RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX		CASE:  PD1301110
BRANCH OF SERVICE:  ARMY		BOARD DATE:  20140103
SEPARATION DATE:  20031219

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a Reserve component active duty second lieutenant (prior-enlisted)/O-1E (66H00/Registered Nurse) medically separated for chondromalacia of the left knee, diagnosed on arthroscopy, present several years, and for “major depressive disorder, atypical, known to have existed prior to service (EPTS) by history, without permanent service aggravation (PSA).”  The CI enlisted in 1996 at age 27 as a 91W20, Health Care Specialist, with a preexisting history of two surgeries on his left knee.  Pain in his left knee recurred 19 days after enlisting.  In 1997, he had another surgery on his left knee.  In 2002, he was commissioned as a nurse corps officer.  In February 2003, he was given a PL2 profile for his left knee, which was upgraded to a PL3 in July 2003.  In April 2003, the CI was admitted for in-patient psychiatric care after expressing suicidal ideation due to stress about an upcoming deployment to the Middle East, pending divorce and health concerns.  He was diagnosed with adjustment disorder with depressed mood, but also reported a history of pre-service alcohol dependence and out-patient counseling for family of origin issues.  In June 2003, the diagnosis was major depressive disorder (MDD) recurrent and the psychiatrist decided to begin a Medical Evaluation Board (MEB) due to the CI’s mental health (MH) conditions and wrote the CI a PS3 profile.  The CI’s conditions could not be adequately rehabilitated to meet the requirements of his Military Occupational Specialty or satisfy physical fitness standards.  The MEB forwarded MDD recurrent, alcohol dependence (in remission), benzodiazepine dependence (in remission), personality disorder not otherwise specified (NOS), left knee chondromalacia, and reactive airway disease to the Physical Evaluation Board (PEB) IAW AR 40-501 for adjudication.  The PEB determined the chondromalacia of the left knee, diagnosed on arthroscopy, present several years, as unfitting rated at 0%.  The PEB adjudicated MDD, atypical, EPTS by history, and without PSA, as unfitting but not ratable.  The remaining conditions were determined to be not unfitting and also not ratable.  The CI made a written appeal, but the PEB’s findings were affirmed and the CI was medically separated.

CI CONTENTION:  “I was misdiagnosed, no personality disorder existed.  I have PTSD and I have osteoarthritis caused by military service.”

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 be eligible for review of the military disability evaluation of his MH condition IAW 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 or eliminated during that process.  The CI, who is eligible for PDBR review of his other conditions evaluated by the PEB has elected review by the PDBR.  The ratings for the unfitting left knee and MH conditions are addressed below.  IAW Secretary of Defense directive for a comprehensive review of MH diagnoses that were changed or eliminated during the Disability Evaluation System (DES) process, the CI’s case file was also reviewed regarding diagnosis change or elimination, fitness determination and rating of any unfitting MH diagnoses IAW 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 20031007	VA - (~ 8 Mos. Post-Separation)  	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chondromalacia Left Knee	5099-5003	0%	Chondromalacia Left Knee	5257	20%	20040820	
MDD, Atypical	9434	EPTS	Major Depression & Insomnia	9434	NSC	N/A*	
Personality Disorder, NOS	Not Unfitting	Personality Disorder	9499-9440	NSC	N/A*	
No Additional MEB/PEB Entries	Other x 4	20040820	
Combined:  0%	Combined:  30%	
Derived from VA Rating Decision (VARD) dated 20041020 (most proximate to date of separation [DOS]).  
* CI withdrew his claims for any MH conditions and declined to go to the scheduled MH C&P exam.  

ANALYSIS SUMMARY:

Left Knee Chondromalacia Condition.  The orthopedic addendums to the narrative summary (NARSUM) noted the CI’s history of multiple knee injuries and surgeries.  The most recent arthroscopic surgery was in June 2003 and led to decreased symptoms, but continuing pain with prolonged standing and walking.  The treatment records indicated prior surgeries included removal (or repair) of the left lateral meniscus.  At the MEB exam, the CI reported ongoing and worsening pain symptoms with prolonged standing and difficulty with the Army fitness test run.  The MEB DD Form 2808, Report of Medical Examination stated “Pain on (down going) maneuvers and unable to do the duck squat.”  Radiographs showed decreased joint space and osteophyte formation.

