IN THE CASE OF: BOARD DATE: 12 July 2016 DOCKET NUMBER: AR20150002190 BOARD VOTE: _________ _______ ________ GRANT FULL RELIEF ________ ________ ________ GRANT PARTIAL RELIEF ________ ________ ________ GRANT FORMAL HEARING ____x___ ____x___ ___x_____ DENY APPLICATION 2 Enclosures 1. Board Determination/Recommendation 2. Evidence and Consideration IN THE CASE OF: BOARD DATE: 12 July 2016 DOCKET NUMBER: AR20150002190 BOARD DETERMINATION/RECOMMENDATION: The evidence presented does not demonstrate the existence of a probable error or injustice. Therefore, the Board determined that the overall merits of this case are insufficient as a basis for correction of the records of the individual concerned. _____________x____________ CHAIRPERSON I certify that herein is recorded the true and complete record of the proceedings of the Army Board for Correction of Military Records in this case. IN THE CASE OF: BOARD DATE: 12 July 2016 DOCKET NUMBER: AR20150002190 THE BOARD CONSIDERED THE FOLLOWING EVIDENCE: 1. Application for correction of military records (with supporting documents provided, if any). 2. Military Personnel Records and advisory opinions (if any). THE APPLICANT'S REQUEST, STATEMENT, AND EVIDENCE: 1. The applicant requests correction of his record to show he was medically retired instead of discharged for expiration of term of service (ETS). 2. The applicant states, in effect, that he had two surgeries to his left shoulder in 2007 and 2009 while on active duty but was refused a Medical Evaluation Board (MEB) because his unit did not do the paperwork properly. After his ETS discharge on 8 August 2010, the Department of Veteran Affairs (VA) granted him 30% disability for post-traumatic stress disorder (PTSD) and 70% overall disability for additional conditions of spondylosis of the neck, carpal tunnel syndrome (CTS) of the left elbow, migraines, and acid reflux. 3. The applicant provides his military service health records (Standard Forms 600), a VA rating decision dated 9 August 2012, and his DD Form 214 (Certificate of Release or Discharge from Active Duty). CONSIDERATION OF EVIDENCE: 1. Title 10, U.S. Code, section 1552(b), provides that applications for correction of military records must be filed within 3 years after discovery of the alleged error or injustice. This provision of law also allows the Army Board for Correction of Military Records (ABCMR) to excuse an applicant's failure to timely file within the 3-year statute of limitations if the ABCMR determines it would be in the interest of justice to do so. While it appears the applicant did not file within the time frame provided in the statute of limitations, the ABCMR has elected to conduct a substantive review of this case and, only to the extent relief, if any, is granted, has determined it is in the interest of justice to excuse the applicant's failure to timely file. In all other respects, there are insufficient bases to waive the statute of limitations for timely filing. 2. The applicant enlisted in the Regular Army on 9 March 2006 for a 4 year period of service. He had 4 years and 5 months of prior service in the Navy. He was assigned to military occupational specialty 14T1O, Patriot Missile Operator/Maintenance, in the rank of Specialist (SPC), pay grade E-04. 3. At the time of his separation, he was assigned to the 1-44 Air Defense Artillery Battalion, Fort Hood, Texas. His medical services were being provided by Darnall Army Community Hospital (DACH), Fort Hood, Texas. 4. His military service health records show that on 3 June 2008 he had arthroscopy surgery on his left shoulder and on 13 November 2009 he underwent another arthroscopic surgery on his left shoulder. 5. His military service health records show the following applicable entries: a. 9 April 2010, psychology clinic – the SM (service member) reported his shoulder injury, flag preventing him from taking the APFT, wants to extend his enlistment, frustration, not sure what to do, unit is not helping him, he has tried his battalion, wants out of his unit, doesn’t like his job, does not know what to do if he has to get out of the Army in August 2010. Clinical Psychologist D.C. stated the SM screened negative for PTSD and TBI. b. 12 April 2010, psychology clinic - Clinical Psychologist D.C. diagnosed the SM with adjustment disorder with mixed emotional features. c. 23 April 2010, orthopedic clinic – lists diagnoses of cervical spondylosis (C4 – C5) and (C5 – C6), and cervical radiculopathy (C5). Discussed these diagnoses and need for a medical extension. (Cervical spondylosis means wear and tear affecting the spinal disks in the neck. Cervical radiculopathy is the damage or disturbance of nerve function that results if one of the nerve roots near the cervical vertebrae is compressed.) c. 20 May 2010, psychiatry clinic – the SM stated he was due to ETS on 8 August 2010 which was an extension due to his shoulder surgery. His command denied another extension for continued recovery from the surgery. The SM stated he would like to reenlist but is unable to due to medical reasons; he has not been able to take the Army