RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXX  	CASE:  PD-2017-03970
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050217

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Aviation Operations Specialist, medically separated for “complex regional pain syndrome type I” with a disability rating of 20%.  

CI CONTENTION:  Review all 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 - 20041028	VARD - 20050412	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Complex Regional Pain Syndrome Type I	8799-8720	20%	Left Ankle Sprain with Complex Regional Pain Syndrome	5271	20%	20041202	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:  

Complex Regional Pain Syndrome Type I.  According to the service treatment record and MEB narrative summary (NARSUM), the CI sustained a left ankle inversion injury in October 2003 after stepping in a pothole while carrying a heavy load.  An ankle X-ray was negative, but physical examination revealed a positive drawer sign.  She was seen by orthopedics in November and December 2003 and treated through physical therapy.  In April 2004, the pain dramatically worsened due to increased activity during a deployment.  The CI was placed in a controlled ankle motion (CAM) walker for one month and showed major atrophy in the left lower extremity.  The CAM walker was replaced with a lace-up brace, but she continued to have recurrent inversion injuries.  An air-cast worsened the pain and steroid injections into left ankle tendons and sheaths did not result in significant improvement.  The CI was diagnosed with tendinosis and pain medication dosages were doubled.  A subsequent ankle MRI was normal and nerve conduction studies and electromyography showed no evidence of peroneal motor neuropathy.  A diagnosis of complex regional pain syndrome type I was made and a permanent L3 profile issued.  The commander’s statement on 24 September 2004 noted the CI was able to perform current duties, but was unable to take the fitness test or perform basic soldiering skills due to ankle problems.  

The 30 September 2004 MEB NARSUM examination, 5 months prior to separation, noted complaints of pain, rated from 3-9/10, and aggravated by cold and prolonged standing or walking.  The CI could not lift more than 10 pounds or wear combat boots, and had become sedentary after giving up soccer, coaching, biking, running and shopping; she could swim up to 30 minutes at a time.  Ankle ROM measurements showed severe pain in all planes with active left dorsiflexion to -25 degrees (normal 20) and plantar flexion to 35 degrees (normal 45); passive left dorsiflexion was to -5.  The examiner noted that the CI could not bring her left ankle to the neutral position and had about “10 degrees of anterior/posterior active” and “50 degrees of anterior/posterior passive” ROM.  On inversion and eversion, she had severe pain and guarding, making passive ROM difficult to measure.  Right ankle dorsiflexion was to 10 degrees and plantar flexion to 55 degrees.  Physical examination revealed moderate to severe pain mainly over the lateral malleolar area.  The examiner also referenced focused lower extremity examinations performed by a physiatrist and pain medicine specialist earlier in the month, which noted an antalgic gait with the left foot turned out.  During these evaluations, there was no gross atrophy, or nail/hair growth changes.  Temperature and skin color on the left was reduced as compared to the right but there was good capillary refill.  Left lower extremity strength was 5/5 proximally and 4/5 distally for the extensor halluces longus and inversion and eversion maneuvers. On plantar flexion against gravity, the CI was able to do 20 repetitions on the right versus 5 on the left with a slow heel raise due to pain.  She could heel and toe walk on the right and perform this maneuver somewhat on the left.  Reflexes and sensation were intact, but there was a mild decrease in sensation in the first web space.  A pain clinic re-evaluation was scheduled in November 2004 at which time a decision was to be made about performing a lumbar sympathetic block.   A left ankle MRI in June 2004 was within normal limits, and the examiner opined that the prognosis was good for a sedentary position but not manual labor or work requiring ambulation.  

At the 2 December 2004 VA Compensation and Pension (C&P) examination, 2 months before separation, the CI reported left ankle pain that made prolonged walking difficult.  She could perform yoga and occasionally swim, but had not run since injuring her ankle.  She was taking anti-inflammatory and nerve medications to treat pain, and a November 2004 bone scan showed no evidence of inflammation.  On examination, she walked with a pronounced limp with the left foot turned out, and was unwilling to attempt toe or heel walking due to pain.  There was no gross atrophy nail and hair growth was normal.  Left ankle active dorsiflexion was to -20 degrees with normal plantar flexion.  The examiner noted the “veracity of her subjective complaints” were difficult to verify.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the ankle condition 20%, analogously coded 8799-8720 (neuralgia of the sciatic nerve), citing severe pain on palpation with decreased ROM and guarding and rated as moderate neuralgia.  The VA also rated the ankle condition 20%, coded 5271 (ankle, limited motion of), based on the C&P examination, citing marked limitation of motion, with pain on motion.  Panel members noted that both the NARSUM and C&P examinations documented an antalgic gait and turned out foot, however the VA examiner also noted normal plantar flexion, normal nail and hair growth, and no atrophy, and that the CI could perform yoga and occasionally swim.  The commander indicated the CI was able to perform the duties required of her in an office setting, although she was not able to perform some general soldier duties.  The panel agreed that a 20% rating, and no higher, was justified for  moderate neuralgia under code 8799-8720 or marked limited ankle motion under code 5271.  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 ankle condition.  

BOARD FINDINGS: In the matter of the ankle condition and IAW VASRD §4.124, 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. 

PD-2017-03970

AR20190010934, XXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXX

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.

PD-2017-03970