At the VA Compensation and Pension (C&P) exam performed about 8 months after separation, the CI reported five left knee surgeries and constant pain with flare-ups of severe pain at least once a week lasting from 1 to 8 hours, relieved by rest and over the counter medications (Tylenol or Motrin).  He considered his knee unstable as he experienced it locking up at least once a month.  Pain was worse with continued walking/standing or any activity that required weight bearing on his knee for a long period of time.  Over 5 years remote from separation the CI had arthroscopic surgery for an unstable knee with ligament and meniscal damage debrided [Noted:  2008 temporary VA 100% rating, then decreased instability rating to 10% with addition of a 10% limited flexion rating].  The goniometric range-of-motion (ROM) evaluations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.

Left Knee ROM
(Degrees)	Ortho MEB ~ 2 Mo. Pre-Sep	VA C&P ~ 8 Mo. Post-Sep	
Flexion (140 Normal)	135	140	
Extension (0 Normal)	0	0	
Comment:  Surgery ~5 Mo. Pre-Sep	Both knees symmetric ROM and ligamentously intact.  Left knee tender and neurovascularly intact.”  	Pain at 140; positive anterior drawer; positive McMurray; DeLuca addressed; estimate flare about 40% decrease flexion; normal gait; can walk on heels and toes; motor/sensory/reflexes normal	
§4.71a Rating	10% (PEB 0%) 	10%-20% (VA 20%)	

The Board directs attention to its rating recommendation based on the above evidence.  Although the orthopedic NARSUM exam did not document limited or painful motion, painful motion was supported on the MEB’s DD Form 2808 with the prior DD Form 2808 documenting crepitus.  The CI had had meniscal surgery and his knee was symptomatic, without in-service evidence of post-surgical locking, give-way or other signs of instability.  The post-separation VA exam documented painful motion along with a positive meniscal sign (McMurray’s) and both a complaint of instability and an objective finding of instability (anterior drawer).  ROM was full and the expected decrease of 40% (to 84⁰) would not reach the compensable ROM for flexion absent application of painful motion.

Given the timing of the CI’s knee recent surgery (within 3 months of the NARSUMs), the Board discussed a possible honeymoon period, as well as post-surgical healing (scarring) and possible post-separation worsening.  The Board considered rating the knee under disability codes 5003 (Arthritis,…) with consideration of VASRD §4.59 (painful motion), 5257 (instability) or 5259 (Cartilage, semilunar, removal of, symptomatic).  There was insufficient evidence of frequent episodes of “locking,” pain and effusion into the joint to support coding under 5258.  IAW VASRD guidance, coding under 5259 includes consideration of painful motion.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the left knee condition, coded 5003-5259.

MH Conditions [MDD, Alcohol Dependence (in remission), Benzodiazepine Dependence (in remission), and Personality Disorder, NOS].  The Psychiatric NARSUM notes initial MH Services contact was through the Emergency Department “where he presented stating that he would ‘take a hammer to my knee’ to ensure that he received adequate medical attention for a chronic knee problem.”  The psychiatrist described a long history of depression starting in childhood relating to a right femur bone cyst and multiple surgeries and complication, with alcohol and illicit drug use.  In February 2003, The CI’s chronic knee pain and postponed surgical intervention increased the CI’s depression.  Increasing symptoms led to thoughts of self-harm related to the knee and he was admitted for a three-day acute psychiatric hospitalization (1-3 April 2003:  discharge diagnoses were adjustment disorder with depressed mood, anxiety disorder, NOS and alcohol dependence in remission).  The CI had 15 outpatient MH contacts and psychometric testing supported the diagnosis of personality disorder NOS.

