RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	    CASE:  PD-2014-01603
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20091123

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was a traditional drilling National Guard E-5 (Motor Transport Operator) medically separated for traumatic brain injury (TBI), chondromalacia right knee, and right middle cerebral artery aneurysm.  The conditions could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS). He was issued a permanent P3L3 profile and referred for a Medical Evaluation Board (MEB).  The “post-concussion syndrome with post traumatic headaches, moderate. to severe,” “postconcussion syndrome with vertigo, mild to severe,“ “chronic right knee pain, secondary to chondromalacia within the knee,” and “right middle cerebral artery aneurysm, stable,” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded two other conditions (PTSD and depressive disorder, NOS) for PEB adjudication.  The Informal PEB (IPEB) adjudicated the TBI condition, right knee condition, and cerebral artery condition as unfitting, rated 10%, 10% and 0%, respectively, with application of the Veterans Affairs 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:  The applicant lists two of his three unfitting PEB conditions (TBI with headache and aneurism) and also lists his not unfitting PTSD condition.  Additionally, he lists or alludes to the following conditions: IBS, Crohn’s, hernia, low back/spine.  His complete submission is at Exhibit A.

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 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 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:  

IPEB - Dated 20090827	VA* - (~14 Mos. Pre-Separation) 	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Traumatic Brain Injury (TBI)…	8045	10%	Traumatic Brain Injury	8099-8045	NSC	20080715	
			Combined Tension Headaches	8100	0% 	20080715	
Chondromalacia Right Knee…	5099-5003	10%	Status Post Right Knee Anterior Cruciate Ligament Repair, (ACL) with Meniscectomy to Include Asymptomatic Scarring	5024	10%	20080715	
Right Middle Cerebral Artery Aneurysm…	7112	0%	Aneurysm	8007	  NSC	20080715	
PTSD	Not Unfitting	Post Traumatic Stress Disorder	9411	NSC  	20080715	
Other MEB/PEB Conditions x 1 (Not In Scope)	Other x 3	
RATING:  20%	RATING:  30%	
*Derived from VA Rating Decision (VARD) dated 20080729 (most proximate to date of separation (DOS)).  

ANALYSIS SUMMARY:  

TBI Condition.  The narrative summary (NARSUM) noted the CI suffered head trauma in April 2006 while deployed to Iraq.  The CI reportedly was working on loading a truck when a strap broke and a metal hook swung around and hit him in the right side of the face.  He was unconscious for several minutes.  The CI reported having had bad headaches with dizziness and problems with memories in the several days following the accident.  Service treatment records were largely silent for this condition.  Although the NARSUM exam occurred 10 months before separation, and largely reported physical findings related to the knee, the physician included specialty examination findings that were 5 months before separation.  At the NARSUM, the CI reported he had continued to experience intermittent headaches (and to some degree daily headaches of intensity 1/10) that were dull in nature and improved with sleep.  He noted he had severe headaches 1-2 times a month and was unable to work for several hours.  His headaches were sometimes triggered with increased activity/heavy lifting.  The examiner noted the treatment record recorded a history of complaints of memory lapses or loss.  The CI reportedly stated that he had problems with short-term memory when he first returned home from Iraq, but this had improved over time.  He compensated by writing down what he wanted to remember. 

Specialty consult entry dated 11 June 2009 noted the CI reported frequent and severe, daily headaches and memory issues (must write down things down).  He reported he was not capable of taking orders and direction and turning into useful activity to the expected level in any MOS.  The examiner documented diagnoses of middle cerebral artery aneurysm, large, post-concussion syndrome with post-traumatic headache, moderate to severe and post-concussion syndrome with vertigo, mild to moderate.  It was opined that the CI was not employable in the military and was minimally employable in the civilian sector. 

At the VA Compensation and Pension (C&P) exam performed 14 months before separation, the physician noted the records showed that the CI had suffered a blow to his chin in October 2005, and that a co-worker reported he had loss of consciousness “for a moment”.  Shortly after the accident, medical personnel noted a “very small laceration on the right side of the tip of the chin.”  He was not confused at that time, and there was no evidence of any neurological abnormalities.  The CI reported since the accident he had some headaches and associated dizziness.  He had headaches 1-3 times a week and they last a few hours.  His headaches were aggravated by stress and relieved by relaxation.  He reported that on one occasion he had to get a shot for a severe headache, and that was the only time he went to the doctor.  He had some sleep disturbance, but no fatigue, malaise, or weakness.  Additionally, he had no problems with balance, sensory changes, or problems with hearing or visual.  The CI noted he had not worked since January 2008 because of his aneurysm diagnosis.  He had a driver’s license and his headaches had not interfered with driving.  Neurological examination was completely normal.  The neurologist diagnosed combined tension-post traumatic headaches, and the general C&P examiner diagnosed history of TBI with headaches.

