RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2016-01660
BRANCH OF SERVICE:  navy 	SEPARATION DATE:  20041025

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Aviation Administration, medically separated for “complex regional pain syndrome left leg origin” with a disability rating of 20%.  

CI CONTENTION:  Her condition was not understood, cannot be cured, and leads to other debilitating conditions.  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 - 20040318	VARD - 20030708	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Complex Regional Pain Syndrome Left Leg Origin	8799-8720	20%	Left Leg Arthroscopy…	5271	10%	20030320	
			Left Knee Pain	5260	NSC	20030320	
			Left Sciatica	8520	NSC	20030320	
			Left Leg Neuropathy	8521	NSC	20030320	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  10%	

ANALYSIS SUMMARY:  

Complex Regional Pain Syndrome (CRPS) Left Leg Origin.  According to the service treatment record and MEB narrative summary (NARSUM), the CI had a history of recurrent bilateral ankle sprains since the age of 12.  During the first week of basic training, she reported pain and popping of the left ankle.  She denied acute trauma and the initial x-rays were normal.  An evaluation in podiatry showed mild instability though.  She was treated with a brace, physical therapy, and modified duty; however, her symptoms persisted and she underwent reconstructive surgical repair on 19 March 2001.  This improved her instability, but her pain persisted.  The CI was then placed on her first period of LIMDU (limited duty).  Electrodiagnostic (EDX) testing on 13 December 2001 was consistent with a left tarsal tunnel syndrome (entrapment of the tibial nerve as it travels between some of the tarsal bones).  This was repaired surgically on 17 January 2002.  She underwent rehabilitation in physical therapy with a return of near normal function but with persistent pain.  It was noted in mental health on 21 March 2002 that the CI wanted out of the Navy and that this might contribute to the chronicity of her ankle problems.  She was placed on an additional 8 months of LIMDU effective 24 June 2002.  In a neurology re-evaluation, she was found to have decreased sensation of the left foot and a gait which slightly favored the left leg.  The muscle tone, bulk, and strength were normal.  Repeat EDX testing was normal.  Repeat X-rays on 13 December 2002 showed normal ankles bilaterally.  

At the 20 March 2003 VA initial Compensation and Pension (C&P) examination, 19 months before separation, the CI reported bilateral foot and ankle issues.  On examination, the scars were well healed.  There was variable tenderness and sensation over the left foot.  She walked with a slight limp, but the ankles seemed stable.  She was thought to have a painful lower left extremity without a diagnosis being made.  The CI was seen again in orthopedics on 26 March 2003.  There it was noted that the CI needed a PEB, but also that she should be evaluated for RSD (at the time, reflex sympathetic dystrophy [RSD] was term in use, prior to CRPS).  The examination showed a well healed ankle without instability and slightly reduced range of motion (ROM) with dorsiflexion (toes up) of 15 (normal 20) degrees and plantar flexion of 30 degrees (normal 45).  The CI also had an MRI and a bone scan on the left knee to see if this was a source of the left ankle pain; both were unremarkable.  The CI was seen in rheumatology on 3 June 2003.  There she reported severe trauma to her left ankle with complete dislocation of the left ankle and “complete damage to all of her ligaments.”  The panel observed that this is not consistent with the record.  She also reported ongoing problems with the left foot and ankle with weakness and increased sensitivity to pain (hyperalgesia; this is also seen in chronic overuse of opioid medications for pain).  On examination, the left lower extremity was much colder than the right with diffuse edema.  This was thought to be most consistent with RSD.  A bone scan of the feet and ankles was requested.  It was normal, which is not expected in RSD.  

The 10 June 2003 MEB NARSUM examination, 16 months prior to separation, noted that the CI had continued ankle pain and an abnormal burning sensation.  She walked without a cane and could drive.  She was doing light office work.  On examination, dorsiflexion was limited to (-) 3 degrees and plantar flexion to 20 degrees.  No explanation for the reduction in the ROM from a few months earlier was recorded.  Motion was painful.  Some swelling was present about the scars, but no comment was made regarding the foot’s color, skin condition, temperature, or hair distribution (findings associated with CRPS).  She was thought to have CRPS.  Repeat EDX testing of the left lower extremity was normal on 13 June 2003.  The CI was seen in orthopedic follow-up on 21 July 2003 and thought to have persistent pain from the tarsal tunnel syndrome and possible RSD.  A follow-up in rheumatology on 29 July 2003 noted that the skin was warm and dry, but there was a slight temperature difference to touch and slightly more swelling on the left compared to the right.  Hyperalgesia persisted.  The diagnosis remained RSD.  The CI was then referred to a neurologist and evaluated on 18 August 2003.  The CI reported pain over the entire ankle and foot.  On examination, she was noted to “not appear to be very uncomfortable at this time.”  She had 2 well healed scars.  Multiple areas of the left foot were tender, but there were no color or temperature changes, loss of hair growth, or edema (swelling) of the left foot.  She favored the left foot while walking and had left foot hyperalgesia.  Otherwise, the motor and sensory examination was normal.  There was no objective evidence for CRPS.  In podiatry on 27 August 2003, the CI was again noted to have severe hyperalgesia of the left foot, but normal sensation and to be without the skin findings associated with CRPS.  The CI was seen by a different neurologist on 14 November 2003.  She was again noted to be very sensitive to touch, but to have a normal motor and sensory examination otherwise.  Other causes for the pain including a nerve growth (neuroma) and referred pain were considered as possible diagnoses.  Her medication regimen was modified.  In a pain clinic on 30 July 2004, the CI underwent a lumbar sympathetic block with good relief of her symptoms, consistent with CRPS.  

The CI underwent another VA C&P examination on 30 May 2006, 19 months after separation and outside the normal 12 month window for higher probative value.  The CI reported ongoing left ankle pain.  On examination, both scars were well healed.  The examination of the skin was otherwise unremarkable.  She had a very slight limp favoring the left.  The ROM was full, but painful.  The examination of the feet showed no signs of edema, disturbed circulation, weakness, atrophy, or tenderness.  Sensory and motor function were normal.  X-rays were normal other than bilateral flat foot (pes planus).  She was not diagnosed with CRPS.  

The panel directed attention to its rating recommendation based on the above evidence.  The formal PEB rated the complex regional pain syndrome left leg origin condition 20%, analogously coded as 8720 (sciatic nerve neuralgia).  An EPTS (existed prior to service) contribution was noted, but no deduction was made.  The VA also rated the left leg condition 10%, coded 5271 (limited motion of ankle), based on the earlier C&P examination, citing moderate limited motion of the ankle.  The VA determined the left knee, left sciatica, and left leg neuropathy conditions were not service-connected.  Subsequently, the VA rated the CI 10% for CRPS, based on examinations approximately 3 years after separation, and coded 8720.  The panel considered the evidence.  Other than the rheumatology examinations, the physical findings on examination were subjective: pain, sensory disturbance, and hyperalgesia.  Skin changes seen in CRPS were absent.  Motor loss and atrophy was also absent.  A diagnosis of neuritis is not supported by the evidence.  No more than a rating for moderate incomplete paralysis is warranted IAW VASRD §4.124a (neuralgia).  There is no specific code for CRPS and the panel found no better coding option than the 8720 code used by both the PEB and VA.  A maximum of 20% is warranted under this code and was adjudicated by the PEB.  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 left leg complex regional pain syndrome.  

BOARD FINDINGS:  In the matter of the complex regional pain syndrome 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 20161024, 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 USN
		- XXXXXXXXXXXXXXXXXX, former USMC

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	     				                        Acting