RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW
NAME:  XXXXXXXXXXXXXXXXXX	CASE: PD-2017-02671
BRANCH OF SERVICE: ARMY	SEPARATION DATE: 20070303

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was a National Guard E4, Infantryman, medically separated for “chronic pain and reflex sympathetic dystrophy of the left foot” with a disability rating of 20%.

CI CONTENTION: Review requested of additional conditions not identified by the Medical Evaluation Board (MEB) and Physical Evaluation Board (PEB). 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 PEB to be unfitting for continued military service, and when specifically requested by the CI, those conditions identified by the 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 - 20070130	VARD - 20070508	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Pain and Reflex Sympathetic Dystrophy of the Left Foot	8799-8721	20%	Residuals of Left Foot Surgery	5299-8525	30%	20061003	
Anxiety Disorder NOS	Not Unfitting	Post Traumatic Stress Disorder (PTSD)	9411	50%	20060831	
Bilateral, Mild to Moderate, Hearing Loss…	Not Unfitting	No VA Examination Proximate to Separation in Evidence	
COMBINED RATING: 10%	COMBINED RATING OF ALL VA CONDITIONS: 70%	

ANALYSIS SUMMARY:

Chronic Pain and Reflex Sympathetic Dystrophy (RSD) of the Left Foot. According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s foot pain began in May 2005 after someone accidentally stepped on his left foot.  On 2 September 2005, he underwent

an open reduction internal fixation (ORIF) and placement of screws to repair a left Lisfranc dislocation and was in a cast for 6 weeks. He then was placed in a controlled ankle motion (CAM) boot and underwent physical therapy. A portion of a screw was removed on 31 March 2006. Left foot pain persisted with increased sweating and mild hypersensitivity, and he was diagnosed with regional pain syndrome (RPS). Left foot X-rays on 29 April 2006 showed a stable left foot status post screw removal with physiologic apparent widening at the Lisfranc joint. A bone scan on 8 May 2006 indicated a possible neurovascular disturbance such as RSD, and abnormal focal left ankle and mid foot bone uptake was consistent with a history of fracture/ORIF. Pain management included a lumbar spinal block, a left ankle saphenous and deep peroneal block, and medications (gabapentin, Pamelor (nortriptyline), and lidocaine patches), which afforded short, but no long-term relief.

The 21 June 2006 MEB NARSUM examination, 8 months prior to separation, noted CI complaints of left foot pain foot when the weather was cold, or when he attempted to run or walk fast. He had pain throughout the night and morning, but minimal pain during the day. His foot did not sweat and the skin remained purplish and dry. Physical examination showed an antalgic gait without use of an aid, and that the left foot was slightly deeper in color than the right. He felt tingling when the lower leg was stroked, but tolerated it. The left arch was normal, and there was a healed linear 4-cm scar on the mid dorsum of the foot. Toe alignment and foot/ankle strength were normal, and maximum bilateral calf circumference was 38 cm. Sensation of the Draglower leg, plantar surface, and medial and lateral border of the foot was intact, but on the dorsum of the foot, he felt touch, but not pinprick. Dorsiflexion was 11 degrees (normal 20) and plantar flexion was 33 degrees (normal 45). Both were limited by pain due to the RPS as well as stiffness. He was uncomfortable when his foot was stroked, but agreed it was “not terrible,” and pain symptoms were reproduced by manipulation of the mid foot.

During the 12 July 2006 MEB examination (recorded on DD Forms 2807-1 and 2808), 8 months before separation, the CI reported the left foot fracture and two operations, and that he could not walk with the left foot and used a cane when needed. Physical examination revealed pain with weight bearing of the left foot, a scar on the dorsum of the foot, and paresthesias with touch on the dorsum of the foot.

At the 3 October 2006 VA Compensation and Pension (C&P) podiatry examination, 5 months before separation, the CI reported left foot pain and the inability to walk or stand without the aid of a cane. Physical examination showed he was unable to bear full weight on his left foot, which caused a significant limp with an apropulsive gait. There was a well-healed scar overlying the midtarsal joint, which was painful to palpation. There was significant swelling of the midtarsal area dorsally, and midtarsal joint motion was restricted to 10 degrees of dorsiflexion secondary to pain He had weakness on inversion and eversion with limited motion. There was a difference in sweating in the left versus right foot, and Tinel’s sign (nerve root irritation) was positive. Left foot X-rays showed evidence of degenerative joint disease at the metatarsal cuneiform joints and screw fixation of a well-healed fracture.