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB rated the condition at 10% coded 8045 (residuals of TBI).  As noted above, the VA did not service connect the condition of TBI; however, did rate the condition diagnosed as combined tension headaches, at 0%, coded 8100 (migraine).  This rating was increased in 2011 to 30% retroactive to 2008.  The PEB indicated the facet related to subjective symptoms was met at the 10% level (total facet of 1) for mild memory loss, vertigo and headaches.  The VA denied service connection of this condition and noted that it was determined that he does not suffer from TBI.  The Board undertook a careful review of the record in evidence for support of a rating higher than the 10%.  The Board is required to evaluate cognitive disorder IAW VASRD.  The VA assigns an evaluation based upon the highest level of severity for any facet (there are ten facets with “3” as highest level of severity) of cognitive impairment and other residuals identified as associated with the condition.  The higher rating of 40% requires demonstration of impairment level corresponding to level “2”; not supported by the evidence.  The record documented no objective findings of memory loss, no evidence of impairment in judgment, inappropriate social interaction, issues with orientation, communication, or behaviors that interfered with workplace interactions. The clinical record did not substantiate clinically significant impairment at the time of separation. The commander’s performance statement did not mention any impairment in memory, judgment, or difficulties with the comprehension of language, or identified any impairment in learning.  

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 adjudication of the traumatic brain injury condition.

Chondromalacia Right Knee.  The NARSUM noted the knee examination was conducted nine months before separation.  The CI reported right knee pain related to a valgus stress injury while on duty with his Reserve unit in 1998.  In September 1998, MRI of the right knee demonstrated a tear at the medial meniscus and a tear at the anterior cruciate ligament.  The CI underwent arthroscopic surgery with repair of the medial meniscus, and had post-operative rehabilitation (rehab) and was able to return to duty, and subsequently deploy.  During the deployment in April 2006, he re-injured his knee during PT.  His injury was treated conservatively with anti-inflammatory medication and profile.  He had an MRI that demonstrated an anterior cruciate ligament deficient knee, and this was treated with physical therapy, a brace, and non-steroidal anti-inflammatory medication.  He continued to report right knee pain with instability.  In March 2008, he underwent right anterior cruciate ligament reconstruction with hamstring autograft, a lateral partial meniscectomy, and a partial synovectomy.  Following surgery, he participated in a post-operative rehab program for 5 months which initially improved his pain.  However, he began to experience pain with increased activity, accompanied by a rubbing/grinding sensation with occasional intermittent locking of the right knee.  He was given a permanent L3 profile and referred to the MEB.  The NARSUM documented that the CI was evaluated by orthopedics in March 2009, eight months before separation (not among records) where he reported increased discomfort in his right knee since returning to full activity after the March 2008 surgery.  The CI reported that he noted the right knee had a tendency to “lock up”.  On physical examination, it was noted by orthopedics that the CI had pronounced supination of his right heel with toe walking, but had a stable knee with some tenderness along the medial and lateral joint lines.  Crepitance was also noted, but swelling or redness was not observed.  The orthopedic physician diagnosed chondromalacia of the right knee and determined that the CI did not meet retention standards.  Range-of-motion (ROM) recorded at the NARSUM documented right knee forward flexion of 115 degrees (140) compared to 120 degrees in the left knee, and extension to 0 degrees (0) in bilateral knees.  The examiner noted moderate pes planus bilaterally without tenderness to palpation over the plantar surface.  Right knee swelling or instability was absent.  The examiner recorded mild tenderness to palpation over the medial and lateral collateral ligaments and joint lines of the right knee, and mild crepitance to palpation over the anterior right knee with ROM testing.

At the VA Compensation and Pension (C&P) exam performed 14 months before separation, the CI reported his knee condition had precluded him from returning to his job as a local truck driver.  He had some minimal pain and discomfort in the knee with prolonged use.  He had some increasing fatigue; however, his knee no longer locked up.  He reported that his knee “feels slightly unstable” when he walks long distances, but he can walk for over a mile without any significant issue.  He does not use assistive devices for ambulation.  He had no episodes of dislocation or subluxation.  The examiner noted that although the CI reported he had not returned to work, he “has apparently been cleared to do so recently.”  Physical examination of the right knee recorded minimal discomfort with “no real pain” on movement.  Knee flexion was to 142 degrees and extension to 0.  Pain on motion was absent.  All other aspects of the right knee examination were normal.  

The Board directed its attention to its rating recommendation based on the above evidence.  The PEB rated the condition 10% analogous to degenerative arthritis code of 5299- 5003 based on painful motion. Likewise, the VA rated the condition at 10% under the 5024 code (tenosynovitis) for painful motion.  A higher rating of 20% under any of the applicable codes (5003, 5024, 5260, 5261, and 5257) requires limitation of flexion of 30 degrees or less, extension limited to 15 degrees, or ankylosis, recurrent subluxation, or lateral instability, or radiographic evidence involving two or more joints with occasional incapacitating exacerbations; not supported by the record in evidence.  The Board considered the 5258 code; however, there was no objective evidence of frequent episodes of locking and effusions to support the use of this code. There is no VASRD sanctioned pathway to a rating higher than the minimal compensable 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 right knee condition. 

