RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXX		BRANCH OF SERVICE: NAVY
CASE NUMBER:  PD0900536		BOARD DATE: 20100707
SEPARATION DATE: 20060816
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SUMMARY OF CASE:  This covered individual (CI) was a Seaman/E3 (Infantry, Gun Crews and Seamanship) medically separated from the Navy in 2006 after 2 years of service.  The medical bases for the separation were History of Right Axillary Third-Degree Burn and Post Traumatic Stress Disorder (PTSD).

The History of Right Axillary Third-Degree Burn and PTSD were determined to be medically unacceptable and the CI was referred to the Physical Evaluation Board (PEB), determined to be unfit for continued military service, and separated at 20% disability using the Veterans Affairs Schedule for Ratings Disabilities (VASRD) and applicable Navy and Department of Defense regulations.
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CI CONTENTION:  “I have received a 80% rating from the VA and I want my military rating reviewed again.  I was recently notified that it was possible.” “Migraines are associated with PTSD.”
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RATING COMPARISON:

Service	VA (9 Mo. after Separation)	
Unfitting Conditions	Code	Rating	Date	Condition	Code	Rating	Exam	Effective	
History of Right Axillary Third-Degree Burn
	7801	10%	20060606	Burn Scar Claimed as Right Shoulder, Chest, Back, Hips & Face	7802	10%	20070516	20060817	
				Chronic Neuritis, Right Arm, Status Post Burn, Right Axilla, Requiring Skin Graft (Also claimed as Right Shoulder Condition w/Radiculopathy) (Dominate)	8611	20%	20070516
	20060817	
Decrease Range of Motion of Right Upper
	CAT II		20060606						
Chronic Pain D/O
	CAT II		20060606						
Status Post Burn Debridement & Skin Grafting	CAT II		20060606	Residual Scar, Right Hip (Donor Site Graft)	7804	10%	20070516	20060817	
PTSD
	9411	10%	20060606	PTSD w/Mood & Undifferentiated Somatoform D/O (Also Claimed as Depression and Pain D/O)
	9411	50%	20070524	20060817	
Somatization D/O
	CAT III		20060606						
Depression
	CAT III		20060606						
Borderline Personality Traits
	CAT IV		20060606						
Mild Dysplasia
	CAT III		20060606	Dysplasia (Also claimed as Cervicitis and Colposcopy)	NSC				
No PEB Entry	2807: Intermittent Low Back Pain	Lumbar Back Condition	5237	10%	20070516	20060817		
No PEB Entry	Not in DES Package	Left Knee Sprain	5299-5257	10%	20070516	20060817	
No PEB Entry	2808: Intermittent Right Knee Pain	Right Knee Sprain	5299-5257	10%	20070516	20060817	
No PEB Entry	2808: Intermittent Right Ankle Pain	Right Ankle Sprain 	5271	0%	20070516
	20060817	
No PEB Entry	MEB Report 20051122: Hx	Acne 	7828	0%	20070516
	20060817	
TOTAL Combined:  20%	TOTAL Combined (Includes Non-PEB Conditions):    
80%  from 20060817 (Bilateral Factor of 2.7 for 5257, 5257, 7804)	
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ANALYSIS SUMMARY:

The CI suffered third-degree flame burn injuries to the region of the right axilla and right chest wall on 08 April 2005 when her clothing was ignited accidentally by a candle.  She underwent debridement and skin grafting on 20 April 2005.  The donor site for the skin grafting of her right axilla and right chest wall was her right hip.  She had chronic pain and limited motion of shoulder and was referred to pain management.  When the patient was seen initially on 06 July 2005 in the Pain Management Clinic she was noted to have 5-6/10 pain that was paroxysmal and could be as bad as 10/10 during exacerbations.  She described the pain as sharp, with an electrical quality, radiating into her arm from the burn scar site, coming in waves and worse with movement; especially with Physical Therapy sessions.  She was unable to describe consistently alleviating factors.  She described her sleep as poor, with frequent awakening throughout the night.  She also noted that she had been depressed subsequent to the burn injury.  She noted that previous treatment with Oxycodone, Ambien (Zolpidem), Ibuprofen, and Lexapro (Citalopram) had not been of much benefit.  She also noted significantly decreased range-of-motion (ROM) of her right upper extremity, especially at the shoulder and was essentially unable to use her right arm for routine activities of daily living.  She is right hand dominant.  The patient ultimately was seen by multiple medical specialties since first being seen at Naval Hospital Bremerton.  These include: General Surgery, Anesthesiology, Orthopedics, Physical Therapy, psychiatry, Dermatology, Gynecology, Neurology, Hospitalist (Internal Medicine), Chiropractic, Behavioral Medicine, Optometry, Nutrition and Primary Care/Case Management (Family Medicine). She also received a referral to Pastoral Care.  Overall, the patient had made some progress in the management of her pain and an increase in the functioning of her right arm.  However, she had not improved to an extent that made it likely that she would be able to return to full duty and she was referred to the PEB.

