RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX		CASE:  PD-2014-01550
BRANCH OF SERVICE:  MARINE CORPS	 SEPARATION DATE:  20070630

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Machine Gunner, medically separated for “posttraumatic stress disorder - chronic” and “hypertrophic scar right foot posteromedial heel,”  rated at 10% each, with a combined disability rating of 20%.  

CI CONTENTION:  “I was diagnosed with severe PTSD from my combat experience in Iraq and Afghanistan.  During my medical board I was not fully looked at for PTSD and several other conditions.”  The CI’s complete submission can be found 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 based upon a 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 – 20070416	VARD - 20080205	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Posttraumatic Stress Disorder - Chronic	9411	10%	Posttraumatic Stress Disorder	9411	30%	20080110	
Hypertrophic Scar Right Foot Posteromedial Heel	7802	10%	Scar, Right Ankle with Retained Shrapnel	5299-5260	10%	20080115	
Right Knee Pain, Status Post Arthrotomy and Foreign Body Removal	Cat III	Right Knee Strain Secondary to Traumatic Injury	5299-5260	10%	20080115	
Right Knee Pain Secondary to Shrapnel	Cat III					
Pain Involving Lower Leg; Pain in Joint Involving Pelvic Region and Thigh and Superficial Foreign Body (Splinter) of Hip, Thigh, Leg and Ankle	Conditions Referred by MEB to PEB but not Specifically Addressed by the PEB	Scar Left Shin	7804	10%	20080115	
		Scar Left Calf with Retained Shrapnel	7804	10%	20080115	
		Scar Right Calf (Shrapnel Wound)	7804	10%	20080115	
		Scar, Left Hip (Shrapnel Wound)	7804	0%	20080115	
		Sciatica Resulting in Right Lower Extremity Numbness	8720	0%	20080115	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  60%	
ANALYSIS SUMMARY:  

Posttraumatic Stress Disorder (PTSD).  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s anxiety condition began in 2004-2006 after deployment to Afghanistan and Iraq respectively.  There was no prior history of psychiatric evaluation or treatment.  The CI reported multiple combat exposures during both deployments and multiple shrapnel injuries during the last deployment.  He reported nightmares, avoidance, depression, loss of interest, and hypervigilance.  He began self-mutilation on his arms and thighs while in Afghanistan.  He also began binging and purging every other month due to overwhelming stress. He returned from Iraq in October 2006 and began mental health (MH) treatment from 15 November 2006.  He received a Purple Heart and Combat Action Ribbon.  

At the MEB examination (recorded on DD Forms 2807 and 2808) dated February 2007, 4 months prior to separation, the CI reported anxiety, depression and night terrors.  A diagnosis of PTSD was noted.  The MEB NARSUM examination on 30 March 2007, 3 months prior to separation, noted complaints of intrusive, nightmares, hypervigilance, exaggerated startle, irritability and a feeling of disconnection to others.  He attended PTSD group, individual therapy, and medication management with two psychotropic agents that addressed nightmares, depression, insomnia and anxiety.  Mental status examination (MSE) noted the CI reported depression but denied suicidal and homicidal ideation.  A diagnosis of PTSD was rendered with a Global Assessment of Functioning (GAF) score of 51-60 (moderate symptoms, impairment.)  
  
At the VA Compensation and Pension (C&P) evaluation, performed 6 months after separation, the CI reported symptoms and concerns consistent with PTSD as well as episodic binging and purging at least once per week, and occasional binging without purging.  He reported generalized anxiety and rumination that interfered with sleep, and panic attacks in large crowds at night.  He also reported episodic alcohol abuse, but denied intoxication since January.   He denied psychiatric treatment since December 2007 but he took over-the counter sleeping medication daily. He had been performing consulting work since discharge and had begun his own contracting business.  He was also scheduled to take 3 classes.  He exercised daily, had contact with his family and had begun dating.  He drove, cooked, did house chores and started going to restaurants.  MSE noted anxious and depressed mood with poor to fair insight and judgement.  A diagnosis of PTSD, mild was rendered with a GAF score of 75 (transient symptoms, slight impairment.)

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB rated the PTSD condition 10%, coded 9411 (PTSD).   The VA rated the PTSD condition 30% coded 9411 and borderline personality disorder based on the VA C&P examination 6 months after separation, citing symptoms of occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks.  

The Board agreed that the provisions of VASRD §4.129 were applicable in this case and agreed that the §4.130 criteria for a rating higher than 50% were not met near the time of separation, and therefore the minimum 50% initial TDRL rating is applicable.  The Board then determined the most appropriate fit with VASRD 4.130 criteria at 6 months for its permanent rating recommendation.  The most proximate source of comprehensive evidence on which to base the permanent rating was the C&P examination for PTSD, performed 6 months after separation.  The §4.130 criteria for a 10% rating is “symptoms controlled by continuous medication,” for a 30% rating is “occupational and social impairment with occasional decrease in work efficiency and intermittent inability to perform occupational tasks,” while criteria for a 50% rating requires “occupational and social impairment with reduced reliability and productivity.” He continued to report symptoms of PTSD, including sleep difficulty, few friends, and nightmares.  Yet, he had worked in the family business for 2 months, managing a landscaping business he owned, was working with the bank to set up self-employment for the past few months, exercised daily, was dating, went to restaurants, and had family relationships and activities he enjoyed.  The Board majority therefore concluded that the 10% rating most accurately depicted the condition at the time of removal from TDRL.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board by majority recommends a disability rating of 50% for 6 months of constructive TDRL and a 10% permanent rating for the PTSD condition. 

