RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00370
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20090724

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E1, Basic Enlisted Airman, medically separated for “left ankle and foot pain secondary to complex regional pain syndrome (CRPS)” with a disability rating of 10%.

CI CONTENTION:  The CI made no specific contention.  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 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 - 20090701	VARD - 20100527	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Left Ankle and Foot Pain Secondary to CRPS	8722	10%	CRPS	8599-8520	20%	20100427	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Chronic Left Ankle and Foot Pain Diagnosis.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI presented on 20 January 2009 with a 2-week history of left ankle and foot pain a left ankle sprain.  On examination, there was diffuse tenderness and pain with motion.  X-rays were normal.  She was treated with medications and duty limitations, but her pain persisted.  Subsequent examinations noted a normal gait and appearance of the foot.  Stress fractures were suspected and a bone scan accomplished on 4 February 2009 which was normal.  She was referred to neurology where she was noted to have a painful gait and possible increased sensitivity to pinprick on the left foot.  There were no skin changes and the motor examination was normal.  
Early CRPS was thought to be possible and a triple phase bone scan was ordered.  It was done on 18 February 2009 and was without changes associated with CRPS.  Stress changes of the knees, ankles, and left mid-foot were present.  She was placed non-weight bearing and prescribed a chronic pain medication, but had persistent pain.  Multiple examination during this time documented a normal gait (abnormal at the neurology evaluation).  She reported that her symptoms increased if she left the leg dependent.  On 3 April 2009, the CI was evaluated in orthopedics.  On examination, the sensory and motor examinations were normal.  No skin changes were present, but global tenderness of the whole foot and ankle was present on examination.  She was given the preliminary diagnosis of CRPS.  She was noted to have a normal gait in trainee health the same day.  She was admitted for pain control for 10 days in late April with some improvement in her symptoms.  In trainee health on 4 May 2009, the neurological and skin examinations were normal, but she had a slight limp.  

The MEB NARSUM examination was performed on 12 May 2009, 2 months prior to separation.  The CI reported that the hypersensitivity of the foot was improved, but her pain persisted.  The appearance of the legs, ankles, and feet was normal.  Motion of the ankle was painful.  The left foot was tender.  The neurological examination and gait were normal.  The CI was seen again on 26 May 2009.  The examination was unchanged, but it is not clear if this was a new examination or if the examination from 2 weeks earlier had been carried forward.  In a VA physical medicine clinic on 18 March 2010, the left foot was red and cool compared to the right with increased sensation over the top of the left foot.  

At the VA Compensation and Pension (C&P) evaluation performed on 27 April 2010, 9 months after separation, the CI reported persistent pain exacerbated by physical activity and relieved by rest.  She had some relief from medications.  It was recorded that she was able to climb stairs, walk, garden, and push a lawnmower.  She was not able to brush her teeth, take a shower, drive a car, or dress herself.  The panel recognized the inconsistency in this and opined that her limitations were in fact reversed.  On examination, the left lower extremity showed a mottled appearance and was cold to the touch with increased sensitivity to touch, although other parts of the examination recorded a normal appearance.  The gait was painful, but the posture normal.  Atrophy and swelling were absent.  The neurological examination was abnormal due to hypersensitivity to touch of the left lower extremity.  Motion of the ankle was full and X-rays were normal.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left ankle and foot pain secondary to CRPS condition 10%, coded 8722 (neuralgia of the superficial peroneal nerve), citing normal gait, normal range of motion, and normal motor exam.  The VA rated the left lower extremity CRPS condition 20%, coded 8599-8520 (analogous to paralysis of the sciatic nerve), based on the C&P examination 9 months after separation, citing incomplete paralysis of the left lower extremity at the moderate level.  The panel considered the evidence.  The NARSUM examination was the most proximate to separation and noted a normal appearance, neurological examination, and gait (consistent with the majority of the clinical encounters prior to separation).  This supported a 0% rating using either code.  Eight months following separation, the CI was noted to have a reddened foot with increased sensitivity in physical medicine.  The VA examination over 6 weeks later had multiple inconsistencies reducing the probative value of the examination.  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 left ankle and foot pain secondary to CRPS condition.  

BOARD FINDINGS:  In the matter of the left ankle and foot pain secondary to CRPS condition and IAW VASRD §4.124a, the panel unanimously recommends no change in the PEB adjudication.  There are no other conditions within the panel’s scope of review for consideration.  The panel, therefore, recommends 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 20160527, with attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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

XXXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXXX:

Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2016-00370.

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.  The Board recommended no re-characterization or modification of your separation.

I 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.  I accept their recommendation that your application be denied.

Sincerely,

Attachment:
Record of Proceedings