RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXX		BRANCH OF SERVICE: army
CASE NUMBER:  PD0900248		BOARD DATE: 20090916
SEPARATION DATE: 20070827
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SUMMARY OF CASE:  This covered individual (CI) was a Specialist Infantryman medically separated from the Army in 2007 after 3 years of service.  The medical basis for the separation was post traumatic stress disorder (PTSD) and left hip post traumatic arthritis; residual of gunshot wound (GSW) sustained in combat.  The CI was deployed to Mosul, Iraq participating in a dismounted urban sweep when he was struck by a single sniper bullet to the left hip.  CI was referred to the PEB, found unfit and separated at 10% disability.  
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CI CONTENTION:  "The Army gave me 0% for a gunshot wound to my left hip which I received in combat.  I have bad aches, pain, and at time trouble climbing stairs or walking long distances.  It has caused me problems doing any jobs that may involve any kind of manual labor.  I now have a son who is only a few months old and I fear that when he is older I won’t be able to run and play with him like a normal father.  The army has rated me 10% for P.T.S.D.  I feel this is unfair, because it is caused by my experiences in combat.  After more three years of being home from Iraq.  I still have nightmares, trouble falling asleep, anxiety, flashbacks, and has been a strain on my marriage.  I separate myself from people I love, for reasons I have no explanation for.  I find myself often avoiding going out in public if I can help it." 
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RATING COMPARISON:

Previous Determinations 	
Service	VA  PTSD exam 8 mos post separation;
   Hip exam 3 mos post separation	
PEB Condition	Code	Rating	Date	Condition	Code	Rating	Exam Date	Effective date	
PTSD (see text)	9411	10%	20070622	PTSD	9411	NSC

30%	Missed, CNX x2

20080407	CI withdrew

20070828	
LEFT HIP POST TRAUMATIC ARTHRITIS
(see text)	5010	0%	20040000	RESIDUAL OF LEFT POSTERIOR ACETABULUM FRACTURE WITH CHRONIC MILD STRAIN OF THE LEFT HIP	5255	10%	20071128	20070828	
				SCARS, GSW RESIDUAL, L ANT HIP AND L GLUTEUS MAXIMUS MUSCLE	7805	0%	20071128	20070828	
TOTAL Combined:  10%	TOTAL Combined (incl non-PEB Dxs):   10% from 20070828                                                                    
                                                           40% from 20070828	

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ANALYSIS SUMMARY:  The CI was deployed to Mosul, Iraq participating in a dismounted urban sweep when he was struck by a single sniper bullet to the left hip.  PEB disability descriptions were:  "9411:  Posttraumatic Stress Disorder due to stress of combat duty in Iraq, where he was shot by a sniper (10 A/C) in Jan 06.  Recovered from wound sufficiently to return to combat, but then developed significant PTSD symptoms and experienced "freezing up" on some missions.  After redeployment he engaged in treatment with significant improvement, although still manifesting anxiety with discussion of combat experiences and future deployment.· Currently reports some difficulty with attention and concentration in the milieu of his unit's preparation for impending deployment but overall performing well in the garrison.  Prognosis is good although long term treatment will be required.  Rated for mild industrial impairment.  5010:  Left hip posttraumatic arthritis, residual of gunshot wound sustained during combat in Iraq, 6 Jan 06 (10 A/C, Purple Heart).  A single sniper bullet entered the groin and exited the buttock, causing a nondisplaced fracture of the femoral head and posterior acetabulum that were treated conservatively.  After healing, he redeployed to Iraq, Aug 06 and experienced worsening hip pain with constant wear of body armor and weight bearing activities, but able to complete deployment.  MRI shows a localized area of aseptic necrosis of the anterior femoral head, a deformity of the posterior aspect of the acetabulum, and a small joint effusion.  Plain films show lucency in the same areas.  Exam shows essentially full range of motion minimally limited by pain.  Pain associated with weight bearing, Load bearing, and impact activities prevent return to duty as an infantryman. Rated for no mechanical loss of motion."  