Hypertrophic Scar, Right Foot/Heel.  According to STR and the MEB Orthopedic NARSUM Addendum, dated 20 February 2007, 4 months prior to separation, the CI’s right foot scar condition began in June 2006 after a shrapnel injury in a blast while deployed.  The MEB forwarded “hypertrophic scar, right foot” for PEB adjudication.  The MEB Orthopedic NARSUM examination on 20 February 2007, 4 months prior to separation, noted complaints of pain in the right medial heel with excessive shoe wear.  Wearing shoes caused abrasion and sloughing of the scar tissue.  There was no pain with stretching or with exercise but he was unable to wear boots and shoes as required by Marine regulations.  Physical examination showed a palpable band of scar tissue on the medial heel of the right foot approximately 4mm in width and 2 cm long, mobile and non-tender.

At the 15 January 2008 VA C&P evaluation, performed 6 months after separation, the CI reported he was receiving ultrasound treatment to strengthen the scar around the right ankle.  It was sensitive to touch.  He felt it was not fully healed and he had pain with friction when he wore any shoes that rose above the level of the ankle.  Physical examination showed entry and exit shrapnel wounds, both measuring 2 cm, tender to touch and slightly darker in color than surrounding tissue and flush to the surface.  There was no muscle herniation, keloid formation, palpable scar tissue or adhesions to underlying structures.

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB rated the hypertrophic scar, right foot condition 10%, coded 7802 (scar not of the face, head or neck).  The VA also rated the scar 10% analogously coded 5299-5260 (leg, limitation of flexion of), based on the VA C&P examination 6 months after separation, citing scar painful on examination.

The only possible rating under the 7802 code is 10%.  There was no pathway to a higher disability rating under other scar codes 7801 or 7804.  The Board noted there was no evidence of underlying tissue damage related to the scar and a higher 20% rating under the 7804 code would require 3 or 4 scars that are unstable or painful and a 30% rating would require 5 or more scars that are unstable or painful.  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 postoperative painful scar condition.  

Contended PEB Conditions:  Right Knee Pain, Post Arthrotomy and Foreign Body Removal;  Right Knee Pain Secondary to Shrapnel; and Pain involving Pelvic Region, Hip, Thigh, Lower Leg, Ankle.    The Board’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  None of the conditions were profiled or judged to fail retention standards.  The commander’s statement did not specifically address the contended conditions only addressing “wounds.”  The Orthopedics NARSUM examination noted the CI was able to perform multiple athletic activities including riding a bicycle, performing elliptical cross-trainer and swimming.  He walked without limitation when wearing open heeled shoes.  The examiner opined that the CI “would likely be able to be retained as a Marine if the [foot/heal] were his only condition.”  There was no performance-based evidence from the record that any of the conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, the Board concluded that there was insufficient cause to recommend a change in the PEB fitness determination for any of the contended conditions and so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the PTSD condition, the Board majority recommends a disability rating of 50%, coded 9411 IAW VASRD §4.129 for 6 months from the time of discharge consistent with a constructive period of TDRL and then a permanent separation rating of 10% IAW VASRD §4.130.  The minority voter recommended a permanent rating of 30% but did not elect to submit a minority opinion.  In the matter of the hypertrophic scar, right foot condition and IAW VASRD §4.118, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended pain involving the pelvic region, hip, thigh, lower leg, ankle; right knee pain secondary to shrapnel and right knee pain, post-arthrotomy and foreign body removal 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 recommends that the CI’s prior determination be modified as follows, effective as of the date of his prior medical separation:  

CONDITION	VASRD CODE	RATING	
		TDRL	PERMANENT	
PTSD	9411	50%	10%	
Hypertrophic Scar, Right Heel	7802	10%	10%	
RATING	60%	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140213, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR DEPUTY COMMANDANT, MANPOWER & RESERVE AFFAIRS
		   COMMANDER, NAVY PERSONNEL COMMAND	
	                          
Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS          

Ref:  (a) DoDI 6040.44
	(b) PDBR ltr dtd 26 Jun 17 XXXXXXXXXXXXXXXXXX  
	(c) PDBR ltr dtd 26 Jun 17 XXXXXXXXXXXXXXXXXX
	(d) PDBR ltr dtd 20 Jun 17 XXXXXXXXXXXXXXXXXX
	(e) PDBR ltr dtd 25 Nov 16 XXXXXXXXXXXXXXXXXX
	(f) PDBR ltr dtd 16 Jun 17 XXXXXXXXXXXXXXXXXX
   (g) PDBR ltr dtd 20 Jun 17 XXXXXXXXXXXXXXXXXX

1.  Pursuant to reference (a), the recommendations of the Physical Disability Board of Review set forth in references (b) through (f) are approved.  The official records of the following individuals are to be corrected as follows:

     a. XXXXXXXXXXXXXXXXXX former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge.

     b. XXXXXXXXXXXXXXXXXX, former USN: Placement on the Permanent Disability Retired List with a 30 percent rating (increased from 20 percent) effective date of discharge.     

     c. XXXXXXXXXXXXXXXXXX, former USMC: Entitlement to disability separation pay with a 20 percent disability rating (increased from 10 percent) effective date of discharge.

     d. XXXXXXXXXXXXXXXXXX, former USMC: Retroactive placement on the Temporary Disability Retired List for six months beginning date of discharge with a 50 percent combined disability rating and a final rating thereafter of 20 percent.  

     e. XXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 20 percent disability rating (increased from 0 percent) effective date of discharge.

     f. XXXXXXXXXXXXXXXXXX, former USN: Entitlement to disability separation pay with a 10 percent disability rating (increased from 0 percent) effective date of discharge.   
     
3.  Please take action to implement these decisions.

	XXXXXXXXXXXXXXXXXX

	Acting,