At a primary care examination on 28 January 2008, 11 months after separation, the CI reported worsening of the left foot pain, for which he took a Percocet (narcotic/pain reliever combination) when symptoms were severe. He had recently returned from an overseas trip, where he noticed left inguinal pain. On examination, the left foot had a healed scar and no erythema or warmth. At a preventative health visit on 31 March 2008, 13 months after separation, he was able to ambulate without assistance, and during an orthopedic appointment on 25 April 2008, he reported pain during jogging or prolonged walking, but “pretty much no pain with short walks or at rest.” He was aware of the fact that there was a broken piece of screw/pin in his foot and wanted to know whether it could be taken out. His gait was non-antalgic, and the left foot had  a dorsal prominence, which was mildly tender. There was tenderness over the plantar fascia laterally, but no tenderness over the posterior tibial tendon, and no palpable loose bodies or

metal objects subcutaneously. Left foot X-rays showed a broken threaded pin/screw tip which appeared to lie within the middle cuneiform without evidence of degenerative joint disease and overall normal bony alignment. Plans included a CT scan, nonsteroidal anti-inflammatory drugs, physical therapy, and a pain management consultation. In a phone conversation on 28 July 2008, he reported he was working full-time and denied any pressing issues with his health.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the chronic pain and RSD of the left foot 20%, analogously coded 8799-8721 (external popliteal nerve (common peroneal) neuralgia), citing chronic, constant pain aggravated by touch and not improved with opioid and non-opioid medications, antalgic gait, slightly deeper color on the left compared to the right, tenderness, and decreased foot sensation. The VA rated the residuals of left foot surgery (also claimed as RSD of the left foot) 30%, analogously coded 5299- 8525 (paralysis of posterior tibial nerve), based on the C&P examination, citing complete paralysis (paralysis of all muscles of sole of foot with frequent causalgic pain; toes cannot be flexed; adduction is weakened; plantar flexion is impaired). Panel members noted that under code 8721 neuralgia can only be rated with a maximum equal to moderate incomplete paralysis. While the VA rated 30% using analogous code 8525 for a complete paralysis, neither the service examinations nor the VA examination noted paralysis of all muscles of the sole of the foot, and the foot could be flexed, albeit the CI had pain as a result of RPS. Therefore, the panel felt the option of coding analogously for complete paralysis would be problematic. Alternatively, panel members considered use of analogous code 8699-8621 (external popliteal (common peroneal) neuritis-severe), since the CI had sensory disturbance and pain, sometimes excruciating, which was not completely responsive to multiple medications. Furthermore, VASRD §4.123 permits a rating maximum equal to severe, incomplete, paralysis as long as not characterized by organic changes, which have the maximum for moderate, or with sciatic nerve involvement, for moderately severe incomplete paralysis. Of interest, VASRD §4.63(b) indicates “complete paralysis of the external popliteal nerve (common peroneal) and consequent, foot drop, accompanied by characteristic organic changes including trophic and circulatory disturbances and other concomitants confirmatory of complete paralysis of this nerve, will be taken as loss of use of the foot.” However, the CI did not have complete foot drop nor did he have significant trophic or circulatory disturbances. To suggest complete paralysis as loss of use of the left foot in this case is clearly overstating the disability, especially since post-separation, many of his symptoms improved. The panel also considered code 5284 (foot injuries, other) since there was an injury that began the process, which evolved to the RSD. While the CI had clinical findings of an inability to bear weight, use of a cane, retained hardware, and postoperative pain, many of the symptoms were improved or resolved post-separation. Therefore, the panel considered the disability to be consistent with a moderately severe foot injury at 20% rather than a severe injury at 30%. After due deliberation, considering all 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 chronic pain and RSD of the left foot condition.

Contended PEB Conditions: Anxiety Disorder NOS and Bilateral, Mild to Moderate, Hearing Loss. The panel’s main charge is to assess the fairness of the PEB determination that the contended conditions were not unfitting. None of the conditions were profiled, and did not fail retention standards. There was no commander’s statement in the STR, although the PEB Proceedings indicated that “the conditions were not commented upon by the commander as to hinder the Soldier’s performance.” There was no performance-based evidence from the record that any of the conditions significantly interfered with satisfactory duty performance at separation. After due deliberation, the panel concluded there was insufficient cause to recommend a change in the PEB fitness determination for any of the contended conditions, so no additional disability ratings are recommended.

BOARD FINDINGS: In the matter of the chronic pain and reflex sympathetic dystrophy of the left foot and IAW VASRD §4.124a, the panel recommends no change in the PEB adjudication. In the matter of the contended anxiety disorder and bilateral hearing loss, the panel recommends no change from the PEB determinations as not unfitting. 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 20170316, w/atchs Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record

AR20190008059, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found your separation disability rating and your separation from the Army for disability with severance pay to be accurate.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed), and I accept its recommendation.  I regret to inform you that your application to the DoD PDBR is denied.  

	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.