RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-00638
BRANCH OF SERVICE:  Marine Corps 	SEPARATION DATE:  20041031

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E3, Aircraft Communications Systems Technician, medically separated for “reflex sympathetic dystrophy” with a disability rating of 10%.  

CI CONTENTION:  “Reflex Sympathetic Dystrophy, Complex Regional Pain Syndrome, and Causalgia.”  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 Medical Evaluation Board (MEB), but determined by the PEB 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.  The panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections when appropriate.  The panel’s assessment of the PEB rating determination is based on review of medical records and all available evidence relevant to application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards for 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, which operates 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 disability at the time of separation.  

RATING COMPARISON:  

SERVICE PEB - 20040816	VARD - 20041216	
Condition	Code	Rating	Condition	Code	Rating	Exam	
RSD	8799-8724	20%	s/p Sprain w/ RSD, CRPS, and Causalgia Left Ankle	8799-8724	20%	20041216	
CRPS	Cat II					
Causalgia						
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Reflex Sympathetic Dystrophy (RSD).  According to the service treatment record and MEB narrative summary (NARSUM), the CI’s RSD began after spraining his left ankle in March 2003.  He was treated with physical therapy.  Examination on 21 April 2003 revealed tenderness of the anterior and posterior tibiofibular ligaments.  An 8-month limited duty board was recommended.  At a physical therapy visit on 29 April 2003 it was noted that the CI was on crutches with non-weight bearing secondary to pain. X-rays of the left ankle were negative for a fracture.  On examination the left foot was erythematous with sensitivity to light touch as were the toes (plantar surface, the worst) and the ankle.   Pitting edema was also present.  On ankle dorsiflexion the ankle locked at 10 degrees to neutral and plantar flexion was 10-30 degrees.  Inversion and eversion were 0-5 degrees each.  The examiner’s assessment was left ankle sprain and rule out early RSD.  Neurologic evaluation on 4 June 2003 confirmed the RSD due to classic signs and symptoms of RSD (now called complex regional pain syndrome, or CRPS), including atrophy of the ankle, skin color changes, hyperhidrosis (sweating), edema, and decreased power secondary to pain.  Treatment consisted of Elavil (amitriptyline for nerve pain) and Ultracet (tramadol, an opioid-like drug, and acetaminophen, a pain reliever) for breakthrough pain.  At a neurology clinic visit on 25 September 2003 the CI reported pain on weight bearing and sensitivity to air conditioning.  Elavil, which was not helping, was replaced by Neurontin (gabapentin for nerve pain).  On 15 December 2003, the CI reported being dizzy from the gabapentin, which was discontinued and replaced with valproic acid.  

The 18 May 2004 MEB NARSUM examination, 5 months prior to separation, noted complaints of recurrent, chronic RSD marked by pins and needles.  Physical examination showed the CI had an antalgic gait with normal cerebellar activity and coordination.  There was skin discoloration noted in the distal left lower extremity with a very slow temperature change appreciated, and decreased sensitivity over the left foot primarily at the ball with some minimal hair follicle changes.  No overt atrophy was present.  Celexa (citalopram, an antidepressant) was added to the medication protocol on 18 May 2004.  During the 18 June 2004 MEB examination (recorded on DD Forms 2807-1 and 2808), 4 months prior to separation, the CI reported an impaired use of the left foot due to CRPS.  Physical examination revealed mild purpura over the dorsum of the left foot/ankle, an absent Achilles reflex of the left ankle, hypesthesia (diminished capacity for physical sensation) of the plantar aspect of the left distal foot, and decreased sensation to light touch at the medial left ankle.  Left ankle strength for extension was 4/5 and 3/5 for flexion, which could not be further evaluated due to hypesthesia.  

At the 29 September 2004 VA Compensation and Pension (C&P) examination, 1 month before separation, the CI reported pain in the left ankle with hot and cold sensitivity as well as sensitivity to touch, which affected his ability to walk, sit still, and run.  He developed CRPS marked by pain in his left ankle and foot along with discoloration in the left foot, which was cold to touch with hypersensitivity.  As a result he could not stand for long periods of time or bear weight on his left foot.  Physical examination showed a markedly abnormal gait with a wide exaggerated limp because of a markedly decreased ability to put weight on the outside of his left foot. The left ankle was purplish from the midcalf to the top of the foot and was extremely tender on the posterior aspect and the sole of the foot.  Range of motion (ROM) of the left ankle was normal without pain, deformity, or ankylosis.  There was extreme hypersensitivity on the sole of the left foot and decreased temperature sensation as well as being cold and clammy.  X-rays of the left tibia-fibula and left ankle were normal, and X-rays of the left foot showed a hallux valgus deformity of the left foot.  The examiner noted the CI’s pain was based on the RSD of his left foot, which was extremely tender to touch, and as a result, he walked in a very hobbled, slow, but determined manner.  It appeared that the CI could put very little weight whatsoever on the left foot without experiencing excruciating pain in the foot.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the RSD 20%, coded analogously 8799-8724 (internal popliteal nerve (tibial) neuralgia-moderate).  The PEB listed CRPS and causalgia conditions as related diagnoses (Category II) contributing to the disability in this case.  The panel concluded the Category II diagnoses were not separate conditions which could be reasonably justified as separately unfitting; nor would separate ratings be achievable without violation of VASRD §4.14 (avoidance of pyramiding).  The VA also rated the three conditions mentioned by the PEB at 20% and used the same code (8799-8724), based on the C&P examination, citing status post sprain with RSD, CRPS, and causalgia left ankle based on history and physical findings.

Panel members noted that use of the analogous code 8724 requires the neuralgia to be severe to warrant a 30% rating, and analogous to the finding of an incomplete paralysis of the internal popliteal nerve (tibial), which pertains to ankle ROM.  However, although the pain was severe, weight bearing was excruciating, and his gait was markedly abnormal, and the many prescribed medications provided only limited relief, the CI had full ROM of the left ankle.  Therefore, a higher rating is not achievable since neuralgia can only be rated up to a moderate disability IAW VASRD §4.124 (neuralgia, cranial or peripheral) with the exception of tic douloureux.  Although other nerves are found in the ankle and/or foot, none offer a higher rating than 20%.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded there was insufficient cause to recommend a change in the PEB adjudication for the RSD condition.  

BOARD FINDINGS:  In the matter of the RSD condition and IAW VASRD §4.124a, the panel recommends no change in the PEB adjudication.  There are no other conditions within the panel’s scope of review for consideration.  Therefore, the panel 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 20160915, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs 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

      In accordance with reference (a), I have reviewed the cases listed below 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 USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXX, former USN

					XXXXXXXXXXXXXXXXXX
	     				Acting