Mental status exam noted abnormal (depressed) mood with generally appropriate affect, poor insight and judgment.  There were no psychotic, homicidal or suicidal ideations.  The MH diagnoses were as noted by the MEB (MDD; alcohol and benzodiazepine dependence in remission; and personality disorder, NOS).  Global Assessment of Functioning (GAF) was 65 (in the range of mild symptoms) with MDD specified as EPTS with no service aggravation.  Profile was S3, and the examiner stated “symptoms persist to a degree that results in interference with effective military performance.”

There was not a VA C&P MH exam performed until 27 October 2009, nearly 6 years after separation as the CI withdrew his claim for compensation for any MH conditions and declined to attend a C&P exam for fear he would be fired from his job.  At the remote VA exams, the CI had diagnoses of MDD and posttraumatic stress disorder (PTSD) which was service-connected with a stressor of being exposed to mass casualties of military personnel and civilians resulting from the attack on the 11 September 2001 Pentagon while working as a nurse at Prince George Hospital Center in a military duty status.  The psychiatrist assigned a GAF of 55 (moderate symptoms).  The examiner opined that the CI’s early military experience as an NCO made it “unlikely that his history of personality disorder diagnosis would be correct.”  The VA rated this exam at 30% effective 5 August 2008.

The MEB DD Form 2808 documented block #77, Summary of Defects and Diagnoses, #3 as “Anxiety and depression.”  Anxiety disorder was not noted to be an Axis I diagnosis elsewhere in the treatment record, although symptoms of anxiety were noted.  The MEB and PEB did not list any type of anxiety disorder.  The Board determined that it could be considered that a diagnosis of anxiety disorder was eliminated from DES consideration.  MDD was a diagnosis in the final PEB, but is not a replacement of, or progression from, the anxiety disorder diagnosis.  The CI therefore did meet the inclusion criteria in the Terms of Reference of the MH Diagnosis Review Project.

The Board deliberated regarding the MH diagnoses at the time of separation and considered the hospital discharge diagnoses, NARSUM diagnoses and the remote VA psychiatric exam diagnosis of PTSD with the examiner’s opinion that the personality disorder diagnosis was unlikely to be correct.  The record had scant evidence of symptoms sufficient to meet the PTSD Diagnostic and Statistical Manual of Mental Disorders criteria proximate to separation and there was not a preponderance of evidence to either add anxiety disorder or remove the personality disorder diagnosis.  The listed MEB and PEB diagnoses were well supported.

Personality disorder does not constitute a disability IAW DoDI 1332.38 and is not a compensable condition.  Although there appeared to be worsening of the CI’s MH symptoms due to his knee condition, family situation and conflicts at work, there was insufficient evidence of permanent aggravation due to service of a clearly pre-existing MDD condition.  The Board determined that the PEB adjudication of unfitting, but non-compensable MDD was well supported by the evidence.  Ideally the PEB would have noted the personality disorder as “not a compensable condition” rather than “not unfitting,” but there is no advantage to the CI in making that administrative change.  After due deliberation, considering all of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the MH condition.

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.  In the matter of the left knee condition, the Board unanimously recommends a disability rating of 10%, coded 5003-5259 IAW VASRD §4.71a.  In the matter of the MH conditions, the Board unanimously recommends no change in the PEB adjudication of MDD as unfitting, but non-compensable EPTS, with alcohol dependence (in remission), Benzodiazepine dependence (in remission) and personality disorder, NOS all as not unfitting.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  The Board recommends that the CI’s prior determination be modified as follows, effective as of the date of his prior medical separation:

UNFITTING CONDITION	VASRD CODE	RATING	
Chondromalacia Left Knee w/History of Multiple Surgeries	5003-5259	10%	
MDD, Atypical EPTS	9434	---%	
COMBINED	10%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20130814, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

		

SFMR-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 XXXXXXXXXXXXXXXXXXXXX, AR20140003690 (PD201301110)

1.  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 to modify the individual’s disability rating to 10% without recharacterization of the individual’s separation.  This decision is final.  

2.  I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum.   

3.  I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures.

 BY ORDER OF THE SECRETARY OF THE ARMY:

Encl