RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXXX	CASE:  PD-2015-01297
BRANCH OF SERVICE:  Army	 SEPARATION DATE:  20051029

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4, Combat Engineer, medically separated for “chronic left foot pain,” with a disability rating of 20%.

CI CONTENTION:  His conditions continue to worsen.  His 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 - 20050808	VARD - 20060130	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Foot Pain	9799-8721	20%	Scar S/P Shell Fragment Wound of Left Foot	7804	10%	20060112	
Anxiety Disorder, NOS	Not Unfitting	Anxiety Disorder, NOS (PTSD)	9413	30%	20060112	
RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  70%	

ANALYSIS SUMMARY:   

Chronic Left Foot Pain.  According to service treatment records and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s history of left foot pain began after he sustained a shrapnel injury while serving in Iraq in March 2004.  He had shrapnel removal surgery and repair on 11 April 2004, without complications.  Radiographs of the left foot (weight-bearing) 13 September 2004 noted improvement and healing of the first metatarsal fracture.  The CI participated in physical therapy and was evaluated and treated at the pain rehabilitation clinic; however, he continued to have left foot pain described as constant with intermittent edema and paresthesia of the toes, and pain primarily on the dorsum and ball of the foot.  At the NARSUM dated 18 April 2005, approximately 6 months before separation, the CI described his pain as burning, cramping, and very sensitive to touch, with flashes of heat or cold sensations, and occasional redness.  His pain did not significantly improve in the past year and although primarily located in the dorsum and ball of the foot, his pain sometimes involved his entire ankle and foot region.  Physical examination recorded a well-healed surgical scar of the left foot.  The foot had normal color, hair growth, and temperature.  Range of motion (ROM) testing noted left great toe motion was limited secondary to pain.  Lower extremity motor strength was normal except for the left extensor hallucis longus muscle which demonstrated mild decrease (4/5). This was judged to be weak due to limited patient effort secondary to severe pain with ROM.  There was diminished sensation in the left great toe and dorsum of the foot.  The physician described the CI’s current status as inability to walk or run without pain, and inability to perform activities of prolonged walking, running, ruck marching, and standing in formation to the expected level secondary to pain.  His prognosis was recorded as fair.  The ROM testing was conducted approximately 2 weeks later.  Left ankle measurements on average of 3 trials documented dorsiflexion to 17 degrees (20) and plantar flexion of 7 degrees (45).

The VA Compensation and Pension (C&P) examination was accomplished 3 months after separation and that examination recorded ROM dorsiflexion of the left ankle to 0 degrees, and plantar flexion to 35 degrees with pain at the extremes of both plantar and dorsiflexion.  Objective evidence of painful motion, effusions, edema, instability, weakness, redness, heat or abnormal movement or guarding of movement was absent.  Tenderness of the left ankle was noted.  Foot examination did not reveal any signs of abnormal weight-bearing or breakdown or callouses.  His gait was antalgic, limping on the left lower extremity; however, he used no assistive device for ambulation.  The physician diagnosed a status-post shell fragment wound of the left foot fracturing the first metatarsal and status post soft tissue infection with residuals.  The examiner noted the CI had been diagnosed with complex regional pain syndrome of the left foot.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB and VA chose different coding options for the condition.  The PEB adjudicated the condition as reflex sympathetic dystrophy, coded 8799-8721 (analogous for neuralgia, incomplete paralysis, common peroneal), with a 20% rating for moderate incomplete paralysis.  The VA rated the left lower extremity at 10% coded 5312 (Group XII-function: dorsiflexion, extension of toes) for moderate impairment.  The higher rating of 30% under the 8721 code requires demonstration of incomplete paralysis of foot movements consistent with a severe degree of impairment.  Pain was present during each examination (NARSUM and C&P), and mild weakness and diminished sensation of the great toe and dorsum of foot were recorded at the NARSUM; however, severe sensory loss was not noted, nor was there evidence of severe impairment of motor functioning.  The CI used no assistive device for ambulation, and an abnormal weight-bearing pattern was absent.  The Board concluded there was insufficient evidence to support a higher rating under any of the nerve (8521-8525) or muscle codes (5311, 5312).  The Board next considered the ankle ROM code; however, there was no benefit to the CI under this code (5271) since there is no rating higher than 20% (marked).  The Board, after due diligence, found no additional route to any higher 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 left foot condition.  

Contended PEB Conditions: Anxiety Disorder Not Otherwise Specified (NOS).  The Board’s main charge is to assess the fairness of the PEB’s determination that the contended condition was not unfitting.  The psychiatry NARSUM was conducted 3 months before separation.  That examination documented that the CI’s first presentation to mental health (MH) in June 2005, was in response to trouble sleeping and increased irritability since returning from Iraq in 2004.  He had two recurring nightmares, one, where he hides behind balloons while people are shooting at him and the other he dreams that his left foot is missing. He had recently begun taking medication to assist with his sleep issue and had plans to enroll in a teacher’s program once separated from the military.  He had a good relationship with his wife and children.  The examiner noted the CI was not depressed, and did not think excessively about his war experiences.  The mental status examination was unremarkable.  The psychiatrist noted the CI did not meet the full diagnostic criteria for posttraumatic stress disorder, he had anxiety disorder NOS, did not require a profile for any MH condition, and had a Global Assessment of Functioning score of 75 (if symptoms are present they are transient and expectable reactions to psychosocial stressors).  The anxiety disorder condition was not profiled or implicated in the commander’s statement and was not judged to fail retention standards.  There was no performance-based evidence from the record that any MH condition significantly interfered with satisfactory duty performance.  After due deliberation, and in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the anxiety disorder NOS condition and so no additional disability rating is recommended.

BOARD FINDINGS:  In the matter of the chronic left foot pain condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended anxiety disorder NOS condition, the Board unanimously recommends no change from the PEB determination as not unfitting.  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 20150607, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR Commander

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXXXXXX AR20160014395 (PD201501297)

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