RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-04728
BRANCH OF SERVICE:  aRMY	SEPARATION DATE:  20070528

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Signal Support System Specialist, medically separated for “reflex sympathetic dystrophy left lower leg” with a disability rating of 20%.

CI CONTENTION:  Current condition supports a higher rating.  He was not evaluated for his sleep disorder.  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 - 20070309	VARD - 20080116	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Lower Leg RSD 	8799-8720	20%	Left Lower Extremity RSD	8523	10%	20071219	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  30%	

ANALYSIS SUMMARY:

Left Lower Leg Reflex Sympathetic Dystrophy (RSD).  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI underwent a posterior talar tubercle fracture non-union excision on 9 June 2006 and during the procedure the sural nerve was lacerated.  

On 27 June 2006, the CI reported increasing shooting pain into the lateral and dorsal aspect of the foot.  Treatment consisted of gabapentin (for nerve pain).  At an orthopedic examination on 21 September 2006, the CI reported persistent paresthesia/dysesthesia of the posterior medial aspect of the ankle.  Despite having been casted for 4 weeks, there was no improvement in symptoms and the CI reported worsening of shooting pain.  Examination of the left ankle revealed a well-healed surgical scar with decreased sensation of the lateral border of the foot, but with diffuse tenderness along the lateral aspect of the leg.  Tinel’s sign (to determine nerve irritation) was positive proximally and distally, and there were no skin changes.  

At a 24 October 2006 medical clinic visit, the CI reported “I have pain in my [left] ankle” with numbness of the lateral left foot.  On examination the CI had an antalgic gait and he walked unaided with apparent pain.  There was a well-healed surgical scar of the lateral left ankle with decreased sensation of the lateral foot and ankle.  Light touch elicited pain.  There was no edema, no color and no temperature changes.  Skin texture, hair and nails appeared normal as were the pulses and range of motion (ROM).  The examiner’s assessment was postoperative neuritis of the left foot, although chronic regional pain syndrome type II could not be ruled out.  An orthopedic examination on 20 January 2007 revealed a well-healed incision with decreased sensation of the lateral border of the foot and diffuse tenderness along the lateral aspect of the leg.  Tinel’s test was positive proximally and distally and there were skin changes consistent with RSD.  

The 30 January 2007 MEB NARSUM examination, 4 months prior to separation, noted complaints of left ankle pain that affected his ability to run or walk without constant pain.  The CI also had difficulty climbing stairs and was unable to stand greater than 20 minutes without pain.  Physical examination showed a well-healed lateral incision with some evidence of mild skin changes in the left lower extremity compared to the right.  The lateral aspect of the foot from the small toe to the mid ankle was hypersensitive to touch in the medial aspect of the foot and the ankle had normal sensation.  The left lower extremity was tender to palpation from the mid-thigh to the ankle laterally with no significant symptoms medially.  The ROM of the knee was full and symmetric with the other side.  Left and right ankle ROMs revealed symmetric dorsiflexion of 10 degrees (normal 20) and plantar flexion of 45 degrees (normal) with inversion of 30 degrees and eversion of 10 degrees.  Pulses were 2+ bilaterally and capillary refill was measured to be brisk.  Strength in the left lower extremity was decreased to 4-/5 in all muscle groups tested secondary to pain. 

On 7 March 2007 the CI underwent a left lumbar sympathetic nerve block.  On 23 March 2007 the CI indicated he was tapering his medications and that the pain was reduced by steroid injections and he no longer needed all the narcotics.  At a VA outpatient visit on 10 July 2007, less than 2 months after separation, the CI complained of left lower extremity pain, which progressed to involve the buttock and left lower back with burning/dysesthesia pain of the left foot and occasional swelling of the left ankle.  Treatment consisted of gabapentin and a narcotic.  

At the 19 December 2007 VA Compensation and Pension (C&P) evaluation, 7 months after separation, the CI complained of severe pain on a daily basis involving the left ankle with radiation proximally to the level of the knee posteriorly and laterally.  Pain was described as burning with sharp electric paresthesias as well as dysesthesias radiating up to the left knee.  He also noted severe pain at night when bed sheets brushed up against his left leg.  He denied any side effects from medication and any use of a brace.  He was working part-time as an electrician.  Physical examination showed mild edema involving the left ankle with slight discoloration, with increased pallor, compared to the right.  He had hypesthesia and allodynia involving the left lower extremity compared to the right primarily over the lateral aspect of the foot involving the small toe as well as the posterolateral aspect of the left lower extremity.  He had an antalgic gait and favored the right lower extremity.  Left knee ROM was normal and there was no instability or evidence of a meniscal tear.  The ROM of the left ankle was normal without any change or pain with repetitive testing.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left lower leg condition 20%, coded 8799-8720 (sciatic nerve neuralgia), citing moderate-incomplete paralysis.  The VA rated the left lower leg condition 10%, coded 8523 (anterior tibial nerve (deep peroneal), paralysis of), based on the VA examination, citing moderate-incomplete foot movement paralysis.

Panel members discussed the severity of the CI’s condition.  While the NARSUM indicated the sural nerve was lacerated, there was no operative report in the STR to confirm the fact nor was there evidence of electrodiagnostic testing (nerve conduction studies and/or electromyography) in the STR to ascertain the actual level of nerve or muscle involvement or lack thereof.  Nevertheless, the CI had decreased sensation of the lateral border of the foot and diffuse tenderness along the lateral aspect of the leg with a positive Tinel’s test proximally and distally and skin changes consistent with RSD.  Furthermore, despite regular use of narcotics and a lumbar sympathetic nerve block, pain persisted.  The sural nerve is a sensory nerve in the calf region made up of collateral branches of the tibial nerve and common fibular nerve.  The lateral cutaneous sural nerve originates from the common peroneal nerve and supplies the skin on the posterior and lateral surfaces of the leg.  Panel members noted the PEB rated based on the sciatic nerve, which for complete paralysis is marked by the foot dangles and drops, no active movement of the muscles below the knee, and weakened flexion of the knee.  Based on the clinical findings, the CI, while he had severe pain, paresthesias and dysesthesias, did not have muscle findings consistent with a moderately severe condition, albeit muscle strength was decreased due to pain.  Severe incomplete paralysis disability under code 8523 is rated at 10%, but the CI did not have complete paralysis marked by lost dorsal flexion of the foot.  Complete paralysis under code 8521 is marked by “foot drop and slight droop of the first phalanges of all toes, cannot dorsiflex the foot, extension (dorsal flexion) of proximal phalanges of toes lost; abduction of the foot lost; adduction weakened; anesthesia covers entire dorsum of foot and toes.”  Incomplete severe paralysis warrants a 30% rating; however, there was insufficient muscle involvement and limited sensory hypesthesia and allodynia not involving the entire dorsum of the foot and toes to meet the requirements of a severe disability at the time of separation.  Therefore, the panel was unable to find a route to a higher rating.  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 left lower leg condition.

BOARD FINDINGS:  In the matter of the left lower leg condition and IAW VASRD §4.124a, 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.

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170522, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record

AR20180006726, 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.

Sincerely,					      
Enclosure