RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-01960
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070820

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Topographic Analyst, medically separated for “neuropathic pain in left ankle and foot” with a disability rating of 0%.  

CI CONTENTION:  No specific contention made.  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 - 20070613	VARD - 20070927	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Neuropathic Pain in Left Ankle and Foot	8722	0%	Status Post Frostbite of the Left 2nd and 3rd Toe with Residual Numbness	7122	10%	20070723	
			Left Achilles Tendonitis	5284	10%	20070723	
			Left Foot Hammertoes	5282	0%	20070723	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

Neuropathic Pain in Left Ankle and Foot.  According to the service treatment record and MEB narrative summary (NARSUM), the CI’s neuropathic pain in left ankle and foot condition began in March 2003 when she sustained a left ankle injury and was exacerbated in January 2005 during conditions of extreme cold when the CI had a cold injury to the left second toe.  

At an orthopedic clinic visit on 12 September 2005, the CI complained of left ankle pain laterally and posteriorly for 2 years.  Her boots showed outside wear (pronator).  There was tenderness along the peroneal tendon.  The examiner indicated the CI had left peroneal tendonitis (chronic) and heel lifts and cups were prescribed along with NSAIDs and a SLWC (short leg walking cast) for 2 weeks.  An X-ray of the left ankle on 12 September 2005 and an MRI of the left ankle on 11 October 2005 were negative.  

At the 15 November 2005 pain management clinic the CI had tenderness anterior to the left Achilles tendon and paresthesias of the left second and third digits.  The examiner’s assessed Achilles tendonitis versus neuropathy.  Treatment consisted of Mobic (meloxicam, an NSAID), and Elavil (amitriptyline for nerve pain).  At the January 2006 pain management visit, the examiner considered the differential diagnosis to include Achilles tendonitis versus neuropathy vs. CRPS (complex regional pain syndrome), which was felt to be unlikely, versus lumbar spine pathology.  

A neurology note dated 5 March 2007 indicated the CI denied any back pain or radiculitis symptoms.  The neurologist noted that some of her complaints could have been related to the frostbite, but not all of them.  An EMG nerve conduction study of the left lower extremity on 9 March 2007 was essentially normal without any evidence for any major or significant nerve damage.  Her peroneal motor stimulation produced a borderline prolonged latency, which might have indicated a very mild left common peroneal neuropathy; however, the cold injury was difficult to explain how it could produce a common peroneal neuropathy or explain all of her symptoms.  The CI claimed her numbness recently progressed up to involving the posterior aspect of the left ankle, which is not supplied by the common peroneal nerve, but is in the distribution of the tibial or sural nerves, which were normal.  The neurologist suggested the some of her symptoms in the left foot may be secondary to the mechanical instability caught after frostbite.  Neurontin (gabapentin for nerve pain) was to be continued with a gradual increase in dose along with Celebrex (celecoxib).  On 26 March, the CI reported the Neurontin was helping. 

During the 3 April 2007 MEB examination (recorded on DD Forms 2807-1 and 2808), 5 months prior to separation, the CI reported continued left foot trouble since 2003.  Physical examination revealed no skin changes, good capillary refill, and no anterior heel tenderness.  The 18 April 2007 MEB NARSUM examination, 4 months prior to separation, noted complaints of numbness and pain in the left foot and ankle, which was aggravated by all high impact events.  Physical examination showed no defining abnormality of the feet.  At a physical therapy clinic visit on 26 April 2007 no ankle weakness or antalgic gait was observed.  The range of motion (ROM) measurements of the left ankle were dorsiflexion -5 degrees (normal 20) and plantar flexion 50 degrees (normal 45).  

