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AF | PDBR | CY2013 | PD-2013-01144
Original file (PD-2013-01144.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXXXX       CASE: PD-2013-01144
BRANCH OF SERVICE: MARINE CORPS  BOARD DATE: 20140213
SEPARATION DATE: 20021001


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty LCpl/E-3 (0121/Personnel Clerk) medically separated for a right lower extremity neuralgia condition. Initial pain and numbness in feet began in boot camp in December 1998. She was diagnosed with a right leg compartment syndrome and underwent a surgical release in May 2001. The condition could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty or satisfy physical fitness standards. She was referred for a Medical Evaluation Board (MEB). The condition, characterized as “neuralgia, in the distribution of the right sural and right superficial peroneal nerve,” was forwarded to the Physical Evaluation Board (PEB) IAW SECNAVINST 1850.4E. No other conditions were submitted by the MEB. The Informal PEB determined the CI was “fit to continue on active duty.” She requested a record review panel reconsider the decision. A reconsideration PEB determined the CI should be “separated from active duty with severance pay” rated 0%. The CI did not accept the preliminary/recommended findings and demanded a Formal PEB (FPEB). The FPEB adjudicated “right lower extremity neuralgia” as unfitting, rated the condition at 20%, with likely application of the VA Schedule for Rating Disabilities (VASRD). The CI made no further appeals and was medically separated.


CI CONTENTION: “Please see attached evidence.” Evidence consists of medical records of treatment from civilian providers, photos of right leg, letters from civilian medical providers, PEB, military medical records and VA rating determinations.


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 right lower extremity neuralgia condition is addressed below; and, no additional conditions are within the DoDI 6040.44 defined purview of the Board. 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 Naval Records.


 RATING COMPARISON :

Service FPEB – Dated 20020730
 VA - (24 Mos. Post-Separation)
Condition
 Code Rating Condition Code Rating Exam
Right Lower Extremity Neuralgia 8721 20% Causalgia w/Compartment Syndrome, s/p Fasciotomy w/Developed Complex Regional Pain Syndrome, Right Lower Extremity 8599-8520 40% 20041001
No Additional MEB/PEB Entries
 Other x 2 20041001
Combined: 20%
 Combined: 40%
Derived from VA Rating Decision (VA RD ) dated 20050107 ( most proximate to date of separation [ DOS ] ).


ANALYSIS SUMMARY:

Right Lower Extremity Neuralgia Condition. In February 2001, after a 2-year history of right left lower leg pain made worse with running, the CI was diagnosed with chronic exercise induced compartment syndrome of the of the right leg based upon clinical and radiologic findings. Physical therapy (PT) was unsuccessful in achieving pain control. On 3 April 2001, the CI underwent an anterior and lateral compartment fasciotomy (surgery to relieve increasing pressure against muscles, nerves, and vessels) of the right lower leg. Despite healing of a post-operative wound infection, her pain continued associated with feelings of numbness and tingling in the lateral portion of her foot and lower right leg. She was additionally diagnosed with reflex sympathetic dystrophy (RSD) originating from the right peroneal nerve (RSD is also known as complex regional pain syndrome [CRPS]; a chronic pain condition in which high levels of nerve impulses are sent to an affected site. It is believed that CRPS occurs as a result of dysfunction in the central or peripheral nervous systems.) A Johns Hopkins medicine report of 30 May 2002 indicated the origin of her pain was secondary to a “partial transection of the superficial peroneal and sural nerves.” After consultation with pain management, anesthesia, orthopedics and neurosurgery, she had spinal cord stimulator electrodes placed in her lower back on 26 September 2002 as a trial in pain control. She had very good pain control for nearly 18 months with a return of painful symptoms when the implanted stimulator began to fail in April 2006. There were no further records in evidence after that date.

At the time of the MEB narrative summary (NARSUM) on 19 November 2001 (11 months prior to separation), the CI’s primary complaint was numbness, pain, and “electrical shock sensation” in her right lower leg and lateral portion of her foot, especially after activity or wearing of boots. She reported no weakness. The examiner noted a normal gait, normal coordination and normal motor examination. Her reflexes and plantar reactions were adequate and symmetrical. There was no comment on muscle atrophy, strength, or peripheral pulse. Pinprick sensation was diminished about her right ankle and the outside of her foot (correlating with the distribution of the right superficial peroneal nerve). Electrodiagnostic studies of the right lower extremity were normal.

At the VA neurology Compensation and Pension (C&P) examination on 1 October 2004 (24 months after separation) the CI reported persistent pain with associated numbness and altered sensation over the peroneal nerve distribution. Episodes of “severe pain” occurred approximately 4 times a week for 4-5 hour duration. She reported no current use of medications and experiencing four incapacitating pain episodes in the last year. The examiner reported an antalgic gait, although the CI “…ambulated with a cane.” Muscle tone, strength and reflexes were normal and symmetrical. The reported subjective altered sensation was present on examination. The C&P examiner commented that her CRPS was secondary to a possible injury through the superficial sensory nerve. There were no conclusive comments as to condition prognosis, impact on activities of daily living, or future occupational and or social functional ability. The Board directs attention to its rating recommendation based on the above evidence.

The Board acknowledged the 2-year remoteness of the VA examination and limits most of the probative value in this case upon the NARSUM and various STR clinical encounters. The PEB’s 20% rating was based on the 8721 code for moderate neuralgia of the common peroneal nerve, while the VA’s 40% rating reflected use of an analogous 8520 code for moderately severe paralysis of the sciatic nerve. While the CI’s disability is not specifically listed in the rating schedule, the PEB’s coding approach and rating is consistent with the CI’s clinical history and §4.124a standards. The VA’s coding approach is also reasonable but there is no clinical evidence specifically indicating sciatic nerve involvement. The VASRD schedule of ratings under “Diseases of the Peripheral Nerves” specifically states, “When the [nerve] involvement is wholly sensory, the rating should be for the mild (10%), or at most the moderate (20%) degree.” Having no motor deficits, this case meets the “wholly sensory” criteria component under §4.124a standards and is most accurately described as being moderately impaired (20%) near the time of service separation. 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’s 20% adjudication for the right leg 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 right leg neuralgia 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
Right Leg; Neuralgia 8721 20%
COMBINED 20%


The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20130814, w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans’ Affairs Treatment Record








                                   
XXXXXXXXXXXXXXX
President
DoD Physical Disability Board of Review






MEMOR A N DUM FOR DIRECTOR , SECR E TARY OF THE NAVY COUNCIL OF REVIEW BOARDS
 S ubj: PHYSI C AL DI S ABIL ITY BOARD OF REVIEW ( PDBR) RECOMMENDATIONS
Ref:     (a) DoDI 6040 . 44
(b)      CORB ltr dtd 8 Aug 14

In accordance with reference (a), I have reviewed the cases forwarded by reference (b) , and, for the reasons provided in their respective forwarding memorandums, approve the recommendations of the PDBR that the following individual's records not be corrected to reflect a change in either characterization of separation or in the disability rating previously assigned by the Department of the Navy's Physical Evaluation Bo ard:

-        XXXXXXXXXXXXXXX , former USMC, XXX XX XXXX
-        XXXXXXXXXXXXXXX , former USMC, XXX XX XXXX
-        XXXXXXXXXXXXXXX , former USMC, XXX XX XXXX
-        XXXXXXXXXXXXXXX , former U SN, XXX XX XXXX
-        XXXXXXXXXXXXXXX , former U J 1C, XXX XX XXXX

XXXXXXXXXXXXXXX
 Assistant General Counsel (Manpower & Reserve Affairs)

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