RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-01461
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20091229

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E6, Human Resource Specialist, medically separated for “mood disorder” and “left knee pain,” rated 10% and 10%, respectively, with a combined disability rating of 20%.

CI CONTENTION:  She was given a higher rating for her conditions by the VA.  The CI’s complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44.  It is limited to those conditions determined by the Physical Evaluation Board (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 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 PEB - 20091013	VARD - 20100512	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Mood Disorder	9435	10%	Major Depressive Disorder, Recurrent	9434	50%	20100125	
Left Knee Pain	5099-5003	10%	Osteoarthritis and Patellofemoral Syndrome, Left Knee	5019-5003	10%		
Post Traumatic Migraines	Not Unfitting 
	Migraine and Occipital Headaches, Recurring	8100	10%		
Chronic Right Shoulder Pain		Osteoarthritis, Right Shoulder AC Joint, Postoperative	5299-5203	10%		
Temporomandibular Joint  (TMJ) Disease		TMJ with Pain	9905	10%		
Right Knee Pain		Internal Derangement, Right Knee, Postoperative	5099-5019	0%		
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  0%	

ANALYSIS SUMMARY:  

Mood Disorder.   According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s mood disorder condition began in 2005 during evaluation and treatment for endometriosis with infertility.  Antidepressant medications including fluoxetine and paroxetine had been only partially effective in controlling her depression.  The CI reported problems with impaired sleep, getting only 4 hours per night, although she has temporomandibular joint syndrome and thought that kept her awake.  She reported low energy and interest, poor appetite and impaired concentration during the prior year.  She complained of feelings of worthless related to her inability to have a child despite in vitro fertilization which resulted in an ectopic pregnancy with surgical termination; and she was resistant to subsequent infertility treatments.  Her treating psychiatrist noted she had several short episodes of depressed mood at a level of adjustment disorder with depressed mood, but it lasted as a long episode of 2 years without remission thereby fulfilling the criteria for dysthymic disorder.  It was felt she would not be able to handle the extra stress of deployment and would not be able to handle the lack of sleep or close proximity with co-workers.  Furthermore, the psychiatrist noted the CI lacked the necessary flexibility to adapt to new situations; and, with low level stress she felt overwhelmed at her job, but could handle sensitive information with caution in a supervised, well-organized environment.  At the NARSUM mental status examination dated 9 August 2009 the CI was alert and oriented and comprehension and memory were grossly intact. She reported symptoms of depression including low mood, decreased energy, anhedonia, guilt feeling, and appetite and sleep disturbance, but denied anxiety and panic attacks.  Thought processes were logical and coherent.  She denied hallucinations, delusions, suicidal ideation or history of self-harm.  There were no psychotic features evident.  The Axis I diagnosis was major depressive disorder, recurrent, severe and the Global Assessment of Functioning (GAF) was 50 (serious symptoms). 

The commander’s statement dated 4 November 2008 indicated the CI was performing her duties and did well at her job, but her medical condition did not allow her to complete basic soldier requirements.  However, she was able to manage two individuals and operate without supervision as well as maintain relationships with supervisors.  At the MEB examination (recorded on DD Forms 2807 and 2808) dated June 2009, 6 months prior to separation, the CI reported treatment for depression and homicidal ideation, which was controlled with Paxil (paroxetine, an antidepressant), but checked no to nervous trouble of any sort (anxiety or panic attacks).  The examiner recorded depression (dysthymia per psychiatry), but did not check off any column related to psychiatric clinical evaluation.  A permanent L3S3 profile was issued on 6 August 2009 for chronic insertional patellar tendinitis (see below), post traumatic migraine (see below), and depression with limitations of all physical fitness training and testing and all military functional activities except wearing a protective mask and all chemical defense equipment.

At the VA Compensation and Pension (C&P) examination in January 2010, performed 1 month after separation, the CI reported symptoms started in 2005 after her endometrial surgery and difficulty getting pregnant and they became worse after the ectopic pregnancy in 2007 that resulted in her losing the baby.  She became depressed and was treated with Paxil.  The VA apparently relied on the MEB NARSUM for examination, diagnosis, and GAF score (see above).  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating using code 9435 (mood disorder, not otherwise specified) for a mood disorder.   The VA assigned a 50% rating using code 9434 for major depressive disorder, recurrent severe, claimed as mood/personality disorder.  The VA rating was based on occupational and social impairment with reduced reliability and productivity.  The Board members discussed a 30% rating which requires:  “Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events).”  Although the CI did have a depressed mood for several years and chronic sleep impairment, her thought processes were logical and coherent.  The record, which lacked notes from individual visits, did indicate evidence of anxiety, suspiciousness, panic attacks, and memory loss.  As a result she was unable to deploy, but the commander indicated the CI was able to perform the duties of her MOS well, have appropriate relationships with supervisors, but could not perform basic soldier functions.  Therefore, the Board members did not feel the CI’s disability rose to the 30% level at the time of separation.  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 mood disorder condition.  

