RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXX	CASE:  PD-2013-00622
BRANCH OF SERVICE:  Army	BOARD DATE:  20141112
SEPARATION DATE:  20040526

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SSG/E-6 (13P/Multiple Launch Rocket System Operations/Fire Direction Specialist) medically separated for a left knee condition.  There are no combat related personal awards in the evidence of record.  The CI’s left knee could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS).  The CI was permitted to take the walking portion of the Army physical fitness test.  He was issued a permanent L3/S1 profile and referred for a Medical Evaluation Board (MEB).  The MEB forwarded “arthritis due to trauma and subsequent infection with pain and loss of function” to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other conditions were submitted by the MEB.  The PEB adjudicated “arthritis left knee following multiple surgical procedures” unfitting rated at 10%.  The CI made no appeals and was medically separated.

CI CONTENTION:  “ Due to having five left knee surgeries, one really bad infection from one of the surgery that left me in hospital once another week.  I wasn’t nowhere near 100% and my unit deployed me to Iraq where I developed PTSD that affected my life to this day.  Why wasn’t my PTSD included in Medical Separation Board.  I’ve seen the doctor from November, 2003 to November ’04.  Because I didn’t want to fight with the Army and get redeployed back to Iraq when I was still messed up and have things go back and forth.  I just accepted the first thing they offer me, which was 20%.  I know I should have received at least 30% or more.  I didn’t get a fair rating.”

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e.(2).  It is limited to those conditions determined by the PEB to be unfitting for continued military service and those conditions identified but not determined to be unfitting by the PEB when specifically requested by the CI.  In addition, the CI was notified by the Army that his case may eligible for review of the military disability evaluation of his mental health (MH) condition in accordance with Secretary of Defense directive for a comprehensive review of Service members who were referred to a disability evaluation process between 11 September 2001 and 30 April 2012 and whose MH diagnoses were changed during that process.  The CI is also eligible for PDBR review of other conditions evaluated by the PEB and has elected review by the PDBR.  The ratings for the unfitting left knee condition is are addressed below.  In addition, in accordance with Secretary of Defense directive for a comprehensive review of MH diagnoses that were changed during the Disability Evaluation System (DES) process, the CI’s case file was reviewed regarding diagnosis change, fitness determination, and rating of unfitting MH diagnoses (to include the contended posttraumatic stress disorder [PTSD] condition) in accordance with the VA Schedule for Rating Disabilities (VASRD) §4.129 and §4.130.  No additional conditions are within the DoDI 6040.44 defined purview of the Board.  Any conditions or contention not requested in this application, or otherwise outside the Board’s defined scope of review, remain eligible for future consideration by the Board for Correction of Military Records.

RATING COMPARISON:

Service IPEB – Dated 20040212	VA - (4 and 11 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Arthritis Left Knee	5003	10%	Left Knee DJD	5003	10%*	20050412	
			Scar, Left Knee	7805	0%	20040828	
No MH Entry	PTSD	9411	30%	20040918	
Other x 0 (not in scope)					
Combined:  10%	Combined:  40%*	
Derived from VA Rating Decision (VARD) dated 20041122 (most proximate to date of separation)
*Original VARD deferred rating for Left Knee DJD.  VARD 20051227 granted 10% disability for Left Knee DJD, effective 20040527 (day after date of separation)  

ANALYSIS SUMMARY:

Left Knee Condition.  An operative reported dated 24 February 1998 noted persistent left knee instability after an injury and surgical debridement of a meniscal tear in 1997.  The operative report documented a left knee arthroscopy and anterior cruciate ligament (ACL) reconstruction.  The CI’s rehabilitation course consisted of physical therapy.  The treatment records were silent for left knee pain until February 2002 when a treatment note documented persistent left knee pain with radiographic evidence of degenerative joint disease (DJD) and varus (outward bend at the knee) deformity.  An orthopedic note dated 4 January 2003 noted “multiple other arthroscopic procedures” and that the CI was not a candidate for surgery to realign the knee and take the stress of the cartilage due to the extent of cartilaginous damage.  The CI subsequently developed right knee pain which was diagnosed as DJD. 

The narrative summary (NARSUM) examination dated 30 June 2004 documented that the CI was unable to run due to left knee swelling, locking, catching, and stiffness.  The physical examination was significant for tenderness to palpation, ACL laxity, decreased flexion to 125 degrees, and marked atrophy of the medical aspect of the quadriceps.  A diagnosis of post-traumatic osteoarthritis of left knee was rendered.  

