RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00790
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20040317

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a mobilized Reserve E5, Personnel Service Specialist, medically separated for “chronic neuropathic pain, left foot” and “chronic neck pain,” rated 10% each, with a combined disability rating of 20%.

CI CONTENTION:  The CI’s conditions continue to worsen and negatively affect daily activities.  The complete submission is at Exhibit A.

SCOPE OF REVIEW:  The panel’s scope of review is defined in DoDI 6040.44.  It is limited to review of disability ratings assigned 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 or non-compensable.  Any conditions outside the panel’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 panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The panel’s assessment of the PEB rating determination 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(s) at the time of separation.  The panel has neither the role nor the authority to compensate for progression or complications of service-connected conditions after separation.  That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws.  The panel 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 - 20040209	VARD - 20050623  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Neuropathic Pain, Left Foot	5099-5003	10%	Residuals of Surgical Removal of Neuroma from Distal Left Foot	5003	10%	20040805	
Chronic Neck Pain	5243	10%	Degenerative Disk Disease of the Cervical Spine	5243	10%		
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Chronic Neuropathic Pain, Left Foot.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s left foot neuropathic pain condition began in October 1992.  On December 17, 1992 she underwent surgery for neuroma removal.  The CI returned to active duty 17 March 2003 and was evaluated for a P2 profile or MEB referral due to the left foot condition.  

The 24 March 2003 podiatry evaluation noted that the CI had previously been given an L3 profile, but no action regarding a Military Occupational Specialty (MOS) Medical Review Board (MMRB) or MEB had been taken.  There was no record of recent treatment and the podiatrist indicated a trial of optimal care would be undertaken before providing a profile or recommending MEB.  

At the 29 July 2003 podiatry follow-up visit, the CI reported that orthotics were helpful, but there was still bilateral foot pain, although reduced in severity.  The physical examination showed tenderness to palpation of the left foot third interspace, near the third metatarsal.  The CI declined injections or repeat surgery for the left foot.  At the 18 August 2003 MEB examination (recorded on DD Forms 2807 and 2808), 7 months prior to separation, the physical examination showed numbness of the left fourth and fifth toes to monofilament testing.  

The MEB NARSUM examination on 20 August 2003, 7 months prior to separation, noted complaints of left foot pain with difficulty with standing or walking more than a mile.  Physical examination showed the same numbness of the left toes noted above.  Foot strength and pulses were normal.  

At the 5 August 2004 VA Compensation and Pension (C&P) evaluation, 4 months after separation, the examiner noted a “mild degree of tenderness” on the bottom of the left foot since the surgery, resulting in pain walking barefooted on hard or uneven surfaces.  The CI did not use a cane or a crutch or shoe inserts.  Physical examination showed a normal gait that appeared comfortable.  There were healed scars on the top and bottom of the foot between the third and fourth toes that were “slightly” tender.  There was no redness or deformity.  The CI could flex and extend the toes but could not actively spread her toes.  Left foot radiographic (X-ray) studies were normal.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left foot neuropathic pain condition 10%, analogously coded 5003 (arthritis, degenerative), citing the US Army Physical Disability Agency pain policy.  The VA also rated the left foot neuropathic pain condition 10%, coded 5003, citing painful and limited motion of a major joint.

The panel reviewed to see if a higher rating was supported with any applicable VASRD foot code IAW §4.71a.  There was no flatfoot (5276) or other foot deformity (5278), tarsal or metatarsal malunion or nonunion (5283), or evidence of other foot injury (5284) that could be characterized as moderately severe for a higher rating under these codes.  The panel considered if rating the neuropathic pain under a nerve code IAW VASRD §4.124a supported a higher rating.  However, if coded analogously to 8525 (posterior tibial nerve-PTN), an analogous code for tarsal tunnel syndrome, which is an appropriate code for the left foot residual pain and numbness, there was no evidence to support higher than a 10% rating (mild or moderate incomplete paralysis of the PTN).  The panel concluded that the left foot condition could not be characterized as “severe” for higher rating based upon the findings of focal numbness between the third and fourth toes, with normal strength and reflexes at the MEB and VA examinations and a normal gait noted at the VA examination.  There was therefore no higher than a 10% rating available with any alternative VASRD foot or analogous code.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded that there was insufficient cause to recommend a change in the PEB adjudication for the chronic left foot neuropathic pain condition.  

