RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01289
BRANCH OF SERVICE:  Navy 	SEPARATION DATE:  20081224

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E1, Service and Supply Handler, medically separated for “reflex sympathetic dystrophy of the left big toe due to compartment syndrome,” with a disability rating of 0%.  

CI CONTENTION:  The CI made no specific contention, but listed the following:  “high blood pressure, lower leg fasciotomy, RSD on R foot rhabdomyolysis, hemodialysis from renal failure.”  The CI’s 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 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 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 - 20080814	VARD - 20100607	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Reflex Sympathetic Dystrophy of the Left Big Toe due to Compartment Syndrome…	8799-8723	0%	Peripheral Neuropathy, Left Lower Extremity	8599-8520	0%	20090312	
Acute Renal Failure, Resolved	Category III	Kidney/Renal Failure	7532	NSC	20090312	
Hypertension	Category III	Hypertension	7101	NSC	20090312	
Abnormal Liver Associated Enzymes	Category III	No VA Placement	20090312	
Sickle Cell Trait	Category III	Rhabdomyolysis	5299-5329 	NSC	20090312	
Rhabdomyolysis Secondary to Sickle Cell Trait Resolved	Category III					
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Reflex Sympathetic Dystrophy of the Left Big Toe due to Compartment Syndrome.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), in April 2008 the CI had syncope during physical exercise and was emergently hospitalized and underwent fasciotomy release for left lower extremity compartment syndrome.  Hospitalization was prolonged and the CI had rhabdomyolysis (muscle breakdown products into the blood) requiring dialysis due to acute renal failure.  The CI had a prolonged intensive care unit stay and was discharged from the hospital on 28 June 2008.  He developed left great toe pain and paresthesias (abnormal sensations) diagnosed as reflex sympathetic dystrophy (RSD) and could not return to training.  The MEB forwarded “rhabdomyolysis;” “essential hypertension unspecified;” “acute renal failure, unspecified;” “reflex sympathetic dystrophy of other specified site;” “nonspecific abnormal results of function study, liver;” and “sickle-cell trait,” for PEB adjudication.  

The MEB NARSUM examination on 26 June 2008, 6 months prior to separation, noted complaints of left great toe pain (RSD).  “He was able to walk long distances without much difficulty” and had 5/10 great toe pain.  The CI was taking neuroactive medication (Lyrica [pregabalin]).  Physical examination showed a normal gait.  There was a healing scar over the left lower extremity.  Strength was 5/5 (normal) bilaterally, and sensory exam was normal.  The NARSUM indicated that the CI “suffered a severe episode of rhabdomyolysis while performing physical exercise … His sickle cell trait places him at high risk for recurrence of rhabdomyolysis during heavy physical exertion.”  

At the 19 February 2009 VA Compensation and Pension (C&P) evaluation, performed 2 months after separation, the CI reported left leg tingling and numbness, abnormal sensation, pain and anesthesia in the left foot.  Physical exam showed normal posture and gait.  The left lower extremity had normal muscle strength and reflexes.  There was a sensory deficit to light touch over the left anterior tibia and top of the foot.  There were no vascular abnormalities.  X-rays of the left ankle and foot were normal.  The physician stated that “the most likely peripheral nerve involved is left saphenous.”  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the RSD condition 0%, analogously coded 8723 (neuralgia, anterior tibial nerve).  The VA rated the left lower extremity peripheral neuropathy (claimed as RSD and foot drop), 0%, analogously coded 8520 (sciatic nerve, paralysis of), based on the C&P examination 2 months after separation, citing a noncompensable evaluation.  

There was no muscle weakness or muscle atrophy in the left lower extremity and the CI had a normal gait.  Although the Service exam showed no sensory deficit, the post-separation VA exam showed a sensory deficit in the distribution of the left saphenous nerve.  Absent motor loss, there is no rating higher than 0% under the internal saphenous nerve (8727).  There was insufficient evidence of moderate incomplete paralysis equivalent under the anterior tibial nerve (deep peroneal) distribution or for mild incomplete sciatic incomplete paralysis for any higher rating than that awarded by the PEB and VA.  

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 RSD condition.  

Contended PEB Conditions:  Acute Renal Failure, Resolved; Hypertension; Abnormal Liver Associated Enzymes; Sickle Cell Trait; and Rhabdomyolysis Secondary to Sickle Cell Trait Resolved.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  There was no limited duty and the NMA commander’s statement did not implicate any specific condition.  The acute renal failure, and rhabdomyolosis conditions were resolved by the date of the NARSUM and therefore not ratable disability conditions.  The hypertension condition was controlled on medication.  The abnormal liver associated enzymes were evaluated by gastroenterology and considered secondary to recent multi-organ system failure as well as from some of the CI’s medications; there was no therefore no diagnosed hepatic condition for disability determination.  Sickle cell trait is a hereditary and/or genetic diseases (DODI 1332.38) and is not disqualifying for continued service.  There was no performance-based evidence from the record that any of the conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded that there was insufficient cause to recommend a change in the PEB fitness determination for any of the contended conditions and so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the “reflex sympathetic dystrophy of the left big toe due to compartment syndrome…” condition and IAW VASRD §4.124a, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the contended acute renal failure; hypertension; abnormal liver associated enzymes; sickle cell trait; and rhabdomyolysis secondary to sickle cell trait conditions, the panel unanimously recommends no change from the PEB determinations as not unfitting.  There were no other conditions within the panel’s scope of review for consideration.  The panel, 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 20150607, 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 10 May 17

      In accordance with reference (a), I have reviewed the cases forwarded by reference (b), and 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:

		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USN
		- XXXXXXXXXXXXXXXXXX, former USN

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