At the 23 July 2007 VA Compensation and Pension (C&P) evaluation, 1 month before separation, the CI reported pain on the left posterior heel at rest, on standing, and on walking.  The CI took Neurontin, which helped, and used sole inserts in her boots, which also helped.  Physical examination showed normal arches with full weight bearing, bilaterally.  The range of motion of the toes was normal with no painful motion.  There was tenderness along the medial arch and not specific to the inferior, medial calcaneal insertion of the plantar tendon but more diffuse, and significant tenderness of the posterior heel and of the Achilles tendon with sensitivity.  There was also diffuse tenderness to entail the lateral, medial and anterior ankle joint with no specific focus of pain.  Dorsiflexion of the ankle was 5 degrees with flinching and reported pain of the Achilles tendon regionally.  Numbness of the distal tips of the second and third toes of the left foot and on the extensor surfaces.  There was no amputation or tissue loss noted specifically of the second toe of the left foot.  Otherwise monofilament testing was normal and there was no skin or vascular changes.  There was no functional limitation noted with standing or walking and no abnormal wearing was noted of the CI’s boots.  X-rays of the left foot showed no demonstrable fracture or dislocation, but there was a cystic lucency (less bone density) at the anterior aspect of the calcaneus.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the neuropathic pain in the left ankle and foot conditions 0%, coded 8722 (musculocutaneous nerve (superficial peroneal)-neuralgia), citing rated as neuralgia equivalent to mild partial paralysis.  The VA rated the status post frostbite of the left second and third toes with residual numbness (includes claimed loss of toe and neuropathy) condition 10%, coded 7122 (cold injury residuals: arthralgia or other pain, numbness, or cold sensitivity), based on the C&P examination, citing a history of cold injury with residual numbness and pain in the left second and third toes without additional symptoms on examination.  The VA also rated the left Achilles tendonitis (claimed as left foot and ankle pain/instability and stress fracture condition 10%, coded 5284 (foot injuries, other: moderate), based on the C&P examination, citing left Achilles tendonitis with moderate symptoms of tenderness to palpation and painful movement on examination.

The panel noted that the PEB combined the neuropathic pain of left ankle and foot condition and coded 8722.  However, from a historical basis the CI sustained a left ankle injury during basic training in 2003, which despite several imaging studies, a possible stress fracture noted on one study could not be confirmed on follow-up studies nor did the pain completely resolve despite treatment.  In 2005 the CI had a frostbite injury to the left second toe, the pain of which spread to the left third toe and subsequently to the lateral aspect of the left foot and ankle.  Neurologic evaluation including EMG nerve conduction studies did suggest a mild peroneal muscle borderline prolonged distal latency, which might have indicated a very mild left common peroneal neuropathy; however, not all of the CI’s symptoms followed that nerve distribution.  Further examinations suggested Achilles tendonitis.  

The panel then discussed whether the foot and ankle pain could be considered separately unfitting based on clinical history and/or an anatomical basis.  However, the residual pain from the ankle sprain and the numbness of the toes could not be explained by neurologic findings alone.  Therefore, use of code 5284 for foot injuries encompasses the constellation of symptoms and injuries that the CI experienced; therefore, the left foot and ankle (portions of which include structures in the foot including the insertion of the Achilles tendon) conditions can be successfully combined as a unity rather than each being considered and/or determined to be separately unfitting, thereby avoiding pyramiding IAW VASRD §4.14.  The panel then determined the CI’s condition warrants a 10% rating using the code 7122-5284 and no higher in the absence of a moderate neuralgia (code 8722), which was not supported by EMG nerve studies, a moderately severe foot injury, or an ankle injury with ankylosis (codes 5270 or 5272), ankle limitation (code 5271), os calcis or astragalus malunion (code 5273), or having undergone an astragalectomy (code 5274).  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the neuropathic pain of the left foot and ankle condition, coded 7122-5284.  

BOARD FINDINGS:  In the matter of the neuropathic pain of the left foot and ankle condition, the panel recommends a disability rating of 10%, coded 7122-5284 IAW VASRD 4.104 and 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, effective the date of medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Neuropathic Pain of the Left Foot and Ankle	7122-5284	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170331, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20180011265, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX

The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found that your disability rating should be modified to 10% but not to the degree that would justify changing your separation for disability with severance pay to a permanent retirement with disability.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed) and I accept its recommendation.  This will not result in any change to your separation document or the amount of severance pay.  A copy of this decision will be filed with your Physical Evaluation Board records.  I regret that the facts of the case did not provide you with the outcome you may have desired.
  
	This decision is final.  Recourse within the Department of Defense or the Department of the Army is exhausted; however, you have the option to seek relief by filing suit in a court of appropriate jurisdiction. 

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

Sincerely,					      
Enclosure