Citation Nr: 21026100 Decision Date: 04/29/21 Archive Date: 04/29/21 DOCKET NO. 16-19 442 DATE: April 29, 2021 ORDER Entitlement to an initial 20 percent for service-connected complex regional pain syndrome involving the sciatic nerve, left lower extremity (LLE), is granted, subject to the law and regulations governing the payment of monetary benefits. Entitlement to an initial rating in excess of 10 percent for service-connected complex regional pain syndrome involving the saphenous nerve, LLE, is denied. FINDINGS OF FACT 1. The Veteran’s service-connected LLE complex regional pain syndrome involving the sciatic nerve has been manifested by symptoms that more closely approximate moderate incomplete paralysis of the sciatic nerve throughout the appeal period including constant pain, intermittent sensory impairment in the LLE, and functional impairment due to pain with resulting antalgic gait. 2. The Veteran’s service-connected LLE complex regional pain syndrome involving the saphenous nerve is rated as 10 percent disabling, which is the maximum schedular rating permitted for paralysis of the saphenous nerve. CONCLUSIONS OF LAW 1. The criteria for an initial 20 percent rating for service-connected complex regional pain syndrome involving the sciatic nerve, LLE, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.123, 4.124a, Diagnostic Code (DC) 8520. 2. The criteria for an initial rating in excess of 10 percent for service-connected complex regional pain syndrome involving the saphenous nerve, LLE, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.123, 4.124a, DC 8527. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS This matter is on appeal from a July 2014 rating decision wherein the agency of original jurisdiction (AOJ) granted an initial compensable rating for complex regional pain syndrome of the LLE pursuant to 38 C.F.R. § 4.124a , DC 8520. See also June 2014 Board decision. The Veteran perfected an appeal as to the initial rating assigned to this disability and, in July 2020, the Board remanded the issue for additional evidentiary development. Thereafter, the AOJ issued a September 2020 rating decision wherein an initial 10 percent rating was awarded for the foregoing disability under DC 8520, effective July 27, 2004, and a separate 10 percent rating was awarded for complex regional pain syndrome of LLE involving the saphenous nerve under DC 8527, effective July 27, 2004. The appeal has returned to the Board for further consideration. While the Veteran has not disagreed with the rating assigned to the saphenous nerve disability, the Board has assumed jurisdiction over this issue, as clinicians have noted that the LLE complex regional pain syndrome disability at issue in this appeal involves two nerves. See e.g., July 2020 VA examination report. In this context, the Board notes that the disability evaluated under DC 8520 will hereinafter be referred to as “service-connected complex regional pain syndrome involving the sciatic nerve, LLE,” while the disability evaluated under DC 8527 will be referred to as “service-connected complex regional pain syndrome involving the saphenous nerve, LLE.” Increased Ratings As noted above, the AOJ has granted separate ratings for complex regional pain syndrome of the LLE involving the sciatic nerve and saphenous nerve. This determination was made based upon the July 2020 VA Peripheral Nerves examination wherein the examiner stated that the Veteran’s complex regional pain syndrome involved the sciatic and saphenous/internal saphenous nerves. The Board notes, however, that the July 2020 VA examiner did not distinguish which of the Veteran’s symptoms are attributable to each nerve and the evidence dated prior to the July 2020 VA examination does not address or identify the nerve or nerves involved or impacted by the service-connected complex regional pain syndrome disability. Nevertheless, the Board will rely upon the description of the nerves and resulting functional impairment provided in the Rating Schedule to evaluate the sciatic and saphenous nerve impairments in this case. Due to the similar evidence related to these claims, the Board will address them in common discussion. As a final initial matter, the Board notes that, while portions of the rating schedule addressing the musculoskeletal system were revised effective February 7, 2021, the diagnostic codes under which the disabilities at issue in this appeal are evaluated were not changed. Paralysis of the sciatic nerve is evaluated in accordance with the criteria set forth in 38 C.F.R. § 4.124a, DC 8520, with neuritis and neuralgia of that group evaluated under DCs 8620 and 8720. Under these criteria, mild incomplete paralysis is rated as 10 percent disabling. Moderate incomplete paralysis is rated as 20 percent disabling. Moderately severe incomplete paralysis is rated as 40 percent disabling. Severe incomplete paralysis, with marked muscular atrophy is rated as 60 percent disabling. Complete paralysis, with the foot dangles and drops, no active movement possible of muscles below the knee, flexion of knee weakened or (very rarely) lost is rated as 80 percent disabling. 38 C.F.R. § 4.124a. Paralysis of the internal saphenous nerve is evaluated under DC 8527 which provides that a noncompensable (zero percent) rating is assigned for mild to moderate paralysis, while a maximum 10 percent rating is assigned for severe to complete paralysis. See 38 C.F.R. § 4.124a, DC 8527. The words “mild,” “moderate,” and “severe” as used in the various DCs are not defined in the Rating Schedule. Regulations provide that ratings for peripheral neurological disorders are to be assigned based the relative impairment of motor function, trophic changes, or sensory disturbance. 38 C.F.R. § 4.120. Consideration is also given for loss of reflexes, pain, and muscle atrophy. See 38 C.F.R. §§ 4.123, 4.124. The term “incomplete paralysis” indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating is for the mild, or at most, the moderate degree. The disability ratings for the peripheral nerves are for unilateral involvement; when bilateral, the ratings combine with application of the bilateral factor. 