BOARD DATE: 3 October 2017 DOCKET NUMBER: AR20160003017 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 BOARD DATE: 3 October 2017 DOCKET NUMBER: AR20160003017 BOARD DETERMINATION/RECOMMENDATION: The evidence presented does not demonstrate the existence of a probable error or injustice. Therefore, the Board determined 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. BOARD DATE: 3 October 2017 DOCKET NUMBER: AR20160003017 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 records to show he was medically retired. 2. He states that after serving in the Army for 5 years, he injured his ankle during special operations training. He adds the injury was more severe than his military records note. All the ligaments in his ankle were snapped or torn. This caused a multitude of other injuries. He states he was forced to go to a Medical Evaluation Board (MEB). The MEB told him that the board could only evaluate his ankle injury. He believes the MEB should have encompassed all of his medical issues that were preventing him from staying on active duty such as his back pain, bilateral leg, bilateral ankle injury, bilateral knee pain, and left foot pain from the injury. 3. He provides: * self-authored statement, dated 7 January 2016 * DA Form 199 (Informal Physical Evaluation Board (PEB) Proceedings), dated 2 March 2015 * DD Form 214 (Certificate of Release or Discharge from Active Duty) * 90 pages of various medical records CONSIDERATION OF EVIDENCE: 1. On 28 April 2010, the applicant enlisted in the Regular Army. He was trained in military occupational specialty (MOS) 91C (Utilities Equipment Repairer). He served in Afghanistan from 13 December 2012 to 22 August 2013. 2. On 2 March 2015, he underwent an informal physical evaluation board (PEB) at Winn Army Community Hospital, Fort Stewart, GA. He received a disability rating of 10 percent for left ankle pain status post left ankle reconstruction. The DA Form 199 contains the following information: a. Section III - Medical Conditions Determined to Be Unfitting, Disability 1: The onset of the injury occurred in May 2011, when the applicant stepped wrong and landed on his left ankle while assigned at Hunter Army Air Field, Georgia. Reasonable performance in the Soldier's 91C MOS requires him to perform certain activities. In accordance with Department of Defense Instructions (DODI) 1332.18, the Soldier is unfit; this condition prevents the Soldier from lifting, lowering, carrying, pushing, and pulling. b. Section IV - Medical Condition Determined Not to Be Unfitting. The applicant is fit for the following conditions MEB diagnoses: unspecified anxiety disorder, gastroesophageal reflux disease (GERD), status post cholecystectomy with residual scars, status post Morton neuroma resection with residual scars, healed right thumb fracture, right shoulder impingement syndrome, left femoral acetabular impingement, right femoral acetabular impingement, Ieft patella femoral syndrome, right patellofemoral syndrome, right posterior tibialis tendinitis, cervical strain, lumbar strain/lumbago, tension headaches, right ankle sprain, and bilateral tinnitus). The conditions are not unfitting because the MEB indicates the conditions meet retention standards; does not indicate that any of the conditions cause profile limitations; and does not indicate performance issues, if any, are due to these conditions. c. Section VI – Instructions and Advisory Statements: "This case was adjudicated as part of the Integrated Disability Evaluation System (IDES). As documented in the Department of Veterans Affairs (DVA) memorandum dated 11 February 2015, the DVA determined the specific VASRD code(s) to describe the Soldiers condition(s). The PEB determined the disposition recommendation based on the proposed DVA disability rating(s) and in accord with applicable statutes and regulations. It is noted that the Soldier's disability rating is less than 30 PERCENT. Soldiers with a disability rating of less than 30 percent, and with less than 20 years of service… require separation from service with disability severance pay…" d. Section IX - Soldier's Election. "I have been advised of the findings and recommendations of the Informal Physical Evaluation Board and have received a full explanation of the results of the findings and recommendations and legal rights pertaining thereto. I understand that if I fail to make an election within the time prescribed after the PEBLO [PEB Liaison Officer] or applicable counselor has informed me of the findings, the PEB may proceed as if I have concurred with the findings and recommendations." The applicant initialed "I concur and waive a formal hearing of my case." He signed his election on 3 March 2015. e. On 9 March 2015, his PEB proceedings were approved with a 10 percent disability rating. 3. He was honorably discharged on 7 June 2015 under the provisions of Army Regulation (AR) 635-40 (Physical Evaluation for Retention, Retirement, or Separation), chapter 4, disability, severance pay, non-combat (enhanced). He completed 5 years, 1 month, and 10 days of creditable active service and received $25,806.00 in disability severance pay. 4. On 17 April 2017, the ABCMR obtained an advisory opinion from the Senior Medical Advisor, Army Review Boards Agency (ARBA), who states the evidence provided does not support the applicant's request for a medical retirement. The medical advisor also states: a. A review of the applicant’s electronic medical record (AHLTA) revealed clinical encounters from April 2010 through April 2015. Additionally, clinical notes were reviewed from April 2011 through April 2014, radiology reports from March 2011 through January 2015, and laboratory results from April 2010 through April 2015. b. His records show a clinic visit on 30 November 2010 and 2 December 2010 for mid-back pain after moving heavy stuff the day prior with a follow-up visit. He was placed on quarters