RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-01458
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20060902

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E7, Cryptologic Linguist, medically separated for “reflex sympathetic dystrophy left ankle” with a disability rating of 20%.  

CI CONTENTION:  “Have crippling pain related to my RSD.  The ankle fusion has changed my gate while walking causing me to have knee surgery and causing serious problems with my lower back.”  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 - 20060705	VARD - 20070103	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Reflex Sympathetic Dystrophy Left Ankle…with Left Ankle Arthrodesis	8799-8721	20%	Status Post Left Ankle Fusion, with Reflex Sympathetic Dystrophy, and Residual Scar Left Ankle	8521	30%	20060708	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Reflex Sympathetic Dystrophy (RSD) Left Ankle, Status Post Multiple Surgical Procedures for Ankle Fracture with Left Ankle Arthrodesis.  The PEB combined the left leg RSD and left ankle arthrodesis conditions under a single disability rating, coded 8799-8721 (analogous to neuralgia of the external popliteal nerve) and rated 20%.  This approach by the PEB not uncommonly reflected its judgment that the constellation of conditions was unfitting, and there was no need for separate fitness adjudications.  The panel’s initial charge in this case was therefore directed at determining if combining conditions under a single rating was justified in lieu of separate ratings.  When considering a separate rating for each condition, the panel considers each bundled condition to be reasonably justified as separately unfitting unless a preponderance of evidence indicates the condition would not cause the member to be referred into the DES or be found unfit because of physical disability.  When the panel recommends separate fitness recommendations in this circumstance, its recommendations may not produce a lower combined rating than that of the PEB.  The evidence for the left leg RSD and left ankle arthrodesis conditions are presented separately, with attendant recommendations regarding separate unfitness, and separate rating if indicated.  

Left Leg RSD.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s RSD left ankle condition began after an April 2004 left ankle fusion operation.  He received treatment with medications, injections, and activity limiting profiles with no sustained improvement of symptoms.  There was no additional surgical indication.  

The 5 May 2006 MEB NARSUM examination, 4 months prior to separation, noted complaints of intermittent burning pain in his left leg, sometimes so intense it was considered incapacitating and required bedrest to resolve.  Physical examination showed hair loss anteriorly with pain on light touch to the left lower leg.  During the 19 May 2006 MEB examination (recorded on DD Forms 2807-1 and 2808), 4 months prior to separation, the CI reported he was constantly in pain, sometimes so severe that he was bedridden and “very sick from it.”  Physical examination revealed abnormal sensation to the anterior left ankle and proximal dorsal left foot.  

At the 8 July 2006 VA Compensation and Pension (C&P) examination, 2 months before separation, the CI reported abnormal sensation and constant pain around the left ankle.  Pain intensity was described as 8/10, and when it increased it was completely incapacitating (three times per month).  The CI reported 18 incapacitating episodes over the preceding 12 months for a total of 30 days.  Physical examination demonstrated decreased sensation of the left ankle and foot with absent knee jerk and ankle jerk reflexes on the left.  Reflexes on the right knee and ankle were normal.  

The panel first considered if the left leg RSD, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The panel noted the RSD condition was profiled, was cited in the commander’s letter as a contributing factor in the CI’s decline in performance, and was judged to fail retention standards.  Panel members agreed the evidence reasonably justified that the functional limitations of the condition contributed to the CI’s inability to perform his military duties, and accordingly a separate disability rating is recommended.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the RSD left ankle condition 20%, analogously coded 8799-8721 (neuralgia of the external popliteal nerve), citing hair loss and increased sensitivity.  The VA combined the status post left ankle fusion, RSD, and residual scar conditions and rated them 30%, coded 8521 (paralysis of the external popliteal nerve), based on the C&P examination, citing incomplete paralysis which was severe.  VASRD §4.124 states when neuralgia is characterized by a dull and intermittent pain, the nerve is rated on the same scale as neuritis with a maximum rating equal to moderate incomplete paralysis.  The panel noted the PEB assigned the rating for moderate incomplete paralysis of the external popliteal nerve to the RSD condition which is the maximum rating available.  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 left ankle condition.  

