RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02289
BRANCH OF SERVICE:  ArMY 	SEPARATION DATE:  20081005

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Chemical Operations Specialist, medically separated for “right patellofemoral pain syndrome,” with a disability rating of 10%.

CI CONTENTION:  The CI made has submitted a lengthy contention.  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 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 - 20080625	VARD - 20090527	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Patellofemoral Pain Syndrome	5099-5003	10%	Right Knee Patellofemoral Syndrome	5010-5260	10%	20090408	
Bipolar Disorder	Not Unfitting	Bipolar Disorder	9432	30%	20090414	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  40%	

ANALYSIS SUMMARY:  

Right Knee Condition.  According to service treatment records (STR), the CI developed shin splints during training in August 2006.  During physical therapy follow-up several months later, she reported right anterior knee pain after a fall on ice.  Pain was aggravated by stairs, bending and stooping.  A magnetic resonance imaging study done in April 2007 showed some degeneration of the patellar cartilage.  Orthopedics consultation confirmed a diagnosis of patellofemoral syndrome without recommendation for surgery.  Despite treatment, the right knee condition could not be adequately rehabilitated to meet the physical requirements of the CI’s military specialty and the CI was referred for an MEB.  The MEB forwarded “right patellofemoral syndrome” for PEB adjudication.
  
At the 14 April 2008 MEB NARSUM, the CI noted pain was localized anterolateral, rated 3/10 at rest but up to 5/10 with daily activities.  She was unable to do an elliptical machine but could bike 5-10 minutes before resting.  She could get most things done around the house, although her mother helped.  Prolonged shopping, sitting, and long drives aggravated the pain.  She was not working in her military occupational specialty but was working in the motor pool and doing administrative duties.  Physical examination showed a slightly antalgic gait favoring the right, no gross abnormality, and full range of motion (ROM) with pain at full flexion. There was no grinding or swelling but tenderness was present. Patellar apprehension tests (subluxation/sprain) and patellar tilt test (functional instability) were positive.  Motor strength was 5/5.  The Lachman’s (no ACL tear) and McMurray’s (no meniscus tear) tests were negative.  Physical Therapy examination of knees for MEB, dated 17 June 2008 and conducted when she was 5 months pregnant, showed an antalgic, unstable gait, with flexion to 128 degrees (normal 140).  She had a grade II anterior drawer (possibly due to pregnancy.)  Flexion bilaterally was limited by pain.  

At the 8 April 2009 VA Compensation and Pension (C&P) examination, performed 6 months after separation, the CI reported daily pain that is transient and lasting a few minutes with swelling, popping and grinding but no locking or buckling, and she used a knee brace.  Activities were restricted to not walking more than 10 minutes, sitting more than 30 minutes, or standing more than a few minutes.  She denied any flare-ups.  She was unemployed but not due to the knee condition.  Physical examination showed a normal gait with no assistive devices.  Sensation was decreased in the knee area but patellar reflexes were normal.  There was no muscle atrophy, calf tenderness, swelling, crepitus or tenderness, and no instability.  She had full ROM without pain and no DeLuca findings.   

The Board directed attention to its rating recommendation based on the above evidence.  Both the PEB and the VA rated the condition at 10% but the PEB assigned the code 5099-5003 (chronic right knee pain) based on §4.59 (painful motion) while the VA assigned the code 5010-5260 (leg, limitation of flexion due to degenerative arthritis) due to the diagnosis of patellofemoral syndrome and subjective report of pain.  Routes to a higher rating were considered, but the alternate knee codes 5260 (leg, limitation of flexion of), 5261 (leg, limitation of extension of), 5258 (cartilage, dislocated) and 5259 (cartilage, removal of) provided no such avenue.  The Board considered a dual rating, inclusive 5257 (instability) but objective evidence showed no tests to support instability.  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 chronic left knee pain condition.  