for mid-back pain for 3 days with a 7-day profile for no physical training. He was treated with muscle relaxers and non-steroidal anti-inflammatory drugs. He denies any previous history or similar complaints. He was recently assigned to unit from Advanced Individual Training and he failed the initial Army Physical Fitness Test (APFT). c. A clinic visit on 18 January 2011 for Survival Evasion Resistance Escape/Airborne (SERE/ABN) training. A physical was completed, labs reviewed electrocardiogram reviewed, and normal sinus rhythm. He was cleared for SERE/ABN with no physical abnormalities. His records also show: * Magnetic Resonance Imaging (MRI) left ankle (11 April 2011) – partial tear of the anterior talofibular ligament suggested; correlation is recommended with physical examination. No tendon disruption noted * Left ankle x-ray series (22 June 2011) – normal * Left ankle x-ray series, stress views (8 July 2011) – no instability noted * Right hand x-ray series (13 January 2012) – focal cortical irregularity head of the right first metacarpal probably post-traumatic or degenerative * Right thumb x-ray series (1 February 2012) – no acute bony injury is seen, periarticular small calcific deposit near the radial aspect of the first metaphalangeal joint that may represent residual of old trauma or inflammation d. A nutrition consult on 13 March 2012 for slowly gaining weight due to inactivity following surgery greater than 6 months ago; he failed height/weight and tape during APFT (February 2012). e. A clinic visit on 22 May 2013 for motor vehicle accident about 1600 hours; applicant had no complaints at that time. f. A DA Form 1059 (Service School Academic Evaluation Report), dated 31 October 2013 for Warrior Leader Course for the period 1 October 2013 through 31 October 2013 shows APFT information of "Pass 20131002 height/weight 72/204 Yes" (indicating he meets standards). * MRI left ankle (6 December 2013) with impression of prior lateral ligamentous injury; poor visualization of the anterior talofibular ligament, central osteochondral lesion talar dome * Nerve Conduction Velocity studies on 20 December 2013 with severe right sural sensory neuropathy and possible right lumbosacral radiculopathy by abnormal F-Wave(s) g. A Discharge Summary, dated 27 January 2014, after a left ankle ligament repair (arthroscopy/debridement; partial excision of bone). h. An MEB, Integrated Disability Evaluation System (IDES), and narrative summary conducted on 2 December 2014 was reviewed. A DA Form 3349 (Physical Profile) shows a PULHES of 123111. "This profile has been reviewed, SM [service member] performs administrative duties in the units training room and he is not working in the motor pool due to his condition and inability to walk on uneven terrain, carry heavy equipment, and climb in and out of military vehicles. SM cannot conduct field training exercises due to an inability to wear military equipment, wear personal protective gear, qualify with assigned weapon or ride in military vehicles, and not able to deploy worldwide to support contingency." i. A DA Form 3947 (MEB), dated 11 December 2014, shows the following diagnosis: * left ankle pain, status post left ankle reconstruction. Department of Veterans Affairs (VA) diagnosis: Ankle sprain – status post left ankle reconstruction with residual pain and scar * unspecified anxiety disorder. VA diagnosis: no diagnosis * GERD; meets retention standards * status post cholecystectomy with residual scars; meets retention standards * status post Morton neuroma resection with residual scars; no medical basis * health right thumb fracture; meet retention standards * impingement syndrome right shoulder; no medical basis * left femoral acetabular impingement; no medical basis * right femoral acetabular impingement; no medical basis * left patellofemoral syndrome; no medical basis * right patellofemoral syndrome; no medical basis * right posterior tibialis tendinitis; no medical basis * cervical strain; meets retention standards * lumbar strain/lumbago; meet retention standards * tension headaches; meets retention standards * right ankle sprain; meet retention standards * bilateral tinnitus; this condition does not constitute a physical disability j. An Informal PEB convened on 2 March 2015. The PEB results are listed in paragraph 2, Consideration of Evidence, of this document. k. The applicant did not meet medical retention standards for left ankle pain status post left ankle reconstruction in accordance with chapter 3, AR 40-501 (Standards of Medical Fitness), and following the provisions set forth in AR 635-40 in effect at the time. l. Limited review of VA records through the Joint Legacy Viewer listed 22 problems of which three were entered by VA to include gastroesophageal reflux disease without esophagitis and pain in left foot. The applicant received an 80 percent service-connected disability rating from VA. m. The applicant met medical retention standards for: unspecified anxiety disorder; GERD; status post cholecystectomy with residual scars; status post Morton neuroma resection with residual scars; healed right thumb fracture; right shoulder impingement syndrome; left femoral acetabular impingement; right femoral acetabular impingement; left patellofemoral syndrome; right patellofemoral syndrome; right posterior tibialis tendinitis; cervical strain; lumbar strain/lumbago; tension headaches; right ankle sprain; and bilateral tinnitus in accordance with chapter 3, AR 40-501 and the provisions set forth in AR 635-40, in effect at the time. He also met the medical retention standards for hyperlipidemia and history of penicillin allergy. His medical conditions were duly considered during his medical separation processing. n. A review of the available documentation found no evidence of a medical disability or condition which would support a change to the discharge in this case. 5. On 19 April 