Right Middle Cerebral Artery Aneurysm.  The NARSUM documented the CI underwent a MRI in December 2006 due to his report of intermittent headaches with episodes of dizziness.  He was diagnosed with a right middle cerebral artery aneurysm (non-ruptured).  He was referred to neurosurgery who determined that the headaches most likely were secondary to the aneurysm which was opined to be stable.  He took an anti-inflammatory medication and an antidepressant for treating both his knee and headache pain.  Treatment records were largely silent for this condition. The NARSUM examiner recorded the CI was informed by the neurosurgeon, that the aneurysm “could have come from trauma, but most likely was present since birth.”  The examiner noted the CI had unremarkable neurological examinations since his diagnosis.  The neurology service documented diagnoses of post-concussion syndrome with post-traumatic headache, moderate to severe and post- concussion syndrome with vertigo, mild to moderate.  The diagnosis of middle cerebral artery aneurysm, large was also noted; however, the neurologist offered no opinion as to whether he had any symptoms related to this condition.  The VA C&P examiner recorded the diagnosis of right middle cerebral artery aneurysm, and opined that this condition was not related to his loss of consciousness or his trauma history.  The neurological examination was unremarkable.
 
The Board directed its attention to its rating recommendation based on the above evidence.  The PEB assigned a 0% evaluation under the 7112 code (aneurysm, any small artery).  A 0% percent rating under this code is assigned when the condition is asymptomatic.  A compensable rating is based on the presence of symptoms and the body system affected.  The VA did not service connect the condition.  The VARD noted the condition was determined to be unrelated to military service or injury during service, and that the CI’s physician indicated the condition was an incidental finding unrelated to injury.  The Board found no evidence to support a rating other than the 0 percent.  The CI had headaches, opined by the neurologist to be of traumatic origin, which is accounted for under the TBI code. There was no documentation of any neurological compromise or of any symptoms solely attributable to the aneurysm.  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 right middle cerebral artery condition.  

Contended PEB Conditions.  

PTSD Condition.  The Board’s main charge is to assess the fairness of the PEB’s determination that the contended PTSD was not unfitting.  The Board’s threshold for countering fitness determinations requires a preponderance of evidence, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  The psychiatry addendum to the MEB was accomplished approximately eight months before separation.  It was noted that during deployment to Iraq in March 2006, the CI reported while driving on a convoy, he witnessed a vehicle hit with an explosive device.  He kept driving; however, later heard the Soldiers in the vehicle were burned, but survived.  He later heard of another exploded IED that had not resulted in any casualties but personnel were pretty shaken up.  The CI noted his performance during the deployment was good, but after the incidents he was very vigilant, although he did not experience any other incidents.  When he returned home from Iraq, he noticed problems with irritability, sleep, energy, motivation, concentration and memory, and experienced feelings of helplessness, and lack of enjoyment.  He had occasional suicidal ideation, and had dreams he could not recall.  At the NARSUM, he reported his concentration was “ok”, he interacted “ok” with his co-workers when he was not laid off, he was close to his family, but didn’t enjoy activities like he use to (fishing and camping).  He was worried about a number of things including his finances, and his brain aneurysm.  He was being treated at the local VA since 2007, but missed his November 2008 appointment and was not seen until March 2009 when his medication was increased.  Mental status examination recorded that he was fully oriented, demonstrated some mild restlessness, complained of stiffness and pain in his knee. There was no evidence of psychosis or formal thought disorder, judgment was not impaired and he was free of suicidal and homicidal ideation.  The psychiatrist opined that by history, the CI met criteria for PTSD.  It was noted the CI was able to drive truck which had been his main source of income for over 15 years and now had stressors which include finances and unsteady income due to the lack of working in trucking.  He was having difficulty in paying his mortgage, and was under negotiation with the bank. The examiner wrote, “He is worried about this and has anxiety and feeling helpless/depressed because of his health which the psych testing indicated somatic issues.”  The psychiatrist documented the diagnoses of PTSD and depressive disorder NOS and assigned a Global Assessment of Functioning (GAF) score of 80 (if symptoms are present, they are transient and expectable reactions to psychosocial stressor, and do not cause more than slight impairment), and concluded his mental health conditions were not medically disqualifying for military service.  No mental health condition was profiled or implicated in the commander’s statement and none were judged to fail retention standards.  All were reviewed and considered by the Board.   There was no performance based evidence from the record that any mental health condition significantly interfered with satisfactory duty performance.  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 contended PTSD condition and so no additional disability rating is 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 Traumatic Brain Injury condition and IAW VASRD §4.124a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the chondromalacia right knee condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the right middle cerebral artery aneurysm condition and IAW VASRD §4.104, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended PTSD condition, the Board unanimously recommends no change from the PEB determination 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 20140319, 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, AR20160003221 (PD201401603)

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