Her first Limited Duty (LIMDU) from 20050616 to 20051216 was for Third Degree Burns Right Arm (20050408) and Chronic Pain.  The restrictions were: No sea, ship or overseas duty.  No sit-ups, pushups or physical readiness test.  May do aerobic exercise at own pace.  She had a second LIMDU from December 2005 to June 2006.

Analysis Right Axillary Third-Degree Burn with Scar:
Navy examinations documented decreased ROM at the shoulder, hypertrophied scar that was very tender to palpation, rigid skin, burn scar contracture.  None of the exams measured the size of the scar but the operative report of 20050421 documented a skin graft of 100cm2. 

The VA examination done nine months after separation did include a measurement of 7cm by 16cm or 112 cm2.  The skin evaluation reported: painful, tender, no limited ROM, not adherent.  No limitation of function and no disfigurement.  However, the joint exam documented decreased ROM.  The limitation was not as severe as that measured on the Navy exam but it was still present.

A thorough neurologic evaluation completed while the CI was on active duty documented no neurologic disorder.  The physical exam did not document deficits in any particular nerve distribution and the mechanism of injury does not support a neurologic injury.  Also Electromyogram (EMG) and Nerve Conduction Velocity (NCV) testing was normal.
A scar over 77cm2 that causes limitation of motion is rated at 20% under 7802.

Shoulder
Right
Movement
	Normal ROM
	NARSUM
 20051122

(9 months prior to separation)	Pain Management Addendum
20060217
(6 months prior to separation)	VA C&P 
20070516

(9 months after separation)	
Forward Elevation (Flexion)	0 - 180	60-90	120	0 -150 (pain anteriorly in the right axilla)	
Abduction	0 - 180	60-90	90	0 – 160 (pain in the AC joint and right axilla)	
External Rotation	0 - 90	Not measured		0 – 70 (pain in the AC joint and right axilla)	
Internal Rotation	0 - 90	Not measured		0 – 70	
Notes:		-Severely limited range of motion in her right upper extremity especially at her shoulder and inability to use her right upper extremity for activities of daily living		- Active range of motion did not produce any weakness, fatigue, or incoordination
- No additional loss of ROM w/repetitive motion	

Donor site scar:
There is no evidence that the graft donor site scar is unfitting.  No restrictions or limitations are attributable to this condition.

Analysis Mental Health Conditions:
PTSD, Chronic Pain Disorder, Somatization/Undifferentiated Somatoform Disorder, Depression, and Borderline Personality Traits

A Psychiatric Addendum to narrative summary (NARSUM) was done in Dec 2005.  At that time was undergoing psychotherapy with the psychologist who had completed the Addendum; it was cosigned by a psychiatrist. 

The addendum reported the diagnoses of Pain Disorder Associated with both Psychological Factors and a General Medical Condition and PTSD.  It concluded her current psychological symptoms represented mild to moderate impairment in occupational functioning outside the military.  Following completion of Physical Evaluation Board process, prognosis is good for spontaneous remission of Pain Disorder and fair for remission of PTSD with 8-10 sessions of psychotherapy.  The CI was not on medication for either condition at that time, but Lexapro was restarted in January 2006.

At her initial visit on 20050913 the psychologist recommended group and individual therapy (6-8 sessions).  She attended a comprehensive group outpatient program.  She had five visits documented in the service treatment record (STR) between September 2005 and February 2006 and all except the initial evaluation concluded:  ‘Patient appears psychologically fit and suitable for full duty at this time; responsible for actions.’ She was on Lexapro from Jan 2006.  She had previously been on this medication and it is not clear when it was stopped but it was restarted in Jan 2006.

An outpatient visit to the Family Medicine clinic in June 2006 documented a normal mental status exam.  The CI reportedly didn’t feel as sad and felt the Lexapro had stabilized her sad mood.  The provider noted this was the first time she had seen the CI appear to be upbeat and not tired.  She did continue to have decreased ROM of her right shoulder. 

At a gynecology visit on 20060712 the list of her active meds did not include Lexapro.  She was still on Nortriptyline 25-75mg by mouth at bedtime for sleep but had been on this previously. Other meds listed were Lidocaine ointment and multivitamin.  No mental health symptoms were reported, review of systems was negative for mental health symptoms, and she was reported to be alert and in no distress.

The VA rating decision states a 50% rating is warranted because the evidence shows occupational and social impairment with reduced reliability and productivity with symptoms flattened affect, disturbances of motivation and mood and difficulty in establishing and maintaining effective work and social relationships.  However, the VA evaluation did not report that her affect was flat, it was reported as labile and there was no evidence of occupational problems.  She was not on any medication for a mental health condition and was not in therapy. She was not working but was going to college.  VA psychiatrist said she might have problems but there is no evidence she was having any problems with college.  She was having nightmares approximately twice a week.  She also was having flashbacks and daydreams of unknown frequency.  The diagnoses of PTSD, mood disorder, and undifferentiated somatoform disorder were reported.  She was found to have superior intelligence on psychometric testing.  The VA psychiatrist noted ‘This individual is despondent and isolated and experiences some mood instability.  All of these factors could present problems if she decides to join the workforce.  At present she is pursuing her college education and could have difficulty in that domain because of her mood instability and her difficulty and embarrassment with facing others since her burn injury.’

