RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW
BRANCH OF SERVICE: ARMY
NAME: XXXXXXXXXXXXX
CASE NUMBER: PD1200285
DATE OF PLACEMENT ON TDRL: 20000531
BOARD DATE: 20121012 DATE OF PERMANENT SEPARATION: 20050616
SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this
covered individual (CI) was an active duty Army SPC/E-4 (54B10/NBC Specialist), medically
separated for vocal cord dysfunction (VCD) and complex regional pain syndrome (CRPS) of the
right lower extremity. The CI suffered a right foot injury and despite treatment developed
chronic right foot pain. During the same time period, she experienced intermittent shortness of
breath and voice changes that ultimately was diagnosed as vocal cord dysfunction. These two
conditions did not improve adequately with treatment to meet the physical requirements of
her Military Occupational Specialty or satisfy physical fitness standards. She was issued a
permanent L3, P3 profile and referred for a Medical Evaluation Board (MEB). The MEB
forwarded vocal cord dysfunction as the only condition for Physical Evaluation Board (PEB)
adjudication. The PEB included right lower extremity CRPS condition with the MEB’s vocal cord
dysfunction and designated them both as unfitting, and not sufficiently stable for final
adjudication. The CI was placed on the Temporary Disability Retired List (TDRL) with the ratings
charted below. On final PEB evaluation, 62 months later, the PEB adjudicated the vocal cord
dysfunction and right lower extremity complex regional pain syndrome as unfitting, rated at 0%
and 10% respectively, with application of the Veteran’s Affairs Schedule for Rating Disabilities
(VASRD). The CI did not concur with the PEB findings, waived a formal hearing, but submitted a
written appeal. The US Army Physical Disability Agency (USAPDA) reviewed the entire case and
concluded that it was properly adjudicated and made an administrative change in the code for
the CRPS condition. The CI was medically separated with a 10% disability rating.
CI CONTENTION: “The severity of the service connected disabilities.”
SCOPE OF REVIEW: The Board wishes to clarify that the scope of its review as defined in the
Department of Defense Instruction (DoDI) 6040.44, Enclosure 3, paragraph 5.e.(2) is limited to
those conditions which were determined by the PEB to be specifically unfitting for continued
military service; or, when requested by the CI, those condition(s) “identified but not
determined to be unfitting by the PEB.” The ratings for unfitting conditions will be reviewed in
all cases. The remaining conditions rated by the VA at separation and listed on the DD Form
294 application are not within the Board’s purview. 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 Army Board for Correction of Military Records.
TDRL RATING COMPARISON:
Service PEB Admin Correction – Dated 20050616
Rating
Condition
Code
Complex Regional Pain
Syndrome, Right Lower
Extremity
Vocal Cord Dysfunction
5299-5003
8799-8725
6599-6520
TDRL
20%
Sep.
-
-
10%
10%
0%
No Additional MEB/PEB Entries
Combined: 10%
VA* – All Effective Date 20000531
Rating
Code
Condition
5299-5278
Chronic Regional Pain
Syndrome, Right Foot
Vocal Cord Dysfunction
Reactive Airway Disease
Tendonitis, Left Wrist
Tendonitis, Right Wrist
6599-6516
6699-6602
5099-5020
5099-5020
Not Service Connected x 3
Combined: 40%*
20%
0%
10%
10%
10%
Exam
19990809
19990809
19990809
19990809
19990809
19990809
* Hypertension, 7101, rated 10% effective 20060726; remainder of ratings unchanged with 5 NSC conditions (combined 50%)
ANALYSIS SUMMARY: The Board notes the current VA ratings listed by the CI for all of her
service-connected conditions, but must emphasize that its recommendations are premised on
severity at the time of separation. The VA ratings which it considers in that regard are those
rendered most proximate to separation. The Disability Evaluation System (DES) has neither the
role nor the authority to compensate members for anticipated future severity or potential
complications of conditions resulting in medical separation. That role and authority is granted
by Congress to the Department of Veterans’ Affairs (DVA). The Board’s operative instruction,
DoDI 6040.44, specifies a 12-month interval for special consideration to DVA findings. This does
not mean that the later DVA evidence was disregarded, but the Board’s recommendations are
directed to the severity and fitness implications of conditions at the time of separation. In this
circumstance, therefore, the evidence from the record is assigned significantly more probative
value as a basis for the Board’s recommendations.
Bilateral True Vocal Cord Dysfunction Condition. The narrative summary (NARSUM) prepared 3
months prior to TDRL adjudication notes history of shortness of breath beginning in March of
1998 initially noted at night and when around smoke in her workplace. She was evaluated with
pulmonary function tests (PFTs) and then treated with bronchodilators. Her symptoms
continued and over a period of a year inhaled corticosteroids were added along with three
short courses of oral steroids. The CI had a negative Methacholine challenge test. Her
breathing complaints persisted and in spite of treatment, her PFTs remained about the same.