2017, the advisory opinion was forwarded to the applicant for his acknowledgement and/or response. No response was received. REFERENCES: 1. AR 40-501 governs medical fitness standards for enlistment, induction, appointment, retention, and separation, including retirement. Chapter 3 provides the various medical conditions and physical defects which may render a Soldier unfit for further military service and which fall below the standards required for the individual in paragraph 3-2, below. These medical conditions and physical defects, individually or in combination: * significantly limit or interfere with the Soldier's performance of duties * may compromise or aggravate the Soldier's health or well-being if the Soldier remains in the military – this may involve dependence on certain medications, appliances, severe dietary restrictions, frequent special treatments, or a requirement for frequent clinical monitoring * may compromise the health or well-being of other Soldiers * may prejudice the best interests of the government if the individuals were to remain in the military service 2. AR 635-40 establishes the Army Physical Disability Evaluation System and sets forth 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. PEB's are established to evaluate all cases of physical disability equitability for the Soldier and the Army. It is a fact-finding board to investigate the nature, cause, degree of severity, and probable permanency of the disability of Soldiers who are referred to the board; to evaluate the physical condition of the Soldier against the physical requirements of the Soldier's particular office, grade, rank, or rating; to provide a full and fair hearing for the Soldier; and to make findings and recommendations to establish eligibility of a Soldier to be separated or retired because of physical disability. a. Disability compensation is not an entitlement acquired by reason of a service-incurred illness or injury; rather, it is provided to Soldiers whose service is interrupted and who can no longer continue to reasonably perform because of a physical disability incurred or aggravated in service. b. Recommendations of the informal PEB are recorded on a DA Form 199. The form lists the election options available to the Soldier for informal determinations. These include: * Accept the PEB decision, thereby waiving his or her right to a formal hearing * Nonconcur with the PEB decision and demand or request, as applicable, a formal hearing with or without a statement of appeal (also called a statement of rebuttal) * Nonconcur with the PEB decision with or without submitting a statement of appeal without demanding a formal hearing. * Accept or request reconsideration of the VA preliminary ratings c. Soldiers indicate their elections by placing a checkmark in the appropriate block and signing and dating the original and the medical treatment facility copies. 3. Title 10, U.S. Code, section 1201, provides for the physical disability retirement of a member who has at least 20 years of service or a disability rating of at least 30 percent. Title 10 U.S. Code, section 1203, provides for the physical disability separation of a member who has less than 20 years of service and a disability rating of less than 30 percent. DISCUSSION: 1. The applicant argues, in effect, that the MEB did not consider all his medical issues. However, the evidence of record shows the MEB considered 16 issues to include: left femoral acetabular impingement; right femoral acetabular impingement; left patella femoral syndrome; right patellofemoral syndrome; right posterior tibialis tendinitis; cervical strain; lumbar strain/lumbago right posterior tibialis tendinitis; lumbar strain/lumbago; and right ankle sprain. His contention that the MEB failed to consider his back pain, bilateral leg, bilateral ankle injury, bilateral knee pain, and left foot pain were not considered is not supported by the available evidence. 2. The available evidence shows the applicant was found unfit for duty for left ankle pain status post left ankle reconstruction with a 10 percent disability rating. He also had 16 other conditions that the PEB considered, but were determined not unfitting because the MEB indicated the conditions met retention standards since there was no indication that any of the conditions caused profile limitations or performance issues. 3. The ARBA Senior Medical Advisor reviewed the applicant's available medical documents and the medical records the applicant provided. The Senior Medical Advisor stated the applicant's medical conditions received proper consideration during his medical separation processing. Additionally, he found no evidence of a medical disability or condition, which would support a change to the character or reason for the applicant's discharge in this case. 4. The condition considered by the PEB and determined to be unfitting was rated at 10 percent. Title 10, U.S. Code, section 1201, provides that physical disability retirement for service members require a disability rating of at least 30 percent. The evidence of record shows he signed the PEB Proceedings concurring with the board's findings and waving a formal hearing. There is no evidence in his records indicating any additional conditions, failed to meet retention standards and/or prevented him from performing his military duties while he was on active duty. A disability rating assigned by the Army is based solely on conditions found to be unfitting while the Soldier is on active duty. //NOTHING FOLLOWS// ABCMR Record of Proceedings AR20150000953 Enclosure 1 ARMY BOARD FOR CORRECTION OF MILITARY RECORDS RECORD OF PROCEEDINGS ABCMR Record of Proceedings (cont) AR20160003017 5 ARMY BOARD FOR CORRECTION OF MILITARY RECORDS RECORD OF PROCEEDINGS Enclosure 1 ABCMR Record of Proceedings (cont) AR20160003017 8 ARMY BOARD FOR CORRECTION OF MILITARY RECORDS RECORD OF PROCEEDINGS Enclosure 2