RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01259
BRANCH OF SERVICE:  NAVY 	SEPARATION DATE:  20050207

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Aviation Electronics Technician, medically separated for “reflex sympathetic dystrophy” with a disability rating of 10%.  

CI CONTENTION:  He received a higher rating from the VA.  Other conditions were not evaluated.  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 - 20041021	VARD - 20050330	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Reflex Sympathetic Dystrophy	8799-8720	10%	Postoperative Left Leg Varicose Vein Stripping and Left Great Saphenous Vein Ligation with Postoperative Residuals of Complex Regional Pain Syndrome with Severe Peripheral Arterial Vascular Disease	8699-8620	20%	20041229	
Left Lower Extremity Venous Insufficiency	Cat II					
Sciatic Nerve Radiculopathy	Cat II					
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  30% 	

ANALYSIS SUMMARY:

Reflex Sympathetic Dystrophy (RSD).  According to the service treatment record and MEB narrative summary (NARSUM), the CI’s left RSD condition began in 1997 with a history of varicose veins.  He underwent left saphenous vein stripping/excision in November 2000 with the pathology confirmation.  A left lower extremity venous duplex scan on 13 February 2002 revealed no evidence of deep vein thrombosis.  On 20 February 2002 the CI underwent vein stripping of the left lower extremity to treat the venous insufficiency.  At a surgical clinic visit on 24 February 2003 the CI complained of numbness/tingling on the medial aspect of the left foot with coldness across the toes and inside the foot.  The examiner’s assessment was venous incompetence and suspected isolated sapheno-femoral junction incompetence.  

At a peripheral vasculature clinic visit on 26 March 2003 the CI noted left foot swelling and throbbing with prolonged standing along with vague complaints of calf to foot pain with feelings of fullness.  The CI underwent left greater saphenous vein high ligation/stripping with stab avulsion on 29 May 2003.  Physical therapy provided instruction for hamstring/piriformis muscles stretching and sciatica nerve gliding in November 2003.  An MRI and plain films dated 29 December 2003 demonstrated minimal annular posterior bulges at L3-L4 through L5-S1, borderline degenerative disc disease at L2-L3 andL3-L4, unremarkable sacrum and sacroiliac joints, no evidence of neural compression or disc herniation, no evidence of moderate or severe osteoarthritic changes, no evidence of significant central or lateral stenosis, unremarkable soft tissue structures, and mild rotatory levoscoliosis (rotation of the spine to the left).  

At a peripheral vascular clinic visit on 26 January 2004, the assessment was status post venous stripping with RSD versus a sciatic nerve problem.  Electrophysiology (heart) studies on 12 February 2004 were normal and without any abnormalities suggestive of left tibial motor or sensory neuropathy including the lateral and medial plantar branches, sural or peroneal neuropathy, left lumbar radiculopathy, plexopathy, or more diffuse polyneuropathy.  Examination at the peripheral vascular clinic on 11 March 2004 revealed no varicosities, trophic changes, or edema.  Motor activity was normal with decreased sensation in the lateral foot fourth and fifth toes antegrade to the mid tibia.  The assessment was venous reflux with continued pain symptoms (RSD) and no relief from prescribed medications.  

On 11 May 2004 the CI was given limited duty for RSD and left lower extremity venous reflux insufficiency with limitations of no running, physical training, prolonged standing, or lifting greater than 25 pounds.  The 7 September 2004 MEB NARSUM examination, 5 months prior to separation, noted complaints of left leg pain.  Physical examination was grossly normal throughout with the left leg examination revealing palpable femoral pulses, normal reflexes, no cyanosis or edema, and decreased light touch to sensation over the lateral foot area.

At the 29 December 2004 VA Compensation and Pension (C&P) general examination, 2 months before separation, the CI reported left little toe tingling and numbness, left calf coldness and left upper hamstring tenderness.  Symptoms were worse when running more than a quarter of a mile, standing more than 5 minutes, or with ambulation.  Physical examination showed eight 1 to 1.5 cm scars on the medial left calf and 2 to 3 mm ovoid scars in the left medial calf.  He had a 9 cm scar in the left medial inguinal area with some numbness around the scar from his great saphenous vein ligation, and other scars in the left medial thigh measuring 3.0 cm, 1.0 cm, 5.0 cm, and 3.5 cm from superior to inferior.  The extremities revealed no clubbing, cyanosis, or edema, and no evidence of varicose veins.  Neurological evaluation revealed decreased left pinprick sensitivity at the inguinal area, medial lower thigh, lateral mid-calf, lateral foot, and little toe.  Knee and ankle reflexes were normal.  The CI had a slight limp and complained of radiating pain and paresthesias in all of the left toes which came from the left heel.  A Doppler arterial flow study revealed severe peripheral arterial vascular disease on the left and moderate on the right.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the RSD condition 10%, analogously coded 8799-8720 (neuralgia).  The PEB listed the left lower extremity venous insufficiency and sciatic nerve radiculopathy conditions as related diagnoses (Category II) that contributed to the disability in this case.  The panel agreed the left lower extremity venous insufficiency and sciatic nerve radiculopathy were diagnoses related to the reflex sympathetic dystrophy and were not separate conditions which could be separately rated IAW §4.14 (avoidance of pyramiding; more than one rating based on the same impairment is prohibited).  The VA rated the sciatic nerve condition 20%, analogously coded 8699-8620 (neuritis), based on the C&P general examination, citing incomplete paralysis below the knee which was moderate.

Panel members noted the PEB rated the CI’s condition as a “mild” neuralgia despite use of pain medications including a narcotic, gabapentin, amitriptyline, and a trial of topiramate as well as a sympathetic block with no significant relief having been obtained.  Additionally, a VA Doppler study, proximate to separation, revealed severe left peripheral arterial vascular disease.  Consequently, the panel agreed that the CI’s RSD condition supported a “moderate” impairment.  Members then deliberated if a “moderately severe” RSD condition was supported.  In consideration of the normal heart studies, lack of varicose veins, no further venous system evaluation after the third surgery, and the CI’s ability to run a quarter mile pain-free, members agreed a “moderately severe” condition was not supported.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 20% for the RSD condition, coded 8799-8720.

BOARD FINDINGS:  In the matter of the RSD condition, the panel recommends a disability rating of 20%, coded 8799-8720 IAW VASRD §4.124a.  There are no other conditions within the panel’s scope of review for consideration.

The panel recommends the CI’s prior determination be modified as follows, effective the date of medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Reflex Sympathetic Dystrophy	8799-8720	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150824, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record  

MEMORANDUM FOR COMMANDER, NAVY PERSONNEL COMMAND	
	                          
Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS          

Ref:  (a) DoDI 6040.44
	(b) PDBR ltr dtd 13 Apr 18 ICO XXXXXXXXXXXXXXXXXX  
	(c) PDBR ltr dtd 13 Mar 18 ICO XXXXXXXXXXXXXXXXXX
	(d) PDBR ltr dtd 19 Apr 18 ICO XXXXXXXXXXXXXXXXXX
	(e) PDBR ltr dtd 20 Apr 18 ICO XXXXXXXXXXXXXXXXXX

1.  Pursuant to reference (a), the recommendations of the Physical Disability Board of Review set forth in references (b) through (e) are approved.  The official records of the following individuals are to be corrected as follows:

     a. XXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 10 percent disability rating (increased from 0 percent) effective date of discharge.       

     b. XXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge.

     c. XXXXXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 30 percent rating (increased from 10 percent) effective date of discharge.  

     d. XXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge.
 
3.  Please take action to implement these decisions and provide notification to the above individuals once those actions are complete.