Physical Fitness Test (APFT). The SM was advised to consult with his chain of command and if necessary the Inspector General. The SM denied suicidal ideation/homicidal ideation and verbalized understanding of how to access emergency mental health services. d. 9 June 2010, psychiatry clinic – (1) The SM stated he had traumatic experiences when his roommate shot and killed himself on 1 April 2010 where he saw the blood in bathroom after the body was removed, and he had two friends that were killed. (2) The SM was divorced in 2009 after 11 years of marriage and has 3 children with his ex-wife. He has a 16 year old daughter he did not find out about until 4 or 5 years ago. (3) The SM stated since his ETS date was extended, he was not paid for 3 months and so is behind in his child support payments. He tried to get assistance but did not have any success. SM voiced frustration with work and stated his chain of command doesn’t understand. (4) The SM stated he had his part 1 physical for a MEB and is pending part 2 on 22 June 2010. e. 28 June 2010 – the SM stated he was rear ended while in a car and was seen at the Emergency Room. He was previously diagnosed with a slipped disc in his neck and has been in pain ever since. The SM is still experiencing mild numbness in the left hand and getting spasms in his neck. The SM stated he had pressure behind his jaw and it builds into a headache. The SM is currently undertaking a medical board for his chronic left should injuries and herniated disk in his neck. f. 2 August 2010, Bennett Family Care Clinic, DACH – (1) Reason for Appointment – Part 2 ETS (2) Health Problems History – (a) Arthropathy pelvic / hip / femur (b) Tendonitis Psoas (c) Left Shoulder Sprain and surgeries (d) obesity (e) Esophageal Reflux (f) Leg Strain Gastrocnemius Right (g) Disorders of muscle, ligament, and fascia (h) Adjustment Disorder with mixed emotional features (i) Cervical Radiculopathy (C-5) (j) Cervical Spondylosis (C4-C5 and C5-C6) (k) Extruded Intervertebral Disc Cervical (C5-C6) (l) Cervicalgia (m) Cubital Tunnel Syndrome (3) No depression or anhedonia (sadness) in the past two weeks. (4) SM reported without his "Phase II physical paperwork." Without the Department of Defense (DD) forms, the clinic could not proceed. The SM stated he understood and would attempt to bring the forms back the next day. He also stated he had no acute concerns and had to current health concerns. The available medical records do not show that he returned with the DD forms. 6. On 8 August 2010, the applicant was honorably discharged by reason of ETS. Based on his enlistment, his 4 year ETS would have been 8 March 2010. It appears that his enlistment was extended voluntarily to 8 August 2010 due to medical issues including his left shoulder surgery. 7. The DD Form 2697 (Report of Medical Assessment), DD Form 2808 (Report of Medical Examination), and DD Form 2807-1 (Report of Medical History) required by Army Regulation 40-501 (Standards of Medical Fitness) upon separation from the Army are not found in the applicant’s military service health records. 8. The applicant provides a copy of a VA disability rating decision, dated 9 August 2012, pages 1-6, showing the following ratings but a combined rating is not shown: a. Service connection for adjustment disorder – 30% b. Migraines – 10% c. Gastroesophageal reflux disease – 10% d. Left shoulder status post surgery – 10% e. Cervical spondylosis with degenerative joint disease – 10% f. Left upper extremity cubital tunnel syndrome - 10% g. Residuals of meniscus tear left knee – 0% h. Residuals of right hip strain – 10% 9. The U.S. Army Office of the Surgeon General (OTSG), Behavioral Health Division, reviewed the applicant’s medical records and his contention that he had PTSD while an active duty that was treated as adjustment disorder. The OTSG observed that a VA letter dated 9 August 2012 indicated that service connection for adjustment disorder was granted and the applicant was assigned a 30 percent evaluation for generalized anxiety disorder. Army Regulation 40-501, paragraph 3-36, states, "situational maladjustments due to acute or chronic situational stress do not render an individual unfit because of physical disability, but may be the basis for administrative separation if recurrent and causing interference with military duly." According to the medical record, the applicant did not seek behavioral health treatment until 9 April 2010 when he was diagnosed with adjustment disorder secondary to acute situational stressors. There was no evidence of a chronic condition. The OTSG opined that after reviewing all available medical records, the applicant was evaluated on several occasions by different behavioral health providers, but there is no available documentation from the military service health records, the VA, or civilian medical system that indicates that a health care provider has diagnosed the applicant with PTSD or that he met the criteria for PTSD during or subsequent to his military service. 