38 C.F.R. § 4.124a, Note at “Diseases of the Peripheral Nerves.” The Note to 38 C.F.R. § 4.124a establishes a maximum disability rating for conditions that are wholly sensory, as opposed to a minimum disability rating for conditions that are more than wholly sensory. See Miller v. Shulkin, 28 Vet. App. 376 (2017). The relevant evidence of record consists of VA and private treatment records dated from 2005 to 2020, VA examination reports dated October 2004, July 2014, and July 2020, and lay statements submitted in support of this appeal. The preponderance of the evidence shows that the Veteran has consistently endorsed having constant pain and weakness in the LLE with intermittent swelling in the left leg and ankle. See e.g., VA examination reports dated October 2004 and July 2020; VA treatment records dated September and October 2005 and August 2016; and August 2007 private treatment records. He has occasionally described his pain and burning and tingling in nature. See e.g., VA treatment records dated October 2005 and August 2016. The Veteran has consistently reported experiencing imbalance and instability due to his LLE condition and has reported falling on numerous occasions. See e.g., September 2005 VA treatment record; Veteran statements dated Setepmber 2005, December 2005, and April 2009; December 2008 lay statement from M.J., and July 2017 VA treatment record. He has also endorsed having numbness primarily along the bottom of his left foot but from his mid tibia to his feet as well. See e.g., VA treatment records dated September, October, and November 2005. He has reported having cramping at night that prevents him from sleeping, and he has also stated that his LLE symptoms prevent him from running or walking for long periods and make it very difficult for him to get around on a daily basis. See e.g., Veteran statements dated Setepmber 2005, December 2005, and April 2009; November 2016 attorney statement. In April 2017, the Veteran’s attorney also reported that the Veteran has difficulty wearing shoes because of swelling in the lower leg and foot and that his left leg muscle is smaller than his right leg muscle. While the Veteran reported having decreased strength and sensory impairment in the LLE as early as 2005, objective clinical evaluation in October 2004 revealed normal muscle strength and intact senses in the LLE, as well as normal reflexes and range of motion in the left knee and ankle. There was no evidence of muscle atrophy in the LLE; nor was there evidence of pain, fatigability, weakness, lack of endurance, or incoordination in the left knee or ankle. In October and November 2005, objective evaluation revealed decreased sensation in the left leg below the knee, left lateral leg, and along the entire sole of the foot. However, the Veteran’s pedal pulses remained palpable, his reflexes were normal in the patella and Achilles, and his muscle strength was normal. See VA treatment records dated October and November 2005. Notably, sensory examination of the LLE was grossly normal during the July 2014 VA examination, and subsequent VA treatment records show that the Veteran’s muscle strength, range of motion, and peripheral pulses remained normal in his LLE. See e.g., VA treatment records dated August and September 2016. In October 2019, the Veteran’s sensation to light touch and pressure was also grossly intact without any motor or sensory deficits noted on clinical evaluation. Nevertheless, during the July 2020 VA examination, sensory evaluation revealed decreased, but not absent, sensation to light touch in the left lower leg/ankle and left foot/toes. However, the Veteran demonstrated normal muscle strength in left knee extension and left ankle plantar and dorsiflexion, his reflexes were normal in the left knee and ankle, and there was no evidence of muscle atrophy or trophic changes. The examiner noted that the Veteran’s constant pain and numbness were moderate, while his intermittent pain and paresthesias/dysesthesias were described severe. See July 2020 VA examination report. The July 2020 VA examiner described the Veteran’s complex regional pain syndrome of the LLE as neuralgia, with a moderately severe impairment of the sciatic nerve and a severe impairment of the saphenous/internal saphenous nerve; however, the examiner noted that there are several medical and neurological examinations of record that show the Veteran’s function is intact except for pain and decreased sensation in the LLE as noted in the examination report. See July 2020 statement. Turning to the ratings assigned for the service-connected disability, the Board initially notes that the Veteran is in receipt of the highest schedular rating for the saphenous/internal saphenous nerve. As a result, there is no basis to award a higher evaluation for paralysis of the saphenous nerve under DC 8527. Nevertheless, after reviewing the foregoing evidence, the Board finds the preponderance of the evidence supports the grant of a 20 percent rating under DC 8520 for the sciatic nerve involvement of the Veteran’s complex regional pain syndrome in the LLE throughout the appeal period. In evaluating the ultimate merit of these claims, the Board finds that the July 2020 VA examiner’s summation of the symptoms attributable to the Veteran’s complex regional pain syndrome of the LLE is accurate and representative of the Veteran’s overall disability picture throughout the appeal period. As noted, the examiner stated that the Veteran’s LLE function was intact except for pain and decreased sensation. In this regard, the preponderance of the evidence dated throughout the appeal period documents the Veteran’s report of constant pain, which he also described as burning and tingling at times. There is also objective evidence of decreased sensation in the LLE throughout the appeal period, albeit intermittently. Indeed, it appears that the sensory impairment in the LLE has fluctuated during the appeal period, as his sensation