RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-00661
BRANCH OF SERVICE:  Army	BOARD DATE:  20141216
SEPARATION DATE:  20090218

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-6 (Multiple Rocket Launcher System Crewmember) medically separated for diabetes.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS).  He was issued a permanent P3S1 profile and referred for a Medical Evaluation Board (MEB).  “Diabetes Mellitus (DM) Type II” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded six medically acceptable conditions (adjustment disorder with anxiety chronic, hyperlipidemia, osteoarthritis knee bilateral, seasonal allergic rhinitis, sickle cell trait and hemorrhoids) for PEB adjudication.  The Informal PEB adjudicated DM Type II as unfitting rated 20% with likely application of the VA Schedule for Rating Disabilities (VASRD).  The remaining conditions were determined to be not unfitting.  The CI made no appeals and was medically separated.

CI CONTENTION:  “Misdiagnosed for posttraumatic stress disorder (PTSD).  Diagnosed anxiety w /adjustment disorder.  Was not rated for arthritic knees even though I been issued a profile limiting me to or from certain activities.”

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 when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting.  Any conditions outside the Board’s defined scope of review and any contention not requested in this application may remain eligible for future consideration by the Board for Correction of Military/Naval Records.  Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards to the unfitting medical condition at the time of separation.  The Board has neither the role nor the authority to compensate for post-separation progression or complications of service-connected conditions.  That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws.  The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation. 

RATING COMPARISON:

Service IPEB – Dated 20081023	VA - (<1 Mos. Pre-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Diabetes Mellitus Type II	7913	20%	Diabetes Mellitus Type II	7913	20%	20090126	
Adjustment Disorder with Anxiety Chronic	Not Unfitting	Adjustment Disorder with Anxiety	9400-9440	10%	20090126	
Osteoarthritis Knee Bilateral	Not Unfitting	Right Knee Degenerative Joint Disease With Baker's Cyst	5260-5010	10%	20090126	
		Left Knee Degenerative Joint Disease	5260-5010	10%	20090126	
Other x 4 (Not in Scope)	Other x 6		
Rating:  20%	Combined:  50%	
Derived from VA Rating Decision (VARD) dated 20090401 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Diabetes Mellitus Type II.  The narrative summary (NARSUM) notes in 2004 the CI was diagnosed with DM Type II (Type II DM) during a screening examination.  He was initially diet controlled and was next evaluated in late 2007 following redeployment.  The CI was started on oral diabetes medication and was eventually on multiple oral medications, but not insulin for his Type II DM.  Blood sugar levels were not well controlled, but there was no evidence in record of episodes of ketoacidosis or hypoglycemia, kidney, eye, neurological or other complications secondary to DM.  At the MEB examination performed on 19 May 2008, approximately 9 months prior to separation, the CI reported Type II DM.  The MEB exam noted a hemoglobin AIC of 10.9% (normal less than 6%) in March 2008 and a fasting blood sugar of 199 milligrams/deciliter (lab normal < 118) on 29 April 2008.  At the VA Compensation and Pension (C&P) examination on 26 January 2009 performed approximately 2 weeks prior to separation, the CI reported DM, but denied any problems or symptoms.  The examiner noted the CI was treated with a restricted diet, multiple oral medications and had no activity restrictions for DM management.

The Board directed attention to its rating recommendation based on the above evidence.  Both the PEB and the VA rated the Type II DM 20%, coded 7913 (Diabetes Mellitus).  The evidence in record supports the CI’s disability due to the DM met the 20% rating specified as DM requiring insulin or oral hypoglycemic agents.  There was no evidence the DM required restriction of activities for management to meet the next higher evaluation of 40%.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded there was insufficient cause to recommend a change in the PEB adjudication for the Type II DM condition.

Contended PEB Conditions.  The Board’s main charge is to assess the fairness of the PEB’s determination that the bilateral knee and adjustment disorder with anxiety conditions were not unfitting.  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.  The 5 August 2008 commander’s statement noted the CI was successfully performing all assigned MOS duties in the unit and recommended retention in his present MOS during the MEB process.  The commander commented that the CI “has small limitation that are manageable under certain circumstances and is still deployable to some extent...I believe this soldier is a legitimate asset to the Army.”

Bilateral knee conditions.  According to the NARSUM, the CI had occasional knee pain with a diagnosis of arthritis treated with daily anti-inflammatory agent.  Notes in the service treatment record indicated the CI had a history of knee pain for several years without a history of trauma.  He was re-evaluated for his bilateral knee pain during the MEB process for DM with a P3L1 profile on 10 January 2008.  Bilateral knee X-rays performed in January 2007 noted degenerative changes and the CI was using over the counter medications with partial relief.  Magnetic resonance imaging on 19 June 2008 demonstrated mild degenerative changes, with small bone contusions of the left patella and the right medial femoral condyle, both expected to heal without problems.  The CI was not considered a candidate for surgery of any type and was provided prescription anti-inflammatory medication.  Physical therapy evaluation on 18 October 2008, approximately 4 months prior to separation, noted full active ROM of the left knee and full flexion with nearly full extension on the right (extension-flexion of 0 degrees – 140 degrees), with tight right hamstring muscles noted.  Functional limitations were noted as “prolonged walk;run.”  The MEB forwarded the bilateral condition as medically acceptable and the CI was given a permanent P3L2 profile on 2 October 2008, which noted that the CI was referred to the MEB for the diabetes condition.