Also during that period, the CI developed voice problems and began evaluation and treatment
by local speech pathologists. After evaluation by ENT and pulmonary services, the CI was given
the diagnosis of vocal cord dysfunction and MEB was initiated. Examination revealed “…one
slight wheeze in her base with rapid expirations; otherwise, the chest seemed clear. The
wheeze seemed to be coming from the neck area, which would be expected with vocal cord
dysfunction syndrome.”
At the MEB exam, the CI reported “RAD (reactive airway disease), VCD cause me to be very
sensitive to getting sick easily” and “they all cause me to have shortness of breath at times.”
The MEB lung and chest exam noted “clear with normal respiration, but upper airway strider
with forced expirations.” The MEB identified the vocal cord dysfunction condition and referred
the package for PEB adjudication.
At the VA Compensation and Pension (C&P) exam performed 6 months prior to initial entry into
TDRL status, the CI reported difficulty breathing, wheezing and dyspnea on exertion after being
exposed to chemicals around January 1998. She also had a voice disorder with hoarseness and
low-pitched voice. She was evaluated by a pulmonary consultant and was told she had
“bronchial asthma” for one year. She also had a + PPD in November 1998 (as did her husband)
with the CI and her family treated with INH prophylaxis. She had normal chest X-rays.
Medications include inhaled bronchodilators and steroids as well as intermittent courses of oral
steroids. Physical examination revealed clear lungs bilaterally. Direct visualization of the cords
was reported as normal.
The final TDRL-reevaluation indicated the CI was taking daily inhaled medications (Flovent, with
episodic Albuterol), and complained of episodic shortness of breath. Exam indicated clear chest
without wheezing and “erythema of the posterior nasopharyngeal wall as the posterior glottis,
and the posterior true vocal cords. There is symmetric motion of the vocal cords and there is
no paradoxical motion noted.” There was no mention of speech volume or clarity; however,
the CI was referred to Speech Therapy. Two examinations with PFT data proximate to
separation demonstrated “Normal Spirometry. No change with bronchodilators.” FEV-1’s were
88% and 75% (Forced Expiratory Volume in one second), and there was no mention of
abnormal flow loops. Medication profile did not indicate dispensing of Flovent or Albuterol
from the military treatment facility, but both medications were listed as being used.
The Board directs attention to its rating recommendation based on the above evidence.
Entering into the TDRL period, the CI’s VCD was coded analogously as 6599-6520 (Larynx,
stenosis) and rated 10% with a stated “FEV-1 86%.” At final PEB adjudication, the VCD was
rated at 0% using a stated “FEV-1 82%.” The source PFT exam was not in the evidence of
record. The VCD condition is not a bronchospastic/asthma related condition, but does use PFT
data for rating purposes IAW §4.97 Schedule of Ratings—Respiratory System. The PFT
evaluation performed one month prior to separation is deemed the most probative exam. That
exam documents a post bronchodilator FEV-1 of 75%. Using VASRD code 6520, the same code
utilized by the PEB, a FEV-1 of 75% is rated at 10%. A 30% rating would require a FEV-1
between 56% and 70% with an abnormal flow-volume loop. The CI never demonstrated
reversible bronchospasm, especially prior to daily inhaled anti-inflammatory medication use,
she had a negative Methacholine challenge test, and pulmonary specialist at interim TDRL
evaluation indicated “this is not asthma”; making reversible bronchospasm unlikely as the
etiology of her breathing complaints. Using an alternative coding/rating schemes related to
asthma (or other “bronchospastic” conditions) is not appropriate in the case, as asthma was not
an unfitting condition.
After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable
doubt), the Board recommends a disability rating of 10% for the VCD condition at entry into
TDRL and at separation.
Complex Regional Pain Syndrome, Right Lower Extremity Condition. Review of service
treatment records (STR) reveals chronic right foot pain since foot trauma in mid 1998 with over
34 medical encounters in the 20 month period prior to the PEB. The vast majority of these
visits were for pain related issues and there were no documented limitations of range-of-
motion (ROM) or weakness issues identified. Neurology evaluation documented no swelling,
no weakness, no atrophy and normal deep tendon reflexes with pain “essentially from the
distal anterior 1/3 of foot 1st > 5th but all involved.” Sensory changes to vibration and light
touch were documented. After complete evaluation, the CI was given the diagnosis of CRPS,
Type I.
The NARSUM prepared a month prior to the CI’s final TDRL review, notes an injury of the right
foot while marching at night in May of 1998. Injury was initially treated with 6 weeks of
immobilization for what was thought to be a fracture but later determined to be a contusion.