Contended PEB Condition.  Bipolar disorder. The CI reported she was inappropriately touched by a Non-Commissioned Officer (NCO) in a bar in the presence of at least one witness, who helped her out of the situation.  However, that NCO continued to harass her in search of a relationship.  She confided in a superior who she regarded as a friend but he reported to other NCOs on the base and she was called a snitch and a sellout.  She felt blackballed and ostracized, isolated, and punished by assignment of unwanted tasks.  She received an Article 15 after a reported threat to another NCO.  She reported a history of panic attacks related to her work environment and a feeling of isolation from her unit during an emergency room visit in September 2007.  She had been taking an anti-depression medication for several weeks and was treated with anxiolytic medication.  She had a history of anxiety and depression.  Consultation with her supervisor noted she was malingering and not doing her job.  She returned to the emergency room in December 2007 with depression and suicidal ideation and was admitted to a psychiatric institution where she spent 3 weeks for treatment of depression and suicidal ideation.  The admission treatment records noted she was significantly depressed following a recent miscarriage (November) and multiple problems with her unit and chain of command, as they did not follow her profile, and allegedly stalked and peered into her quarters.  She blamed them for the miscarriage. 

The MEB NARSUM dated 26 February 2008, documented the CI’s report of sleep difficulties, panic attacks and counseling and indicated a diagnosis of anxiety disorder vs. bipolar disorder.  She was receiving treatment for her psychiatric symptoms. The DD Form 2808, Report of Medical Examination, recorded a diagnosis of bipolar disorder and assigned a S2 profile.  The NARSUM examination, dated 14 April 2008, noted the CI had a past diagnosis of bipolar disorder.  She had been taking Effexor but stopped due to pregnancy.  A psychiatry authored a statement for the MEB in May, reviewed the STR, and noted the CI had numerous appointments in Behavioral Health since March 2007, had a brief hospitalization in the context of a miscarriage and reactions to it.  He found no evidence of a bipolar disorder.  Diagnoses included depression NOS, adjustment disorder with mixed emotional features and personality disorder with histrionic and narcissistic features.  The psychiatrist concluded the latter two diagnoses were appropriate and noted they “would not be seen as boardable.” The commander noted the CI could not perform duties associated with her MOS due to knee problems and to her psychological disorder.  She ceased to function normally when under any amount of physical or mental duress.  Her stress increased and performance decreased when given a tight deadline.  She was not getting along with superiors and did not perform consistently without direct supervision.  She required assistance in establishing work-related priorities.  

At 14 April 2009 VA C&P examination, performed 6 months after separation, the CI reported she was prescribed an anti-depression medication, counseling 3 times a week and anger management classes as part of the discharge plan post hospitalization.  One of her doctors told her she was bipolar but she did not understand what that diagnosis meant and she resisted the idea that she was “crazy.” She was seeing a psychiatrist every 2 weeks for medication management.  She reported crying spells 3 to 4 times per week, mood swings, and near nightly sleep difficulties.  She did not take a prescribed sleep aid due to concerns that her infant son might need her in the night.  She reported continued panic attacks 1 to 2 times per month and trouble managing her anger.  Despite episodes of high energy and excessive spending, she was beginning to feel more positive about herself and more confident.  She had a good relationship with her mom but felt marital stress.  She had moved to be near her mom and refused to return to her previous base in Alaska, the site of her alleged harassment.  Mental status examination (MSE) noted the CI appeared slightly anxious but endorsed the mood swings, depression, panic attacks, and sleep difficulties as described.   She was able to care for her child.  Diagnoses of bipolar disorder and anxiety disorder were rendered with a Global Assessment of Functioning (GAF) score of 50 (serious bordering on moderate symptoms, impairment).  

The Board directed its attention to its fitness recommendation based on the above evidence. The PEB determined the CI’s bipolar disorder condition was not unfitting.  The VA rated the bipolar disorder, claimed as depression and anxiety condition at 30%, coded 9432 (bipolar).  The Board noted the commander strongly implicated a mental health condition as a limiting factor in performance of duty.  However, there were few records in evidence to support the bipolar disorder diagnosis.  The Board discussed the case at length, concluding the preponderance of available records did not support a finding of unfitting bipolar disorder.  

BOARD FINDINGS:  In the matter of the right patellofemoral pain syndrome condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended bipolar disorder 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.  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 20140509, w/attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

	

SAMR-RB						

XXXXXXXXXXXXXXXX

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 XXXXXXXXXXXXXXXXXX, AR20160016555 (PD201402289)

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