Chronic Neck Pain.  According to the STR and the MEB NARSUM, the CI’s chronic neck pain condition began in August 2003 without any specific injury or trauma.  

The MEB NARSUM examination on 20 August 2004, 7 months prior to separation, noted complaints of neck pain for months with left arm pain for the past week and also noted the CI did not meet retention standards due to the left foot condition only.  Magnetic resonance imaging (MRI) of the cervical spine was performed on 4 September 2003 and showed degenerative disc disease and degenerative joint disease with a moderate disc herniation at C5-6, without evidence of nerve impingement.  

The 24 November 2003 MEB NARSUM addendum, 4 months before separation, noted the cervical MRI results and indicated the neck condition should be included in the MEB.  At the 4 February 2004 physical therapy (PT) evaluation, 1 month before separation, cervical spine ROM was flexion 45 degrees (normal 45) and combined ROM 280 degrees (normal 340).  Painful motion was not addressed.  Electrodiagnostic studies were performed on 9 December 2003 and were stopped before completion at the CI’s request, but showed no evidence of left upper extremity radiculopathy, but there was evidence of cubital tunnel syndrome (ulnar nerve entrapment at the elbow).

At an 11 December 2003 neurosurgery evaluation, the CI reported neck pain that radiated to the left trapezius region, with occasional numbness and tingling of the fifth fingers of both upper extremities.  The physical examination showed tenderness of the trapezius muscles bilaterally.  There was no posterior neck tenderness.  Muscle strength, sensation, and reflexes were normal.  The neurosurgical assessment was that the CI’s symptoms were not correlated with the cervical disc herniation noted on the MRI and no surgery was recommended at the time.  The CI was referred to physical therapy.  The 27 February 2004 PT treatment visit, 1 month before separation, noted decreased flexion and extension of the neck and bilateral trapezius muscle spasms.  The CI was treated with ultrasound and electrostimulation therapy and given a home stretching program.  

At the 5 August 2004 VA C&P evaluation the CI reported intermittent neck pain for the past year, with occasional numbness and tingling in the fourth and fifth fingers of both hands at night, relieved by a change in position.  The neck pain was aggravated by bending forward and opiate pain medication provided significant relief.  Physical examination showed a normal gait and posture.  There was no muscle spasm or abnormal spinal curvature.  Cervical spine range of motion (ROM) measurements showed a flexion of 45 degrees (normal 45) and combined ROM of 300 degrees (normal 340).  The VA examiner indicated there was no pain with cervical ROM.  Strength, sensation, and reflexes of the extremities were normal.  Cervical X-rays showed degenerative disc disease.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic neck pain condition 10%, coded 5243 (intervertebral disc syndrome), citing combined ROM measurements.  The VA also rated the neck pain condition 10% coded 5243 (intervertebral disc syndrome), also citing ROM measurements.  

The panel agreed that a 10% rating, but no higher, was justified for limitation of cervical combined ROM (greater than 170 degrees but not greater than 335 degrees), as reported on the MEB NARSUM and VA examinations proximate to separation.  There was no muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour, thus the next higher 20% rating was not justified on this basis.  There was no evidence of intervertebral disc syndrome (IVDS) which resulted in incapacitating episodes requiring physician-prescribed bed rest to warrant consideration of rating under the alternate VASRD formula for that condition.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded that there was insufficient cause to recommend a change in the PEB adjudication for the chronic neck pain.  

BOARD FINDINGS:  In the matters of the chronic left foot neuropathic pain and the chronic neck pain conditions IAW VASRD §4.71a, the panel unanimously recommends no change in the PEB adjudications.  There are no other conditions within the panel’s scope of review for consideration.  The panel, therefore, recommends that there be no modification or re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150610, with attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170008468, XXXXXXXXXXXXXXXXXX. 

Dear XXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found your separation disability rating and your separation from the Army for disability with severance pay to be accurate.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed), and I accept its recommendation.  I regret to inform you that your application to the DoD PDBR is denied.  

	This decision is final.  Recourse within the Department of Defense or the Department of the Army is exhausted; however, you have the option to seek relief by filing suit in a court of appropriate jurisdiction.

Sincerely,