The CI began experiencing severe right foot/ankle pain and was diagnosed with reflex
sympathetic dystrophy after a completely normal evaluation that included magnetic resonance
imaging (MRI), bone scan and neurologic evaluation. She was treated by pain management
specialist, physical and occupational therapy utilizing numerous medications, sympathetic block
and epidural steroid injections without relief. Physical examination revealed painful gait
favoring right leg with light touch producing increased uncomfortable sensation. The foot had
full active and passive ROM and stable ligaments. Sensation was intact throughout her entire
lower extremity, although there was a slight decrease in sensation to light touch in the distal
leg. “The service member continues to state that her foot is in constant moderate pain, it is a
throbbing type of pain which changes occasionally to an achy type of pain in the foot with
weather changes or if it is cold outside. Overall she believes that her condition is stable, is not
getting any worse, but certainly not getting any better.”
At the C&P exam the CI reported that in May 1998 while training at the National Training
Center, she injured her right foot when “it fell in-between the rocks.” She experienced
significant pain and swelling and X-rays were negative for fracture. She was immobilized for 2
months but continued to experience chronic daily pain of moderate to severe degree. She
underwent two lumber blocks. She had an extensive evaluation and well documented right
foot pain, weakness and numbness with a diagnosis of chronic regional pain syndrome. She
reported tingling on the lateral aspect and hyperesthesia of the right foot. Examination
revealed use of a walker with CI holding her foot in an everted position. Exam was limited due
to pain but seemed to have decreased muscle strength right foot/ankle. Normal deep tendon
reflexes.
The Board directs attention to its rating recommendation based on the above evidence.
Entering into the TDRL period, the CI’s CRPS was coded analogously as 5299-5003 and rated
20% with application of the USAPDA Pain Policy for moderate constant pain. At the CI’s TDRL
re-evaluation 62 months later, the PEB utilized VASRD-only rules for the final adjudication of
the CRPS condition with an analogous code of 8799-8725 (Neuralgia, Posterior tibial nerve;
[tarsal tunnel]) and rated 10% for mild incomplete neuralgia of the lower extremity. For rating
at TDRL entry, VASRD-only rating would be at most 20% for 8799-8525, (severe) as there was
documented weakness and pain, and conceding the severe level. At TDRL separation,
alternative coding under VASRD code 8525 (Paralysis) is not applicable as there was no motor
weakness documented. Analogous rating under 8725 (Neuralgia) requires adherence to VASRD
§4.124: “When the involvement is wholly sensory, the rating should be for the mild, or at most,
the moderate degree.” Rating as “moderate” due to antalgic gait would result in a rating of
10% and provide no benefit to the CI (“Mild” and “Moderate” each rate 10% under 8725). 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 for the complex regional pain syndrome condition on TDRL entry or permanent
separation.
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 that any prerogatives outside the VASRD were exercised in the PEB’s
final adjudication exiting the TDRL period. In the matter of the bilateral true VCD condition, the
Board unanimously recommends a disability rating of 10%, coded 6599-6520 IAW VASRD §4.97.
In the matter of the CRPS condition, 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 recommends that the CI’s prior determination be modified as
follows, effective as of the date of her prior medical separation:
RATING
TDRL PERMANENT
10%
20%
10%
-
VASRD CODE
6599-6520
5299-5003
8799-8725
COMBINED
-
30%
10%
20%
UNFITTING CONDITION
Bilateral True Vocal Cord Dysfunction
Complex Regional Pain Syndrome
The following documentary evidence was considered:
Exhibit A. DD Form 294, dated 20120311, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans’ Affairs Treatment Record
XXXXXXXXXXXXXXXX
President
Physical Disability Board of Review
SFMR-RB
MEMORANDUM FOR Commander, US Army Physical Disability Agency
(TAPD-ZB / ), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557
SUBJECT: Department of Defense Physical Disability Board of Review Recommendation
for XXXXXXXXXXXXXXXXXX, AR20120020636 (PD201200285)
1. 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 to modify the individual’s disability rating to 20% without recharacterization
of the individual’s separation. This decision is final.
2. I direct that all the Department of the Army records of the individual concerned be corrected
accordingly no later than 120 days from the date of this memorandum.
3. I request that a copy of the corrections and any related correspondence be provided to the
individual concerned, counsel (if any), any Members of Congress who have shown interest, and
to the Army Review Boards Agency with a copy of this memorandum without enclosures.
BY ORDER OF THE SECRETARY OF THE ARMY:
Encl
CF:
( ) DoD PDBR
( ) DVA
XXXXXXXXXXXXXXXXX
Deputy Assistant Secretary
(Army Review Boards)
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