% (moderate) rating.  The VA additionally rated the left ankle 10%, coded 5003-5271 (degenerative arthritis-limited motion, ankle) citing MEB findings of pain limited ankle motion.  The CRPS rating at 20% was well supported with no higher nerve rating warranted since IAW §4.124, neuralgia has a maximum rating equal to moderate incomplete paralysis, which is 20% for the sciatic nerve (the “highest level” nerve in the lower extremity).  Members deliberated whether the left ankle pain limited motion (NARSUM) and the arthritis on radiographs (VA) were separately unfitting and ratable from the CRPS rating.  The Board majority adjudged that the evidence did not show significant limitation of motion and that pain (or pain-limited motion) of the ankle area was properly considered in the primary unfitting CRPS diagnosis (IAW §4.14, avoidance of pyramiding), and therefore concluded that this condition could not be recommended for additional 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 CRPS (left foot and ankle) condition.  

BOARD FINDINGS:  In the matter of the CRPS (left foot and ankle) condition and IAW VASRD §4.124a, the Board majority recommends no change in the PEB adjudication.  There were no other conditions within the Board’s scope of review for consideration.  The single voter for dissent recommended re-characterization and did not elect to submit a minority opinion.  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 w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB
						
29 JUL 2016

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 AR20160011599 (PD-2014-04146)

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