Left Ankle Arthrodesis.  According to the STR and MEB NARSUM, the CI’s left ankle condition began in December 2001 when he underwent open reduction and internal fixation of an ankle fracture and dislocation.  He had several other procedures resulting eventually in an ankle fusion in 2004 and removal of hardware in January 2006, which did not result in resolution of his ankle pain.  A 19 July 2006 X-ray of the left ankle showed almost complete obliteration of the talo-tibial joint (ankle) with trabeculae (bone formation) from the tibia to the talus, indicating the joint was fused.  There was no further surgical indication.  

The MEB NARSUM examination noted complaints of ankle pain and difficulty with ambulation.  He was unable to complete a regular or alternate Army physical fitness test (APFT).  Physical examination showed an antalgic gait.  The examiner quoted the results of a 27 April 2006 physical therapy visit to obtain range of motion measurements for the MEB, which showed left ankle dorsiflexion was to -11 degrees (normal 20) and planter flexion was to 27 degrees (normal 45).  At the 11 May 2006 pain management evaluation, the CI complained of left ankle pain.  Physical examination showed dorsiflexion to 0 degrees and planter flexion to 0 degrees.  The MEB examination reported marked decrease in range of motion without providing measurements.  

At the C&P examination the CI reported pain, swelling, stiffness, and lack of endurance in the left ankle.  Physical examination revealed an abnormal gait with a limp due to left ankle pain.  Dorsiflexion was 0 degrees and plantar flexion was 0 degrees.  The examiner reported X‑ray findings of an old healed fracture of the distal tibia and fibula with fusion of the talo-tibial joint.  

The panel then considered if the left ankle arthrodesis, having been de-coupled from the combined PEB adjudication, remained separately unfitting as established above.  The left ankle arthrodesis was profiled, implicated in the commander’s statement, and judged to fail retention standards.  The CI was unable to participate in even an alternate event APFT due to the abnormal gait caused by his ankle fusion.  Panel members agreed the evidence reasonably justified that the functional limitations of the condition contributed to the CI’s inability to perform his military duties, and accordingly a separate disability rating is recommended.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB did not separately rate the left ankle arthrodesis condition.  The VA combined the status post left ankle fusion, RSD and residual scar conditions and rated them 30%, coded 8521 (paralysis of the external popliteal nerve), based on the C&P examination, citing incomplete paralysis which was severe.  

The ankylosis of the ankle joint was in neutral, not plantar flexion, which does not provide a rating using code 5270.  There was no ankylosis of the subastragalar joint (5272) or malunion of the os calcis or astragalus (5273), and no history of astragalectomy (5274).  There was marked limitation of ankle motion for a 20% rating under code 5271.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a separately unfit determination with a disability rating of 20% for the left ankle arthrodesis condition, coded 5271.  

BOARD FINDINGS:  In the matter of the RSD left ankle and left ankle arthrodesis conditions, the panel recommends each condition be separately adjudicated as follows: an unfitting RSD left ankle condition coded 8799-8721 and rated 20% IAW VASRD §4.124a, and an unfitting left ankle arthrodesis condition coded 5271 and rated 20% IAW VASRD §4.71a.  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; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective the date of medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Reflex Sympathetic Dystrophy Left Ankle, Status Post Multiple Surgical Procedures for Ankle Fracture	8799-8721	20%	
Left Ankle Arthrodesis	5271	20%	
COMBINED	40%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170222, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20180007885, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

I accept the recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) to re-characterize your separation as a disability retirement with the combined disability rating of 40% effective the date of your medical separation for disability with severance pay.  Enclosed is a copy of the Board’s recommendation and record of proceedings for your information.

	The re-characterization of your separation as a disability retirement will result in an adjustment to your pay providing retirement pay from the date of your original medical separation minus the amount of severance pay you were previously paid at separation.
 
	The accepted DoD PDBR recommendation has been forwarded to the Army Physical Disability Agency for required correction of records and then to the U.S. Defense Finance and Accounting Service to make the necessary adjustment to your pay and allowances.  These agencies will provide you with official notification by mail as soon as the directed corrections have been made and will provide information on your retirement benefits.  Due to the large number of cases in process, please be advised that it may be several months before you receive notification that the corrections are completed and pay adjusted.  Inquiry concerning your correction of records should be addressed to the U.S. Army Physical Disability Agency, (AHRC-DO), XXXXXXXXXXXXXXXXXX.

	A copy of this decision has also been provided to the Department of Veterans Affairs. 

Sincerely,					      
Enclosure