PTSD.  The CI reported decreased sleep and concern about work-related health problems following hospitalization (weeks) for his left hip gunshot wound (GSW) from combat in Iraq.  He was seen in Apr 06 for redeployment, denied clinically significant distress, was returned to duty without limitations, and redeployed to Iraq for a second time.  During deployment and post-redeployment, the CI reported PTSD related episodes: 12 Feb 07 the service member was more forthright about his symptoms and did meet criteria for PTSD which had been ongoing since he was injured in Iraq in Jan 2006.  He was diagnosed with PTSD and treated with counseling and medications.  He was subsequently referred for a MEB for PTSD.  The CI was on chronic medications for PTSD-related nightmares and insomnia.  The CI had psychomotor agitation that lessened over the course of treatment, resolved rhythmic tic in his neck, appeared anxious and nervous.  Mood was described as anxious, worried, not sleeping well and having nightmares.  Affect was mood congruent and anxious appearing.  His anxious affect decreased with aggressive treatment status post his second deployment.  The CI was being seen two to three times per month for medication management and four times a month for PTSD group therapy.  Per NARSUM extracted:  His symptoms continued to be exacerbated by exposure to military triggers such as discussion of combat experiences and pending deployment.  The CI was motivated for continued military service and returned to deployment, but "his failure secondary to PTSD symptoms during his second deployment has caused the service member significant concern about "freezing up"  in the future and being killed in combat or failing his fellow unit members.  As the result of the service member's psychiatric symptoms and PTSD, he has manifested significant difficulty maintaining an acceptable level of attention and concentration to carry out instructions and tasks commonly found in his work setting, difficulties completing tasks in a timely fashion, difficulties communicating with others on work-related matters, difficulties civilly relating to supervisors and other workers, difficulty sustaining an ordinary routine without special supervision and work with or near others without being unduly distracted by them.  His anxiety also makes it difficult for him to respond appropriately to changes in the work setting.  The service member has been unable to be depended upon in combat as evidenced by his second deployment.  Although he reports motivation, he has "frozen up" multiple times while engaged in combat and has been unable to fire his weapon or function effectively which puts him at very high risk as well as the members of his unit.  The patient's overall prognosis is good if he is able to engage in ongoing medication management group or individual therapy and maintain a low to moderate stress civilian job.  The service member is not expected to be able to function in any kind of deployment setting so a switch of MOS will not make this Soldier world-wide deployable. He does report significant motivation for the military, so if a non-deployable position was available this service member may fit well.  The service member is at high likelihood for continued problems in any austere combat environment.  He has been able to work adequately in the garrison situation, although he has had multiple medical appointments and group therapies which have taken him out of his work setting.  The service member has been fully compliant with all treatment regimens and the medical evaluation process.  Ideally, the service member would benefit from once weekly therapy and once monthly medication management with a psychiatrist.  The service member has not required inpatient psychiatric services at the time of this dictation.  Axis I: Post-traumatic stress disorder, chronic, as manifested by nightmares, insomnia, angry outbursts, difficulty concentrating; hypervigilance, increased startle response to noises, decrease interest in social activities and hobbies, social detachment from other people, restrictive emotional range, avoidance of discussion of combat, avoidance of Soldiers preparing for deployment and a sense of foreshortened future if deployed again.  The patient was not predisposed to develop this condition. Impairment for further military duty: Severe.  The patient is moderately impaired for social and industrial adaptability.  He is expected to have moderate job instability and moderate social maladjustment.  For his symptoms he is expected to require ongoing outpatient treatment and use of medications for his condition."  Occupational stressors: Deployment to a combat zone and gunshot wound in Iraq.  Global assessment of functioning (GAF) was 55.  

The above exam would independently rate at 50% to 30% as "adequate work in garrison" is considered a protected work environment.  Since the military exam would not rate greater than 50%, the recommendation is for 6 months rating at 50% IAW §4.129 Mental disorders due to traumatic stress and new DOD guidance.    

The VA originally denied service connection for PTSD as the CI cancelled or missed two appointments for initial PTSD evaluation.  When the CI was evaluated for PTSD and rated in Apr 07 the VA did not apply §4.129, but rated the exam by criteria at 30% effective the date following the CI's discharge.  The VA initial PTSD evaluation exam of 20080407 (8 months post discharge) indicated mild to moderate impairment in social and occupational functioning.  Extracts: you and your wife are living at your parents home; you and your wife have been fighting more and she wonders, why you do not talk as much as you used to; reported upsetting nightmares which included depictions of Iraq staling "being shot, bombs going off, (IED) friends being shot even though they never were."  You also had upsetting dreams about family members being in Iraq stating "I couldn't explain the dreams," You reported flashbacks, nightmares and difficulty with going outside; You are always hypervigilant when outside and have to sit with your back against the wall; You have diminished interest in activities and prefer to avoid conversations about the Iraq experience, You reported ongoing difficulty falling asleep, once asleep can sleep for a long time unless awakened by nightmares; You still get up and check doors and windows with the smallest noise; some difficulty securing employment following your return from military service; physical appearance and dress reflected adequate personal care and hygiene; mood was sullen, depressed and mildly irritable; appeared mildly anxious at points during the course of our time together. You denied recent suicidal and homicidal ideation.  Your affect was flat; GAF of 64, indicating mild to moderate impairment in social and vocational functioning.  The examiner noted VA treatment records of 20080109 (5 months post discharge) indicating VA psychiatric consultations with moderate PTSD symptoms and a GAF of 48-53.     
 
