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AF | PDBR | CY2012 | PD2012 01281
Original file (PD2012 01281.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXX   CASE: PD1201281
BRANCH OF SERVICE: Army  BOARD DATE: 20130919
Date of SEPARATION: 20040731


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was a mobilized Reserve SGT/E-5 (88M20/Truck Driver) medically separated for a foot injury. He suffered a crush injury to the distal left foot and great toe; resulting in several surgical interventions; and, he was subsequently diagnosed with complex regional pain syndrome (CRPS). The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS) or satisfy physical fitness standards. He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB). Both CRPS and “osteoarthritis left big toe” were forwarded to the Physical Evaluation Board (PEB) as medically unacceptable conditions IAW AR 40-501; and, no other conditions were submitted. The PEB adjudicated “chronic regional pain syndrome, left foot with osteoarthritis great toe” as a single unfitting condition, rated 20%, citing criteria of the Veterans Affairs Schedule for Rating Disabilities (VASRD). The CI made no appeals and was medically separated.


CI CONTENTION: “I was granted 30 percent from the VA on my initial rating decision for the same condition effective August I, 2004, the earliest date after my ETS.”


SCOPE OF REVIEW: The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e. (2). It is limited to those conditions determined by the PEB to be unfitting for continued military service and those conditions identified but not determined to be unfitting by the PEB when specifically requested by the CI. The rating for the unfitting left foot condition is addressed below; and, no additional conditions are within the DoDI 6040.44 defined purview of the Board. The Board considers VA evidence proximate to separation in arriving at its recommendations; and, DoDI 6040.44 defines a 12-month interval for special consideration to evidence after separation. Evidence after separation is probative to the Board’s recommendations only to the extent that it reasonably reflects the disability at the time of separation. Any conditions or contention not requested in this application, or otherwise outside the Board’s defined scope of review, remain eligible for future consideration by the Board for Correction of Military Records.


RATING COMPARISON:

Service IPEB – Dated 20040304
 VA (5+ Mos. Post-Separation
Condition
 Code Rating Condition Code Rating Exam
CRPS w/ Osteoarthritis of Great Toe, Left Foot
 8799-8720 20% Crush Injury w/ Surgical Residuals Great Toe and Hallux Valgus, Left Foot 5280-5284 30% 20050119
No Additional MEB/PEB Entries
 Other x 3 20050115
Combined: 20%
 Combined: 70%
Derived from VA Rating Decision (VA RD ) dated 200 50420 ( most proximate to date of separation [ DOS ] ).


ANALYSIS SUMMARY:

Left Foot Condition. The CI's foot was crushed by an aircraft ramp in Afghanistan in March 2003; with X-rays and operative reports indicating that the damage was limited to the great toe and contiguous forefoot. He suffered a comminuted fracture of the proximal phalanx (great toe) which was irrigated, debrided, and wire-fixated soon after the injury. In July 2003 he was diagnosed with osteomyelitis (bone infection) which was surgically managed by incision and drainage, hardware removal, and a course of outpatient intravenous antibiotics. With persistent symptoms, he underwent a 3rd surgical intervention in September 2003 for resection and arthrodesis (surgical fusion) of the interphalangeal (IP) joint. This operative note indicates that this surgery was performed under a deep peroneal nerve block. The CI then developed severe pain sensitivity of the great toe and distal foot (without sensory impairment or weakness) which significantly interfered with ambulation and activity. A diagnosis of CRPS was suspected and confirmed by neurology in December 2003. Treatment ensued with neuropathic type medications, and the arthrodesis screw was removed. Temporary relief was achieved with nerve blocks (posterior tibial nerve), and the symptoms improved with extensive conservative treatment over the ensuing months; but, insufficiently to permit full performance within his MOS. Various entries in the service treatment record (STR) document normal neurologic findings, although confirming the presence of severe pain and touch sensitivity of the great toe and distal foot. Ankle range-of-motion (ROM) measurements were provided by physical therapy (PT) in February 2004; noting a 5 degrees loss of dorsiflexion and plantar flexion of 35 degrees (normal 45 degrees) for the left ankle. The narrative summary (NARSUM) documented, “The pain is still persistent with numbness across the toes from the fourth toe to the big toe. At present, he still can't wear shoes since he is in a walking boot and crutches…”; and characterized the pain as “continuous and slight to moderate in intensity.” The physical exam noted “diminished touch sensation on the left fourth to the big toe,” ankylosis of the great toe IP joint, and cited the PT ROM measurements (above). The last STR entry prior to PEB proceedings (4 months after the NARSUM, 7 weeks prior to separation) noted the use of a brace on the left foot which resulted in a “slightly abnormal” gait. At the VA Compensation and Pension (C&P) exam (5 months after separation), the CI reported he was working as a truck driver, but had significant pain in the foot. On exam, he had a normal gait, stance, and coordination. A thorough and normal neurological evaluation was documented, with normal motor and sensory findings. A specific VA joint examination 4 days later documented, “There was 40 degrees of passive flexion extension of the metatarsophalangeal joint with exquisite pain. There was also a generalized exquisite tenderness.” This examiner provided a diagnosis of “status post left great toe fusion - hallux valgus.”