At the VA Compensation and Pension (C&P) examination (performed 3 months after separation), the CI reported that he was unable to bend the left knee, squat or walk more than a few blocks, and stand for more than 15 minutes due to left knee pain.  He reported use of a brace for the left knee.  He continued use of antiinflammatory medications for pain.  The physical examination demonstrated a normal gait, nontender-surgical portal scars, a stable knee, decreased flexion to 120 degrees, and the absence of quadriceps wasting.  A diagnosis of left knee arthritis was rendered.

The Board directs attention to its rating recommendation based on the above evidence.  The PEB adjudicated the left knee arthritis as unfitting.  The PEB and VA rated that left knee arthritis at 10%, coded 5003 (degenerative arthritis).  The Board considered whether there was evidence for a higher than 10% rating or dual rating for pain and instability.  Multiple treatment notes and VA C&P examination documented evidence of a stable left knee after the ACL reconstruction.  Arthroscopic and radiographic evaluation evidence left knee arthritis as the source of the persistent left knee pain.  There was no evidence of knee ankylosis or compensable limitation flexion to 45 degrees or extension to 15 degrees for a rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the left knee arthritis condition.  The Board concluded therefore that this condition could not be recommended for additional disability rating.

Mental Health Condition.  The Board’s main charge is to review the records for evidence of inappropriate changes in diagnosis of the MH condition during processing through the DES.  The Board’s threshold for countering fitness determinations is higher than the VASRD §4.3 (reasonable doubt) standard used for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  There were no MH treatment notes available for review.  The NARSUM noted sleep problems and anxiety after returning from Iraq.  VA PTSD screening questions administered on 20 July 2004 were negative.  At the VA initial PTSD examination dated 18 September 2004, the CI reported “psychiatric symptoms” since returning from deployment in 1991 which worsened with subsequent deployments.  He reported occasional feelings of anxiety described as tremors, shortness of breath and increased heart rate last five to 20 minutes.  He related his anxiety to his wartime experiences and reminders of those experiences.  He reported re-experiencing, avoidance behavior, and emotion numbing and detachment.  He denied direct combat.  He was employed after separation and remained married.  The mental status examination was normal except for a slightly guarded demeanor.  The examiner determined that the CI met criteria for PTSD with a Global Assessment of Functioning score of 63 (mild).  The VA rated the PTSD at 30% for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks.

The Board reviewed the records for evidence of changes in diagnosis of the MH condition during processing through the DES.  The available records evidenced that the CI was treated for symptoms of anxiety and insomnia; however had not received a formal MH evaluation with a formal diagnosis.  The Board noted the diagnoses of depression, anxiety, and PTSD was listed on the DD Form 2808 without clinical documentation to support any MH diagnosis.  Therefore, at the time of processing through the DES, no MH diagnoses were changed to the CI’s possible disadvantage.  This applicant, therefore, did not appear to meet the inclusion criteria in the Terms of Reference of the MH Review Project.  The Board considered whether any mental condition, regardless of specific diagnosis, was unfitting for continued military service.  Board members agreed that evidence of the record reflected minimal MH related symptoms.  There was evidence of psychotropic medication prescription and use prior to separation for sleep problems and anxiety symptoms.  The commander’s statement, 4 months prior to separation, noted that the CI’s profiled medical condition prevented him from performing the duties of his MOS.  No MH conditions were profiled.  There was no emergency room or unscheduled clinic visits nor psychiatric hospitalizations for any MH condition.  The Board concluded that the preponderance of evidence did not support an unfit determination for any MH disorder at the time of evaluation in the DES or prior to separation and therefore, none were subject to disability rating.

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.  The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised.  In the matter of the left knee arthritis condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended PTSD condition or MHR, the Board unanimously determined that no mental condition, regardless of specific diagnosis, was unfitting for continued military service.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  The Board, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination.

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20130911, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

		
SAMR-RB									

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXX, AR20150006402 (PD201300622)

I have reviewed the enclosed Department of Defense Physical Disability Board of Review (DoD PDBR) recommendation and record of proceedings pertaining to the subject individual.  Under the authority of Title 10, United States Code, section 1554a,   I accept the Board’s recommendation and hereby deny the individual’s application.  
This decision is final.  The individual concerned, counsel (if any), and any Members of Congress who have shown interest in this application have been notified of this decision by mail.

 BY ORDER OF THE SECRETARY OF THE ARMY:

Encl						     
						         
CF: 
(  ) DoD PDBR
(  ) DVA