At the 26 January 2009 pre-separation VA C&P General examination, approximately 2 weeks prior to separation, the CI reported bilateral knee pain aggravated by “a lot of running and marching.”  The examiner noted the CI had knee pain two to three times per week that was alleviated by medication; the CI wore elastic knee braces for physical training and, there was no history or report of subluxation or dislocation. On examination the CI had normal posture and gait.  Bilateral knee ROM was normal, and there was no loss of ROM with three repetitions.  Lower extremity strength, sensation and reflexes were normal.

Chronic adjustment disorder with anxiety.  The CI was seen for administrative processing into the Warrior in Transition Unit on 12 March 2008 and reported brief episodes of depression.  The examiner noted the CI was in the MEB process for DM, but desired to stay in the military if possible.  Scant mental health (MH) treatment notes in record indicated the CI had been involved in off-post marital counseling in May 2008 and listed a diagnosis of depression.  On 17 June 2008 the CI reported increased anxiety.  At the 5 September 2008 MEB behavioral health evaluation performed by a psychiatrist, approximately 5 months prior to separation, the CI reported that since November 2007, a year after returning from deployment, he felt increased anxiety about the safety of his house, without any actual safety incidents.  He reported anxiety in confined spaces and though he could be in public places, his anxiety would increase with increased crowds.  He reported checking window and door locks three to four times per throughout the night and related difficulty sleeping.  The CI reported five to six nightmares per month of combat-related events and flashbacks two to three times per month triggered by his children slamming doors.  The CI denied avoidance behaviors, changes in trust or memory problems, but endorsed mild hypervigilance.  The examiner noted additional stressors of family and health issues.  The CI reported that his mood was fine and endorsed guilt (without further explanation) but no other symptoms of depression, mania, hallucinations or delusions.  The mental status examination (MSE) was normal.  The examiner noted that the CI had been prescribed an anti-anxiety agent in August 2008, which the CI did not think was of benefit.  The Axis I diagnosis was chronic adjustment disorder with anxiety with a Global Assessment of Functioning (GAF) of 60 (cusp of moderate to mild impairment range).  The examiner indicated the CI had PTSD symptoms that did not fully meet diagnostic criteria “which have progressively improved and have not been impairing to his military duty.”  On a performance evaluation report (NCOER) from the post-deployment period on 1 August 2006 to 31 July 2007 the CI was rated in the highest block for overall performance and superior promotion potential.  There was no evidence of legal problems or substance abuse issues in record and the psychiatric profile was S1 throughout the service.

Approximately 3 weeks later on 22 September 2008, the CI had a civilian evaluation for MH disability.  At the evaluation the CI reported he thought anxiety symptoms were getting worse.  The examiner noted the history as recounted in the psychiatric evaluation.  The examiner indicated that compulsive routines had diminished, panic attacks had mostly subsided and that the CI was vigilant “but not excessively so.”  The CI reported nightmares a couple times per week and sleep somewhat improved on medication.  He reported an improved marital relationship since counseling.  The MSE was normal and the examiner noted that it was easy to develop a rapport.  The examiner indicated the CI “most closely fit the diagnostic criteria for post-traumatic stress disorder…an obsessive-compulsive disorder, and a pain disorder, chronic” with a GAF of 55 (moderate impairment range).

At the 22 January 2009 VA C&P PTSD examination, approximately a month prior to separation, the CI reported he had never been treated by a psychiatrist and that he had been prescribed an anti-anxiety medication by a nurse practitioner in September 2008, but had not taken it since December 2008.  The examiner noted the history of a panic attack in a store in 2007 and symptoms of irritability and depression in 2008.  The CI reported his mood had recently been “alright.”  The CI reported nightmares three or four times per month and one flashback 6 or 7 months earlier.  He denied physical reactions to triggers of memories of combat related events and noted mental distress to triggers occurred rarely.  He denied any avoidance symptoms, but endorsed sleep difficulties and mild hypervigilance.  The examiner noted that regarding anxiety and hypervigilance symptoms, the CI reported that he “still has these feelings now and then, but not noticing it as much.”  The MSE was normal.  The Axis I diagnosis was adjustment disorder with anxiety with a GAF of 70 (on the cusp of mild to minimal impairment range).  The examiner noted that the CI was “functioning fairly well”, was not on psychotropic medication and he had “some PTSD symptoms but does not meet the criteria for PTSD.”

The bilateral knee condition was provided a permanent L2 profile (which indicates a condition requires some activity limitations but is not in all cases disqualifying) following the MEB, but as of January 2008 the profile was L1 and the psychiatric profile was SI throughout the service.  The commander’s statement did not implicate either the knee condition or the adjustment disorder and recommended the CI’s retention and indicated he was an asset to the Army.  The post-deployment NCOER report indicated superior overall performance and promotion potential.  The bilateral knee and the adjustment disorder conditions were not judged to fail retention standards and there was no performance based evidence from the record that either of the knees, individually or combined, or the adjustment disorder condition significantly interfered with satisfactory duty performance.  The Board acknowledges that the CI contended a MH diagnosis of PTSD but the Board found the preponderance of evidence in record did not support a diagnosis of PTSD according to DSM –IV-TR criteria at the time of separation.  The Board noted that IAW DoDI 1332.38, enclosure 5, adjustment disorder is a condition not constituting a physical disability and was not eligible for disability rating.  Members found no evidence to support recommending any MH disorder, regardless of specific diagnosis, as unfitting for continued military service at the time of separation.  After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for the bilateral knee condition or the adjustment disorder and so no additional disability ratings are recommended.

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 Type II DM condition and IAW VASRD §4.119, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended bilateral knee and adjustment disorder conditions, the Board unanimously recommends no change from the PEB determinations as not unfitting.  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 20140131, 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 XXXXXXXXXXXXXXXXXXXX, AR20150013205 (PD201400661)

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