The Board directs attention to its rating recommendation based on the above evidence. The PEB rated analogously to sciatic nerve neuralgia for ‘moderate’ peripheral nerve impairment. It is clear that the unfitting features of the condition were most related to the limitations imposed by the pain from the neuralgia. VASRD §4.124 (neuralgia, cranial or peripheral) specifies that the maximum rating for neuralgia is limited to the moderate rating for the involved nerve. The PEB’s 20% determination was thus the maximal VASRD compliant rating for sciatic nerve neuralgia; and, it should be noted that the sciatic (root) nerve is the most generously rated nerve for the lower extremity. The clinical evidence (specifically the operative anesthesia and therapeutic nerve blocks cited above) and anatomy of the injury suggest that the actual nerve involvement was well distal to the sciatic nerve. The deep peroneal (operative note) and posterior tibial (therapeutic block) nerve confer 10% ratings for moderate impairment. Members therefore agreed that, if peripheral nerve coding and rating for neuralgia is judged to be the most appropriate course, then the PEB’s coding and rating is the most favorable recommendation that can be achieved under the VASRD. Alternate coding to achieve a rating higher than 20%, IAW VASRD §4.7 (higher of two evaluations), was then deliberated. The VA’s rating was conferred under the hyphenated code 5280 (hallux valgus) rated analogously to 5284 (foot injuries, other), the latter conferring 30% for severe impairment. Members note, however, that the actual injury was localized to the great toe; and, generalization to foot injury is somewhat tenuous. The VASRD §4.71a rating for great toe amputation at the metatarsal joint is 10%. This case, however, is compounded by the fact that there is both direct injury with mechanical impairment; and, additional disability associated with the significant pain of CRPS. This is likely the rationale for the VA’s choice of hyphenated code and analogous rating; and it is noted that both the PEB and VA nomenclatures recognized both diagnoses. It remains that the direct sequelae of the injury would achieve no higher rating than 10% (analogously to hallux valgus) and that the most defensible rating for the neuralgia associated with CRPS would be 10% as elaborated above. The modest mechanical ROM limitation was neither significantly disabling nor logically unfitting; thus, pain is the ratable disability for both diagnoses; and, separate ratings would not comply with VASRD §4.14 (avoidance of pyramiding). Members further agreed that, even defaulting to analogous rating under 5284, the disability in evidence was more appropriately characterized as moderately severe, i.e., the same 20% rating. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication of the left foot condition.


BOARD FINDINGS: IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication. The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised. In the matter of the left foot condition and IAW VASRD §4.124a, the Board unanimously recommends no change in the PEB adjudication. There were no other conditions within the Board’s scope of review for consideration.


RECOMMENDATION: The Board, therefore, recommends that there be no recharacterization of the CI’s disability and separation determination, as follows:

UNFITTING CONDITION
 VASRD CODE RATING
Complex Regional Pain Syndrome with Osteoarthritis of the Great Toe, Left Foot
 8799-8720 20%
COMBINED
 20%


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20120717, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans’ Affairs Treatment Record





XXXXXXXXXXXXXXXXX, DAF
President
Physical Disability Board of Review


SFMR-RB                                                                         


MEMORANDUM FOR Commander, US Army Physical Disability Agency
(TAPD-ZB / XXXXXXXXXX), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557


SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXXXXXXXXXXXX, AR20130021937 (PD201201281)


I have reviewed the enclosed Department of Defense Physical Disability Board of Review (DoD PDBR) recommendation and record of proceedings pertaining to the subject individual. Under the authority of Title 10, United States Code, section 1554a, I accept the Board’s recommendation and hereby deny the individual’s application.
This decision is final. The individual concerned, counsel (if any), and any Members of Congress who have shown interest in this application have been notified of this decision by mail.

BY ORDER OF THE SECRETARY OF THE ARMY:




Encl                                                  XXXXXXXXXXXXXXXXXXXXXXXX
                                                      Deputy Assistant Secretary
                                                      (Army Review Boards)

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