Left Knee.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), because of local pain after trauma, the CI underwent left knee X-rays on 31 October 2007, which was negative.  In April of 2008 during work that required bending and kneeling, the CI felt a “pop” and the left knee became painful.  Examination demonstrated a full range of motion (ROM) with a positive apprehension test, but there was no effusion, deformity, patella abnormality, laxity, or evidence of a meniscal tear.  X-rays showed no evidence of fracture, dislocation, or joint effusion.  Physical therapy evaluation on 10 April 2008 of the left knee did demonstrate patella crepitus, decreased medial mobility, tenderness on palpation and a full ROM with pain on flexion and extension.  Knee pain continued and the CI was diagnosed with tendinitis of the attachment of the sub-patellar tendon in August 2008 and was treated with “short-wave type kinesitherapy” (diathermy-heat treatment).  In October 2008 motion of the left knee was normal, but there was patellar crepitus and tenderness of the mild distal patella.  Magnetic resonance imaging (MRI) demonstrated a Grade IIA focal fissure chondromalacia and moderate signs of poor patellar tracking with a degenerative meniscus and moderate subluxation of the meniscus, but no evidence of a fissure.  Orthopedic evaluation on 22 October 2008 revealed a full ROM of the knee with a moderate valgus configuration with a slight increase in the Q angle.  There was no laxity or evidence of a meniscal tear, but the CI did have pain with patellar compression on both the left and right (see below) knees.  Surgery was not recommended, but exercises were recommended.  Physical therapy evaluation in January 2009 revealed genu valgum with poor patellar tracking, but there was no swelling, instability or amyotrophy (muscular atrophy).  On examination the left knee ROM following repetitive movement was flexion 70 degrees (normal 140) and extension 0 degrees (normal 0) with pain occurring at 65 degrees of flexion.  X-rays of the left knee in February 2009 were stable and a whole body bone scan was normal.  In March 2009 X-rays of the left knee were negative as were the left tibia and fibula and in August 2009 X-rays of the left knee demonstrated mild mediolateral joint space narrowing.  

There was no surgical indication, and conservative treatment did not result in improvement sufficient to allow unrestricted duty.  The MEB forwarded “chronic left knee pain, multifactorial in etiology:  (a) insertional patellar tendinitis, (b) post-traumatic osteoarthritis-marginal osteophytes of the patellofemoral compartment and (c) patellofemoral syndrome” for PEB adjudication.

During the MEB examination (recorded on DD Forms 2807 and 2808) in June 2009, 6 months prior to separation, the CI reported left knee pain, swelling, numbness, and tingling in the lower extremities.  Physical examination showed crepitus, but no test for ligamentous laxity was performed due to the CI’s inability to relax muscles because of pain.  At the MEB NARSUM examination in August 2009, the CI reported dull aching of the knee, 3-4/10 severity (10 being the worst pain) with occasional flare-ups to 5-6/10, which occurred daily on first walking and was aggravated with longer times on her feet, climbing and descending stairs, kneeling and repetitive squatting.
At the 25 January 2010 VA C&P evaluation the CI reported that she could handle routine office administrative work, to include typing and carrying items weighing no more than 20 pounds and an ability to handle routine household chores.  Physical examination revealed tenderness on palpation of the patella and patellar tendon and an abnormal (reduced) ROM.  Repeated movement did not significantly reduce the ROM but caused pain.  There was no evidence of a meniscal tear, instability, or an effusion.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB assigned a 10% rating using code 5099-5003 (degenerative arthritis) for left knee pain.  The VA assigned a 10% rating using code 5019-5003 (bursitis-degenerative arthritis) for osteoarthritis and patellofemoral syndrome, claimed as left knee condition.  In the absence of knee ankylosis (5256), knee impairment (5257), dislocated or removal of cartilage (5258 and 5259), leg limitation of flexion and extension (5260 and 5261), or tibia and fibula impairment (5262), the Board was unable to find a route to a higher 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 disorder condition.  