10. The applicant was provided a copy of the OTSG opinion but did not provide a response. REFERENCES: 1. Army Regulation 40-501 (Standards of Medical Fitness), provides the following directives concerning separation physicals for Soldiers who ETS. a. Paragraph 8-24a states that Soldiers separating from the Army will be given a medical interview using DD Form 2697 (Report of Medical Assessment). The interview will be conducted by a physician, physician assistant, or nurse practitioner to document any complaints or potential service–related (incurred or aggravated) illness or injury. The Soldier must acknowledge with his or her signature in block 19 of the form that the information provided is true and complete. This form will be filed in the individual’s military service health record. b. Paragraph 8-24b states Soldiers separating from the Army will receive a separation medical examination if the Soldier requests it, or if, on review of the military service health records or the DD Form 2697, a physician, a physician assistant, or a nurse practitioner feels an examination is appropriate. c. Table 8-2 states that Soldiers separating due to expiration of term of service will are not required to have a separation examination unless they request one - or - upon review of health record, evaluating physician or physician assistant at servicing MTF determines that, because of medical care received during active service, medical examination will serve the best interests of the Soldier and Government. d. Paragraph 8-5 states that the DD Form 2808 (Report of Medical Examination) and DD Form 2807-1 (Report of Medical History) are to be used in administering examinations and are filed in the individual’s military service health record. 2. Army Regulation 635-40 (Physical Evaluation for Retention, Retirement, or Separation) establishes the policies, responsibilities, and procedures that apply in determining whether a Soldier is unfit because of physical disability to reasonably perform the duties of his office, grade, rank, or rating. The regulation provides that the mere presence of impairment or physical disability does not of itself justify a finding of unfitness. In each case, it is necessary to compare the nature and degree of physical disability present with the requirements of the duties the member reasonably may be expected to perform because of his or her office, rank, grade, or rating. The Army must find that a service member is physically unfit due to medical conditions to reasonably perform his or her duties and assign an appropriate disability rating before he or she can be considered for medically retirement or separation. 3. Army Regulation 40-501, chapter 3, lists the causes for referral to an MEB. These include: a. Paragraph 3-3b(1), as amended, which states that for an individual to be found unfit by reason of physical disability, he must be unable to perform the duties of his office, grade, rank or rating. b. Paragraph 3-32, affective disorders (mood disorders) (which includes MDD), persistence or recurrence of symptoms sufficient to require extended or recurrent hospitalization, necessity for limitations of duty or duty in protected environment or resulting in interference with effective military performance. 4. PTSD is unique among psychiatric diagnoses because of the great importance placed upon the etiological agent, the traumatic stressor. In fact, one cannot make a PTSD diagnosis unless the patient has actually met the "stressor criterion," which means that he or she has been exposed to an event that is considered traumatic. Clinical experience with the PTSD diagnosis has shown, however, that there are individual differences regarding the capacity to cope with catastrophic stress. Therefore, while most people exposed to traumatic events do not develop PTSD, others go on to develop the full-blown syndrome. Such observations have prompted the recognition that trauma, like pain, is not an external phenomenon that can be completely objectified. Like pain, the traumatic experience is filtered through cognitive and emotional processes before it can be appraised as an extreme threat. Because of individual differences in this appraisal process, different people appear to have different trauma thresholds, some more protected from and some more vulnerable to developing clinical symptoms after exposure to extremely stressful situations. 5. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), produced by the American Psychiatric Association, was released in May 2013. This revision includes changes to the diagnostic criteria for PTSD and acute stress disorder. The PTSD diagnostic criteria were revised to take into account things that have been learned from scientific research and clinical experience. The revised diagnostic criteria for PTSD includes a history of exposure to a traumatic event that meets specific stipulations and symptoms from each of four symptom clusters: intrusion, avoidance, negative alterations in cognitions and mood, and alterations in arousal and reactivity. The sixth criterion concerns duration of symptoms; the seventh assesses functioning; and the eighth criterion clarifies symptoms as not