RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXX	CASE:  PD-2017-03452
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20090114

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Knowledge Operations Management Craftsman, medically separated for “intractable neuritis of sural nerve with left foot pain” and “Soft tissue contracture of left ankle,” rated 10% each, with a combined disability rating of 20%. 

CI CONTENTION:  In addition to the left ankle and foot conditions, the CI also requested review 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 - 20081119	VARD - 20090714	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Intractable Neuritis of Sural Nerve with Left Foot Pain 	8699-8622	10%	Left Foot Neuropathy of the Lateral Dorsal Cutaneous Nerve 	8525	0%	20090604  	
Soft Tissue Contracture of Left Ankle 	5271	10%	Left Ankle and Foot...Tenosynovitis	5099-5019	10%	20090604  	
			Scars, Left Foot 	7804	10%	20090604  	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  60% 	

ANALYSIS SUMMARY:  

Intractable Neuritis of the Sural Nerve and Soft Tissue Contracture of the Left Ankle.  The separate conditions adjudicated by the PEB, as charted above, were intrinsically part of the same pathology and associated with the same clinical evidence.  The panel is therefore presenting the total evidence, followed by a rating analysis incorporating the separate PEB coding and rating determinations.

According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI underwent surgical correction of hallux valgus (calcaneal osteotomy with percutaneous Achilles tendon lengthening) of the left foot in July 2006.  Painful hardware was removed in February 2007.  She then developed incisional and hindfoot pain that was subsequently diagnosed by MRI as sural nerve entrapment in surgical scar tissue (sural neuritis).  The surgery was additionally complicated by excessive keloid scar formation.  In August 2007 the CI underwent surgery consisting of a bunionectomy, excision of keloid scar tissue and excision of the sural nerve.  Although the initial response was positive with resolution of pain and restoration of near-normal range of motion (ROM), she experienced a recurrence of the neuropathic pain and new keloid formation about six months after that procedure.  This was diagnosed by MRI as a stump neuroma of the sural nerve and Achilles tendinopathy.  The CI underwent a final surgical intervention in March 2008 (10 months before separation) for excision of the neuroma and revision of scar tissue.  A course of post-operative radiation to reduce keloid formation after that procedure yielded positive results, but the sural neuritis persisted and remained intractable.  It was opined that additional surgery was not indicated.

There were multiple STR entries that documented left ankle ROM after the final surgery, which showed a persistent loss of dorsiflexion (DF) with inability to achieve a neutral foot position.  There were numerous entries that attributed this to a flexion contracture that could not be remedied due to the CI’s inability to tolerate physical therapy (PT), typified by one PT comment that “the patient simply will not stretch the calf and/or sural nerve.”  Recorded measurements of DF ranged from minus 15 to minus 20 degrees (normal 20), with plantar flexion (PF) from 35 to 50 degrees (normal 45).  There was ample STR evidence that there was no significant recurrence of keloid scar formation after the final surgery, noting that the CI was pleased with the results.  There were no neurologic or additional VASRD-ratable findings documented in STR clinical notes.

The 25 August 2008 MEB NARSUM examination, 5 months prior to separation, documented “pain in the incisional area and in hindfoot...described as severe, unrelenting and prevents her from wearing a duty boot and performing her duties ... initially responded well...but has not returned to fully functional capacity...little improvement overall.”  The physical examination recorded ambulation with use of a full brace (CAM walker), supplemented by cane or crutches, and mild calf atrophy without specifying other physical findings.  With regard to ankle ROM, the examiner documented DF of minus 15 degrees and PF to 35 degrees, stating “unable to achieve neutral dorsiflexion of the ankle due to stretching of the sural nerve.”

The PEB requested goniometric ROM measurements with clarification of whether ROM was limited by pain or by “soft tissue contracture due to keloid.”  An addendum to the NARSUM did not directly opine with regard to that question, but attached goniometric ROM measurements by PT on 12 November (2 months prior to separation).  These were charted as average DF of minus 32 degrees and average PF to 50 degrees and stated “Limited motion due to pain, swelling, scar, hypersensitive.”  

