RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-04206
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20020422

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Security Journeyman, medically separated for “reflex sympathetic dystrophy left lower extremity,” 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 upon a 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 - 20020308	VARD - 20021115	
Condition	Code	Rating	Condition	Code	Rating	Exam	
RSD Left Lower Extremity	8721	20%	RSD Left Lower Extremity	8721	10%	20020826	
COMBINE RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Reflex Sympathetic Dystrophy (RSD) Left Lower Extremity (LLE).  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s RSD condition also referred to as complex regional pain syndrome, type 1, and began in July 2001.  The CI reported left ankle pain, but denied specific trauma or injury, but noted he ran a lot.  The CI developed coolness, paleness, and skin hypersensitivity of the LLE with swelling and pain that traveled to the upper calf.  In July 2001 lower leg radiographic (X-rays) studies were negative, but a bone scan was consistent with RSD.  A magnetic resonance imaging scan of the ankle in October 2001 was negative for any tendon or ligament injury.  The CI was evaluated by multiple specialists including orthopedics, neurology and pain medicine and all agreed with the RSD diagnosis.  Despite treatment the left ankle RSD symptoms continued.  
The MEB NARSUM examination on 13 February 2002, 2 months prior to separation, noted complaints of continued pain, swelling, and color changes of the left ankle and foot.  The CI was taking medication for nerve related pain and pain medications.  Physical examination on 16 January 2002 showed a normal gait.  There was tenderness to palpation of the left ankle.  The CI was “able to flex and extend at the knee and ankle.”  Sensation was intact to light touch. 

At the 26 August 2002  VA Compensation and Pension (C&P) evaluation, performed 4 months after separation, the CI reported pain in the lower one third of his left leg that “comes and goes,” at times with little provocation, such as putting covers over his foot in bed.  He reported that the symptoms had become less severe in the previous 6 months and he was not on any medications for the condition.  He reported his left leg remained bigger than his right and that he was limited because he could not run, or walk or stand for prolonged periods.  Physical examination showed the left ankle was larger than the right and to a lesser degree the left calf was larger than the right.  The CI was able to walk on his heels and toes comfortably.  Strength, sensation, and reflexes of the lower extremities were normal and there was no tenderness, swelling, warmth, or color changes of either foot.  Left foot X-rays noted a deformity of the talus bone (meets the tibia and fibula to form the ankle joint) which may have been congenital or due to previous injury, such as a bone infarct.  

At a VA C&P muscles examination the same day, the CI reported that his LLE symptoms were “not as bad” since being out of the service.  The examination noted the CI could ambulate without aids, was able to toe and heel walk and squat.  The left leg showed “only a light amount of tenderness around the distal tibia and ankle,” without swelling or deformity.  There was “excellent” full range of motion (ROM) of the ankle and foot.  The orthopedic specialist noted the bone scan performed in the service showed no evidence of a stress fracture.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the RSD LLE condition 20%, coded 8721 (common peroneal nerve), for moderate incomplete paralysis of the common peroneal nerve.  The VA rated the RSD, LLE condition 10%, also coded 8721 (VASRD condition name), based on the VA C&P examination 4 months after separation, citing moderate incomplete paralysis of foot movements “which is mild.”  There was evidence of RSD with residual pain, with normal strength, sensation, reflexes and normal ROM of the ankle and foot.  The Board agreed that there was no path to a higher evaluation than the 20% rating assigned by the PEB.  VASRD 4.123 (neuritis) and VASRD 4.124 (neuralgia) both provide guidance that rating for nerve related impairment as evidenced in this case (no weakness, atrophy, sensory or reflex changes) should be no higher than for the “moderate” level of impairment coded as 8721.  The Board considered if coding the RSD condition as 8720 (sciatic nerve) was the more appropriate nerve code to utilize since it allows a maximum rating of 40% for neuritis or neuralgia characterized as “moderately severe.”  However, the Board determined that this was a moot issue because the absence of any permanent residuals other than pain (as noted above) did not support characterizing the condition as “moderately severe.”  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 RSD LLE condition.  

BOARD FINDINGS:  In the matter of the reflex sympathetic dystrophy left lower extremity 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, 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 20141016, w/attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAF/MR
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD  20762

Dear XXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2014-04206.

After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was appropriate.  Accordingly, the Board recommended no re-characterization or modification of your separation.

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding and their conclusion that re-characterization of your separation is not warranted.  Accordingly, I accept their recommendation that your application be denied.

Sincerely,

Attachment:
Record of Proceedings