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AF | PDBR | CY2014 | PD-2014-00152
Original file (PD-2014-00152.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXX    CASE: PD-2014-00152
BRANCH OF SERVICE: Army  BOARD DATE: 20150116
SEPARATION DATE: 20070712


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was a National Guard E-5 (Signal Support Specialist) medically separated for reflex sympathetic dystrophy (RSD) of the right lower extremity. The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty or satisfy physical fitness standards. He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB). The condition, characterized as “reflex sympathetic dystrophy,” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. The MEB also identified and forwarded two other conditions (lumbago and hyperlipidemia) as medically acceptable. The Informal PEB adjudicated the RSD condition as unfitting, rated 20%, citing application of the VA Schedule for Rating Disabilities (VASRD). T he remaining conditions were determined to be not unfitting . The CI made no appeals and was medically separated.


CI CONTENTION: “All”


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 when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting. Any conditions outside the Board’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/Naval Records. Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate. The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the VASRD standards to the unfitting medical condition at the time of separation. The Board 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, operating under a different set of laws. The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation.


RATING COMPARISON :

Service IPEB – Dated 20070612
 VA* - (4 Months Post-Separation)
Condition
 Code Rating Condition Code Rating Exam
Reflex Sympathetic Dystrophy Right Lower Extremity 8599-8520 20% Reflex Sympathetic Dystrophy Right Lower Extremity 8599-8520 20% 20071108
Lumbago Not Unfitting Lumbago with Lumbar Spine Degenerative Disc Disease 5299-5239 20% 20071108
Hyperlipidemia Not Unfitting No VA Entry
Other x 0 (Not In Scope)
 Other x 8
RATING: 20%
 COMBINED RATING: 50%
* Derived from VA Rating Decision (VA RD ) dated 20 080313 ( most proximate to date of separation [ DOS ] ).

ANALYSIS SUMMARY:

Reflex Sympathetic Dystrophy Condition. In July 2005, while deployed to Iraq, the CI dropped a heavy item on his right foot. Fracture of a small bone in the foot (sesamoid) was initially suspected (though later ruled out) and treated with 3 weeks of casting and necessitated aeromedical evacuation in September 2005. Ongoing foot pain, numbness and tingling were ultimately thought to be a consequence of a type of neuropathic pain (RSD, also known as complex regional pain syndrome). A pain management specialist in 2006 determined, through a series of specialized lumbar nerve blocks, that the persistent pain (which now included the proximal right lower extremity) was clearly due to RSD.

At a neurosurgical evaluation on 25 January 2007, the CI complained of right foot pain since the foot injury. The pain extended up into the right leg, but focused mostly in the foot. Examination noted right foot tenderness and weakness, but the weakness appeared to be secondary to the pain. He was noted to use a cane for ambulation “mostly due to pain.” There were no abnormalities of appearance in the right lower extremity or foot. The examiner rendered a diagnosis of neuropathic pain in the right foot that had extended into the right leg. Due to a recent successful trial of a spinal cord stimulator, the neurosurgeon planned the placement of a permanent stimulator. At a physiatry evaluation on 20 March 2007, hypersensitivity of the right leg was observed but muscle strength was normal. Electrodiagnostic studies showed evidence of L3 and L4 radiculopathy.

The narrative summary (NARSUM) evaluation on 25 April 2007 (3 months prior to separation) noted a chief complaint of right foot pain. Since placement of a permanent spinal cord stimulator in February 2007, the CI experienced 100% pain relief. Examination showed an antalgic gait with use of a cane. The right lower extremity showed normal skin appearance and temperature, no atrophy and no tenderness. Sensation and muscle strength of the lower extremities was intact. At the MEB exam, the CI reported the use of a cane was due to the crush injury of the right foot. Case manager note in June 2007 (a month prior to separation) reported that the CI’s pain level still varied between 3-6 (on a severity scale of 0-10), and could interfere with his sleep. He used his cane “at times” due to balance and pain issues, depending on if the stimulator was on or off.

The VA Compensation and Pension exam performed 4 months after separation was not in evidence. Details as reported by the VA rater on 13 March 2008 included the report of right leg weakness and pain. Impact on daily, recreational, occupational or leisure activities was not described. Cited exam findings were decreased light and sharp sensation, and decreased position sensation. Lower extremity muscle strength was not described, and gait quality was not reported.

The Board directed attention to its rating recommendation based on the above evidence. Both the PEB and the VA assigned a 20% rating under an analogous 8520 peripheral nerve code for “moderate incomplete” paralysis of the sciatic nerve. Board members deliberated if the next higher 40% rating, characterized by “moderately severe” paralysis, was supported by the evidence, but agreed the clinical picture was most accurately described by the “moderate” stipulation. Therefore, a rating higher than 20% was not supported. 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 reflex sympathetic dystrophy condition.

Contended PEB Conditions. The Board’s main charge is to assess the fairness of the PEB’s determination that lumbago (low back pain [LBP]) and hyperlipidemia were not unfitting. The Board’s threshold for countering fitness determinations is higher than the VASRD §4.3 (reasonable doubt) standard used for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.

The CI reported that he developed some LBP while in Iraq, not associated with trauma or injury. However, on a Report of Medical Assessment on 13 December 2005, the CI indicated that only his right foot injury limited his duty performance; and a physician intake note in December 2005 did not identify LBP as a current complaint or as a medical problem. Lumbar imaging studies in May 2006 showed mild disc protrusions at L4-5 and L5-S1 without nerve root compression. A neurosurgeon diagnosed mild lumbar spondylosis in July 2006 and recommended physical therapy (PT). Over the course of three PT appointments in August and September 2006, the CI reported “minimal improvement” in his low back and right lower extremity pain. In January 2007, the neurosurgeon characterized the condition as “some minor back problems.” A statement by the CI’s Readiness NCO on 8 March 2007 indicated that “due to his chronic back and leg problems” the CI was incapable of performing his duties. The back condition specifically prevented the handling of heavy equipment. Multiple case management notes between February and June 2007 highlighted medical issues, but were silent regarding lumbago. The NARSUM examiner considered the condition medically acceptable. The final permanent L3 profile specified RSD, but not a back condition. Previous temporary L2 or L3 profiles were only for RSD or foot pain.

The CI also had a history of high cholesterol (hyperlipidemia) for which he took two medications that controlled the condition.

The lumbago and hyperlipidemia conditions were not judged to fail retention standards. Both conditions were reviewed by the action officer and considered by the Board. There was no performance based evidence from the record that either of these conditions significantly interfered with satisfactory duty performance. After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for either of the contended conditions and so no additional disability ratings are recommended.


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 RSD right lower extremity condition and IAW VASRD §4.124a, the Board unanimously recommends no change in the PEB adjudication. In the matter of the contended lumbago and hyperlipidemia conditions, the Board unanimously recommends no change from the PEB determinations as not unfitting. There were no other conditions within the Board’s scope of review for consideration.


RECOMMENDATION: The Board, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination.
The following documentary evidence was considered:

Exhibit A. DD Form 294, dated 20131231 w/atchs
Exhibit B. Service Treatment Record
Exhibit C. Department of Veterans Affairs Treatment Record





XXXXXXXXXXXXXXX
President
DoD Physical Disability Board of Review
SAMR-RB                                                                         


MEMORANDUM FOR Commander, US Army Physical Disability Agency
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557


SUBJECT: Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXX, AR20150011018 (PD201400152)


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              XXXXXXXXXXXXXXX
                           Deputy Assistant Secretary of the Army
                           (Review Boards)
                                                     
CF:
( ) DoD PDBR
( ) DVA

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