was intact in the LLE in October 2004 but is shown to be decreased below the left knee and in the sole of the left foot in October and November 2005. See e.g., October 2004 VA examination; VA treatment records dated October and November 2005. Similarly, the evidence reflects that objective sensory examination of the LLE was intact in July 2014 and October 2019, but the Veteran’s sensation to light touch was decreased in the LLR in July 2020. See July 2014 VA examination; October 2019 VA treatment record; July 2020 VA examination. Nevertheless, the Veteran has consistently endorsed experiencing numbness and other paresthesias in his LLE, which is competent and credible evidence of such. Otherwise, however, the objective evidence of record does not reflect that the Veteran’s complex regional pain syndrome in the LLE has been manifest by impairment of motor function or other organic changes, such as loss of reflexes, trophic changes, muscle atrophy, or complete paralysis. In this regard, the Board acknowledges his report that his symptoms have included weakness, imbalance, instability, and muscle atrophy and notes that the Veteran is capable of describing symptoms that are capable of lay observation, such as pain, weakness, and instability. However, the Board finds probative that the medical evidence of record shows his LLE motor strength, range of motion, reflexes, and muscle tone have been evaluated by medical professionals on numerous occasions between 2004 and 2020 and have consistently been within normal limits. Similarly, while the Veteran has reported experiencing intermittent swelling in the left leg and ankle, there is no objective or clinical evidence of swelling or edema during the entirety of the appeal period, including as reflected in the VA and private treatment records or during VA examinations of record. The Veteran has been shown to have an antalgic gait due to his complex regional pain syndrome of the LLE; however, there is no medical evidence of record that attributes any instability in the LLE to the Veteran’s antalgic gait or complex regional pain syndrome in general. In evaluating this claim, the Board notes that muscle strength, function, and tone, and loss of reflexes are findings that require medical observation and testing and, notably, the Veteran has not provided any basis in lay knowledge to support his assertions of such, particularly in contrast to the medical evidence of record. Therefore, the Board finds that the medical of evidence of record is more probative and credible than the lay evidence of record with respect to whether the Veteran’s complex regional pain syndrome of the LLE is manifest by impairment of motor function, muscle atrophy, loss of reflexes, or trophic changes. Therefore, based on the above and after resolving reasonable doubt in his favor, the Board finds that the Veteran’s complex regional pain syndrome of the LLE has been most analogous to moderate, incomplete paralysis of the sciatic nerve, which warrants a 20 percent rating, but no higher, under DC 8520. In making this determination, the Board acknowledges that the July 2020 VA examiner described his sciatic nerve involvement as moderately severe, but the examiner further noted that the Veteran’s disability is primarily manifest by constant pain and sensory impairment without identifying any additional impairment of motor function or organic changes in the LLE. The evidence does show that the Veteran experiences a functional impairment due to pain and resulting antalgic gait due to his service-connected complex regional pain syndrome of the LLE; however, without objective evidence of impaired motor function, muscle atrophy, loss of reflexes, or other organic changes in the LLE, the Board finds that the Veteran’s overall disability picture is consistent with no more than a moderate impairment as contemplated by DC 8520. See 38 C.F.R. § 4.124. Indeed, a moderately severe or severe impairment is not shown in this case. For example, while the Veteran’s sensory impairment is decreased in his LLE, his sensation to light touch was not absent or shown to be manifest by a diffuse sensory impairment in his LLE at any point during the appeal period. Further, the Board again notes that the Veteran’s sensory impairment has been intermittent, at best, as opposed to consistently decreased throughout the appeal period and there is no objective evidence of motor impairment in the LLE to suggest a more severe impairment of the sciatic nerve. The Board also notes that the separate 10 percent rating assigned under DC 8527 for the saphenous nerve involvement contemplates at least a portion of the symptoms and functional impairment of the Veteran’s complex regional pain syndrome, such as constant pain in the LLE. Therefore, the Board finds that all of the symptoms shown and functional impairment described in the lay and medical evidence of record are properly contemplated by the ratings currently assigned for the sciatic and saphenous nerve involvement of the Veteran’s complex regional pain syndrome in the LLE. There is no evidence showing the Veteran’s disability is manifest by a neurological impairment associated with any other peripheral nerves that has not already been service-connected. Therefore, a separate or higher rating under a different DC is not warranted. In conclusion, the Board finds that an initial rating in excess of 10 percent is not warranted for service-connected saphenous nerve involvement of complex regional pain syndrome in the LLE, as that is the maximum rating available for a saphenous nerve impairment. However, the Board finds the evidence supports the grant of an initial, 20 percent rating, but no higher, for service-connected sciatic nerve involvement of complex regional pain syndrome in the LLE. In making these determinations, all reasonable doubt has been resolved in favor of the Veteran. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. James Springer Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Turnipseed, Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.