Contended PEB Conditions: Post-traumatic migraines, right shoulder pain, temporomandibular joint disease and right knee pain.

The right shoulder pain, temporomandibular joint disease and right knee pain conditions were not profiled or implicated in the commander’s statement and were judged to meet retention standards.  However the post-traumatic migraines were profiled, but were not implicated in the commander’s statement, and were judged to meet retention standards.

Post Traumatic Migraines.  The CI developed headaches with associated photo- and phonophobia when she was in a car accident in 2001.  Treatment consisted of Topamax (topiramate for migraines) and neck injections.  Ibuprofen (a nonsteroidal anti-inflammatory drug (NSAID)) and Zomig (zolmitriptan for migraines) were introduced on 25 June 2007.  Magnetic resonance imagining in February 2009 demonstrated no abnormal signal in the brain.  A magnetic resonance angiogram (MRA) in March 2009 revealed focal narrowing of the proximal left vertebral artery without post-stenotic dilatation.  However, an artifact was favored.  An occipital nerve block was given in March 2009.  Computerized tomographic angiography (CTA) of the vertebral and carotid systems was normal without any flow-limiting stenosis of the cerebral vasculature in March 2009.  Additional occipital nerve blocks were given in August 2009 and in December 2009 with immediate relief of the migraines.  Tylenol 3 (codeine, a narcotic and acetaminophen, a pain reliever) and cyclobenzaprine (a muscle relaxer) were prescribed to alleviate or mitigate the headaches.  At the VA C&P examination the CI indicated she had a migraine headache once every 3 months and lesser headaches every 2 months.  No significant TMJ tenderness was elicited on palpation.  

Right Shoulder Pain.  Right shoulder X-rays of the right shoulder in August 2005 were normal, while an MRI demonstrated minimal osteophytosis (early arthritis) of the acromioclavicular joint and the radiologist’s impression was mild acromioclavicular degenerative joint disease.  The CI had right shoulder arthroscopy with arthroscopic subacromial decompression and distal clavicle excision for right shoulder impingement syndrome on 28 October 2005.  Physical therapy evaluation and measurements were performed in January 2009.  There was no swelling, muscle spasm, or atrophy.  ROM measurements were 170-178 degrees flexion, 130-135 degrees, internal rotation 32-40 degrees and external rotation 85 degrees and there was painful motion for each of the examinations.  An MRI in February 2009 demonstrated a right shoulder S/p clavicular osteotomy with partial thickness incomplete tearing of the superior surface of the supraspinatus tendon underlying the acromion.  Pain persisted and X-rays showed resorption of the right distal clavicle and a bone scan was normal.  

Temporomandibular Joint Disease (TMJ).  The CI complained of an earache with excruciating pain in the left ear in the absence of an infection, which was treated with naproxen (an NSAID) and ear drops.  At the VA C&P examination in July 2010 the CI indicated she had a migraine headache once every 3-6 months and lesser headaches once every 2 week.  On examination there was no TMJ tenderness on palpation and her neck was normal.  The CI felt the TMJ disease kept her up at night.  

Right Knee Pain.  The CI had a history of right knee arthroscopic surgery for a medial meniscus tear in 2004.  An X-ray series of the right knee, which was ordered for chronic anterior knee pain was normal in August 2006, while another showed minimal early degenerative disease.  A right knee X-ray series in October 2004 showed no evidence of a fracture.  In August 2006 the CI complained of bilateral knee pain; X-rays of the right knee showed no acute process; and treatment consisted of Motrin.  In April 2008 examination of the right knee was normal.   Orthopedic evaluation in October 2008 indicated she had some pain in the right knee associated with running and jumping and had less pain than the left knee with patellar compression. An X-ray and an MRI in 2009 showed two popliteal cysts.  A VA physical examination in January 2010 revealed tenderness on palpation of the patella and patellar tendons with a normal ROM and without significant reduction of the ROM with repetition.  There was no evidence of a meniscal tear or laxity and she denied any significant function or activity limitations from the condition.  

There was no performance-based evidence from the record that the conditions) significantly interfered with satisfactory duty performance at separation.  After due deliberation, and 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 contended conditions; and so, no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the mood disorder condition and IAW VASRD §4.130, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the left knee condition and IAW VASRD §4.71a the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended post traumatic migraines, right should pain, temporomandibular joint pain, and right knee 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.  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 20140309, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

SAMR-RB						

13 SEP 2016

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, AR20160010970 (PD201401461)

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:
 						         
Enclosure

CF: 
(  ) DoD PDBR
(  ) DVA