The Informal PEB decision is dated 20060606 and PEB determined PTSD was unfitting for continued Naval service.  The treating psychologist thought she was fit for full duty at four of four visits after the first session of therapy.  At the time of the VA evaluation at nine months after separation, she was not on medication, was not in therapy, and was attending college.  It is not clear how long she had been attending college.  While she might have problems in the future there is no evidence of any problems at the time of this evaluation. 

Other Conditions:  Lumbar back condition, right knee sprain, right ankle sprain, and acne.  None of these conditions appear to be unfitting. There were no duty restrictions attributable to these conditions and no accommodations were made.

Conditions Not in Disability Evaluation System (DES) package:
Left knee sprain.  This condition was not mentioned in the DES and is outside the scope of PDBR.
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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 Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication.  After careful consideration of all available information the Board unanimously determined that the CI’s Burn condition is most appropriately rated at 20% for 7801 History of Right Axillary Third-Degree Burn with Tender 112 cm2 Scar and Restricted Range of Motion.  The Board considered PTSD and all the other mental health diagnoses but found no evidence that any mental health condition warranted a rating of greater than 10% at the time of separation from service or at nine months after separation.  Therefore no permanent rating recharacterization is recommended.  However, in retroactive compliance with VASRD §4.129, an initial Temporary Disability Retired List (TDRL) rating of 50% for six (6) months is recommended with a permanent rating of 10%.

The CI’s burn scar measured 112 square centimeters and restricted the movement of her right shoulder. These findings warrant a rating of 20% under VASRD 7801.

The CI was noted to be ‘psychologically fit and suitable for full duty at this time’ on four separate visits by her treating psychologist.  Outpatient visits to other healthcare providers in Family Medicine and Gynecology failed to report any functional impairment related to mental health.  At nine months after separation, the CI was experiencing symptoms of PTSD but was not taking medication, was not in therapy, and was attending college.  The VA psychiatrist noted that while she could have problems with work or school in the future, she was not currently experiencing any difficulties.

The Board also considered the following conditions and unanimously determined that none were unfitting at the time of separation: Residual Scar, Right Hip; Chronic Neuritis, Right Arm, Status Post Burn, Right Axilla, Requiring Skin Graft; Chronic Pain Disorder; Somatization/Undifferentiated Somatoform Disorder; Depression; Lumbar Back Condition; Right Knee Sprain; Right Ankle Sprain; and Acne. 

The other diagnosis rated by the VA (Left Knee Sprain) was not mentioned in the Disability Evaluation System (DES) package and is therefore outside the scope of the Board.  The CI retains the right to request her service Board of Correction for Naval Records (BCNR) to consider adding this condition as unfitting.
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RECOMMENDATION: The Board recommends that the CI’s prior separation be recharacterized to reflect that rather than discharge with severance pay, the CI was placed on the TDRL at 60% for a period of 6 months (PTSD at a minimum 50% IAW §4.129 and DoD direction) and then permanently retired by reason of physical disability with a final combined 30% rating as indicated below.

UNFITTING CONDITION	VASRD CODE	TDRL RATING	PERMANENT
RATING	
Post-Traumatic Stress Disorder	9411	50%	10%	
History of Right Axillary Third-Degree Burn with Tender 112 cm2 Scar and Restriction Range of Motion	7801	20%	20%	
COMBINED	60%	30%	
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The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20090903, w/atchs.
Exhibit B.  Service Treatment Record.
Exhibit C.  Department of Veterans' Affairs Treatment Record.

                            

MEMORANDUM FOR DEPUTY COMMANDANT, MANPOWER & RESERVE AFFAIRS

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATION
          ICO XXX, FORMER USN, XXX-XX-XXXX

Ref:   (a) DoDI 6040.44

Encl:  (1) PDBR ltr dtd 19 Jul 10 

1.  I have reviewed the subject case pursuant to reference (a).  Subject member’s official records are to be corrected to reflect the following disposition:

	a. Separation from the naval service due to physical disability with placement on the Temporary Disability Retired List with a disability rating of 60 percent for the period 16 Aug 2006 thru 15 January 2007.

	b. Final separation from naval service due to physical disability effective 16 January 2007 with a combined disability rating of 30 percent and placement on the Permanent Disability Retired List.

3.  Please ensure all necessary actions are taken to implement this decision, including the recoupment of previously paid funds if appropriate, and notification to the subject member once those actions are completed.