Independently rating the CI's discharge exam was between 50% and 30%.  Independently rating the VA exam of 20080407 (8 months post discharge) was 30%.  Given the additional psychiatric assessment at 4-5 months post-discharge and the examiner's specification of moderate social and occupational impairment, the CI's rating at the 6-month post discharge timeframe was appropriately evaluated at the 30% level.  

LEFT HIP POST TRAUMATIC ARTHRITIS.  The CI was struck by a single sniper bullet which entered the left groin and exited through the left buttock.  Initial evaluation indicated that he sustained a nondisplaced fracture of the femoral head and posterior acetabulum.  After stabilization, he underwent physical therapy and rehabilitation.  The CI was able to walk and had slight painful limited range of motion compared to his non-injured hip.  CI had a healed bullet wound in the left groin about the size of a dime, an exit wound in the left buttock perhaps the size of a silver dollar. NARSUM exam showed he had pain on both internal and external rotation, full range of motion with pain at the limits of rotation of the left hip.  Complete range of motion evaluation was performed by physical therapy on 05 April 2007 as follows: Left hip flexion 110/120 limited by pain (normal 0-125˚).  Left hip extension 15/20 limited by pain.  Left hip abduction 35/40 limited by pain (normal 0-45˚).  The PEB noted essentially full range of motion minimally limited by pain and rated for no mechanical loss of motion.  The VA exam of 20071128 documented range of motion of 125˚ flexion, extension 30˚, adduction 25˚, abduction 45˚, external rotation 60˚ and internal rotation 40˚ with painful motion on flexion, internal rotation and adduction.  Plain X-rays were read as normal.  The VA rated the CI for slight hip disability and symptoms of painful motion were taken into consideration.   

Left Hip:          	                           
Movement
	Normal ROM
	ROM Mil (active/passive)
20070405	ROM VA 20071107	
Left Flexion	0 - 125	110/120, limited by pain	125/pain	
Left Extension		15/20, limited by pain	30	
Left Abduction	0 - 45	35/40, limited by pain	45 	

SCARS, THROUGH AND THROUGH GSW RESIDUAL, LEFT ANTERIOR HIP AND LEFT GLUTEUS MAXIMUS MUSCLE:  This condition was not addressed by the PEB/MEB as a diagnosis.  The NARSUM did address the well healed GSW.  The VA exam noted no additional impact on joint limitation of motion and no other criteria sufficient to rate above a 0%.  There is no indication in the record that this condition should be found to be unfitting.
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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 PDBR to the extent they were inconsistent with the VASRD in effect at the time of the adjudication.  The Board determined that absent the Army pain rule, painful motion IAW §4.59 should be applied for a 10% rating.  The Board opined that code 5010 Arthritis due to trauma was the predominate code given the history of the CI's injury.  Although the Board could not reconcile the CI's VA rating determination for his GSW in light of §4.56 dealing with minimum ratings for through and through GSWs, it was not applicable to the Board's determination as the Board opined that residual scars or muscle injury of CI's GSW should not be added as separately unfitting conditions.  

The Board unanimously agreed that as the CI would not have rated higher than 50% for PTSD at discharge, that the CI's PTSD rating for a 6 month TDRL period should be 50% for 6 months IAW §4.129 and DoD direction.  The Board could not follow why the VA did not apply §4.129 in this case, but agreed with the VA 30% PTSD rating level from their examination 8 months post-discharge.  The Board opined that this exam best approximated the CI's disability picture at 6 months post-discharge and that the CI met the criteria for a 30% PTSD rating.  The Board unanimously voted for a 10% left hip rating, and PTSD at 50% for 6 months then a permanent PTSD rating level of 30%.  
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RECOMMENDATION: The Board recommends that the CI’s prior determination be modified as follows; TDRL at 60% for 6 months following the CI’s prior medical separation (PTSD at minimum of 50% IAW §4.129 and DoD direction, combined with 10% Hip rating), and then a permanent combined 40% disability retirement as below. 

Unfitting Condition	VASRD Code	TDRL Rating	Permanent
Rating	
RESIDUAL OF LEFT POSTERIOR ACETABULUM FRACTURE WITH CHRONIC MILD STRAIN OF THE LEFT HIP	5010	10%	10%	
PTSD 	9411	50%	30%	
COMBINED	60%	40%	

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The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20090319, w/atchs.
Exhibit B.  Service Treatment Record.
Exhibit C.  Department of Veterans' Affairs Treatment Record.