At the 4 June 2009 VA Compensation and Pension (C&P) examination, 4 months after separation, the CI reported “constant...severe” left foot pain that was exacerbated by standing and walking.  She required no brace or orthotics, but still used a cane “to keep the weight off her left foot.”  Overall occupational and functional limitations attributable specifically to the left foot could not be ascertained because of contributions from multiple other reported orthopedic conditions and complaints.  The physical examination recorded an antalgic gait, non-specific swelling, tenderness, normal alignment (specifying surgically corrected hallux valgus), a sensory deficit of the lateral foot and 4/5 ankle strength.  A detailed scar examination did not note keloid formation, and although two scars were tender, all were described as non-adherent and the examiner specified that none of them affected ROM.  Goniometric ROM measurements for the foot or ankle were not included.  The examiner grossly described ROM as “poor,” without note of a flexion contracture, and documented painful motion.  Two months later (10 August), a note from the same orthopedic consultant who followed the CI on active duty documented continued improvement of ROM and recorded DF of minus 10 degrees.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the sural neuritis (albeit with nomenclature subsuming ROM limitation) 10%, coded analogously as 8622 (neuritis of the superficial peroneal nerve).  The PEB did not elaborate a rationale, but the 10% rating under code 8622 is for “moderate” nerve impairment.  The PEB adjudicated the contracture due to keloid and scar formation as a separate unfitting condition rated 10% under code 5271 (limited motion of the ankle).  Again no rationale was elaborated, but the 10% rating under code 5271 is for “moderate” limitation of motion.  The highest 5271 rating is 20% for “marked” limitation.  

The VA rated the neuropathy 0%, coded 8525 (incomplete paralysis of the posterior tibial nerve), based on the C&P examination, citing failure to satisfy the minimum 10% criterion of “mild” nerve impairment.  The VA collectively rated the surgical residuals of tendinopathy and muscle strain at 10%, coded analogously as 5019 (bursitis), citing painful motion.  The VA also rated the surgical scars 10%, coded 7804 (unstable or painful scars), based on the C&P examination, citing tenderness.  

The panel first agreed that only coding options supported by the evidence were rated for nerve impairment (subsuming pain) and/or for ROM limitation due to pain or mechanical limitation.  There were no applicable ankle joint or foot codes more favorable than those of the PEB, and the pathology was localized such that rating for muscle disability was not justified.  With regard to rating for nerve impairment it was noted that neither of the codes applied by the PEB and VA were specific to the sural nerve.  The latter arises from branches off several major nerves, to include the superficial peroneal (as rated by the PEB), but not the posterior tibial (as rated by the VA).  The choice is moot in that all the applicable rating scales confer a 20% rating for “severe” nerve impairment, the only more favorable option subject to consideration in this case.  Of additional note, the sural nerve is purely sensory with no motor function, and is therefore not a direct cause for limitation of ankle motion due to weakness.  

Because it appeared to be the justification for the PEB’s second rating for ROM limitation, a key issue relevant to the panel’s recommendations was whether there was mechanical limitation of ankle joint motion; although, somewhat confusingly, ROM limitation appeared to be subsumed with the PEB’s neuropathy rating as well.  The panel agreed that there was compelling clinical evidence that there was no significant mechanical interference with ankle joint motion from the keloid or scar contractures; i.e. “soft tissue contracture due to keloid” as rated by the PEB.  Although this question was not explicitly addressed by the NARSUM addendum, it was directly answered by the C&P examiner’s opinion that the scars did not affect ROM.  The latter was also well corroborated by evidence in STR clinical notes.  The preponderance of evidence indicated that it was the pain from sural neuritis, not keloid or scarring, which was responsible for the unfitting disability and ROM limitation.  Having so concluded, the panel had to consider the impact of VASRD §4.14 (avoidance of pyramiding) on any separate rating recommendations.  

The panel’s overall analysis was as follows:  Separate ratings for neuropathic pain and for ROM limitation were reasonable only to the extent that each could be isolated from pyramiding.  To justify concession of the 20% “severe” rating for neuropathic pain (the maximum available as above), it would be necessary to subsume the ROM deficit.  As a result, additional rating under code 5271 for ROM limitation would be prohibited by pyramiding; or, if conceded, the minimum compensable rating could not be supported since painful motion was due to neuropathy (already rated), not to joint disease.  Conversely, concession of the 20% “marked” rating for ROM limitation would logically subsume the bulk of the disability (painful motion, pain with use, etc.), leaving only the relatively minor sensory deficit (confined to the lateral foot) subject to nerve rating.  The latter would not justify the minimum compensable rating (as per the VA opinion), nor could it be defended as separately unfitting for service rating.  The panel agreed that the PEB approach of dividing the disability as moderate for each component was reasonable and fair, considering the issues with apportionment of ROM limitation between ratings as elaborated above, because any defensible separate rating options would not affect the combined rating.

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 sural neuritis and keloid scar conditions.

BOARD FINDINGS:  In the matter of the left foot sural neuritis and IAW VASRD §4.124a, the panel recommends no change in the PEB adjudication.  In the matter of the left ankle contracture and IAW VASRD §4.71a, 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 there be no modification or re-characterization of the CI’s disability and separation determination.  

SAF/MRB
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD 20762

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Dear XXXXXXXXXX:

		Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2017-03452.

After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was appropriate.  Accordingly, the Board recommended no re-characterization or modification of your separation.

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding and their conclusion that re-characterization of your separation is not warranted.  Accordingly, I accept their recommendation that your application be denied.