attributable to a substance or co-occurring medical condition. a. Criterion A, stressor: The person was exposed to: death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence, as follows: (one required) (1) Direct exposure. (2) Witnessing, in person. (3) Indirectly, by learning that a close relative or close friend was exposed to trauma. If the event involved actual or threatened death, it must have been violent or accidental. (4) Repeated or extreme indirect exposure to aversive details of the event(s), usually in the course of professional duties (e.g., first responders, collecting body parts; professionals repeatedly exposed to details of child abuse). This does not include indirect non-professional exposure through electronic media, television, movies, or pictures. b. Criterion B, intrusion symptoms: The traumatic event is persistently re-experienced in the following way(s): (one required) (1) Recurrent, involuntary, and intrusive memories. (2) Traumatic nightmares. (3) Dissociative reactions (e.g., flashbacks) which may occur on a continuum from brief episodes to complete loss of consciousness. (4) Intense or prolonged distress after exposure to traumatic reminders. (5) Marked physiologic reactivity after exposure to trauma-related stimuli. c. Criterion C, avoidance: Persistent effortful avoidance of distressing trauma-related stimuli after the event: (one required) (1) Trauma-related thoughts or feelings. (2) Trauma-related external reminders (e.g., people, places, conversations, activities, objects, or situations). d. Criterion D, negative alterations in cognitions and mood: Negative alterations in cognitions and mood that began or worsened after the traumatic event: (two required) (1) Inability to recall key features of the traumatic event (usually dissociative amnesia; not due to head injury, alcohol, or drugs). (2) Persistent (and often distorted) negative beliefs and expectations about oneself or the world (e.g., "I am bad," "The world is completely dangerous"). (3) Persistent distorted blame of self or others for causing the traumatic event or for resulting consequences. (4) Persistent negative trauma-related emotions (e.g., fear, horror, anger, guilt, or shame). (5) Markedly diminished interest in (pre-traumatic) significant activities. Feeling alienated from others (e.g., detachment or estrangement). (6) Constricted affect: persistent inability to experience positive emotions. e. Criterion E, alterations in arousal and reactivity: Trauma-related alterations in arousal and reactivity that began or worsened after the traumatic event: (two required) (1) Irritable or aggressive behavior (2) Self-destructive or reckless behavior (3) Hypervigilance (4) Exaggerated startle response (5) Problems in concentration (6) Sleep disturbance f. Criterion F, duration: Persistence of symptoms (in Criteria B, C, D, and E) for more than one month. g. Criterion G, functional significance: Significant symptom-related distress or functional impairment (e.g., social, occupational). h. Criterion H, exclusion: Disturbance is not due to medication, substance use, or other illness. DISCUSSION: 1. There is no evidence that the applicant was diagnosed with or treated for PTSD. According to his military service health records, he was diagnosed on 12 April 2010 by a DACH clinical psychologist with adjustment disorder with mixed emotional features. On the clinical psychologist’s 9 April 2010 examination report which led to the 12 April 2010 diagnosis, the psychologist stated that the applicant screened negative for PTSD and TBI. The VA rating decision does not name PTSD as a diagnosis but names the applicant’s behavioral condition as an adjustment disorder. The OTSG opined that no evidence was found to meet the criteria for PTSD during or subsequent to the applicant’s military service. 2. These is insufficient evidence to support a discharge by reason of medical retirement. It is noted that the applicant had a number of health conditions at the time of his ETS. He also had regular contact with care providers and it appears that he was referred to an MEB at some point in the last several months he served. In the absence of evidence showing otherwise, it must be presumed that the MEB found no basis upon which to continue disability evaluation processing. This conclusion is supported by the fact that, by 2 August 2010, he was undergoing part 2 of his ETS physical (which appears to be undocumented by the appropriate forms because the applicant failed to bring those forms with him to the appointment). 3. There is no evidence of error in his ETS discharge, nor is there evidence that would support correcting his record to show he was retired due to disability. //NOTHING FOLLOWS// ABCMR Record of Proceedings AR20150000953 Enclosure 1 ARMY BOARD FOR CORRECTION OF MILITARY RECORDS RECORD OF PROCEEDINGS ABCMR Record of Proceedings (cont) AR20150002190 2 ARMY BOARD FOR CORRECTION OF MILITARY RECORDS RECORD OF PROCEEDINGS Enclosure 1 ABCMR Record of Proceedings (cont) AR20150002190 10 ARMY BOARD FOR CORRECTION OF MILITARY RECORDS RECORD OF PROCEEDINGS Enclosure 2