RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02720
BRANCH OF SERVICE:  ARMY	BOARD DATE:  20150618
SEPARATION DATE:  20070510

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-3 (Basic Trainee) medically separated for major depressive disorder (MDD) and chronic pain of both lower extremities.  The conditions could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty or satisfy physical fitness standards.  He was issued a permanent L3S3 profile and referred for a Medical Evaluation Board (MEB).  The “major depressive disorder” and “chronic right leg pain and left foot pain secondary to stress fracture of the proximal tibia and left calcaneus” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other condition was submitted by the MEB.  The Informal PEB adjudicated the MDD and chronic pain of both lower extremities as unfitting rated 10% and 0% respectively, with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  Soon after, an administrative correction was made to the PEB, but there was no impact on the service ratings during the final administrative adjudication.  The CI made no appeals and was medically separated.

CI CONTENTION:  He was given a higher rating for his conditions by the VA.  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/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 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:

Admin IPEB – Dated 20070430	VA* - ~3 and 5 Mos. Post-Separation 	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Major Depressive Disorder…	9434	10%	Major Depressive Disorder with Anxiety (also Claimed as
Difficulty Sleeping)	9434	70%	20071018	
Chronic Pain of Both Lower Extremities…	5099-5022	0%	Left Calcaneus Stress Fracture	5262	10%	20070817	
			Right Proximal Tibia Stress Fracture	5262	0%	20070817	
Other x 0 (Not In Scope)	Other x 1	
RATING:  10%	RATING:  70%	
*Derived from VA Rating Decision (VARD) dated 20070607 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Major Depressive Disorder Condition.  Multiple physical therapy (PT) notes documented that the CI reported decreased motivation and that he was being followed by community mental health.  The treatment problem list indicated diagnoses of adjustment disorder with depressed mood and insomnia.  The psychiatry MEB addendum noted reports of increasing depression and trouble sleeping.  The CI reported depressive symptoms of “fluctuating mood, poor concentration, poor energy, poor appetite with stable weight, poor motivation, anhedonia, apathy, and feelings of worthlessness due to not finishing training.”  He also reported anxiety symptoms of excessive worry.  He reported the use of Wellbutrin for the depressive symptoms, Diazepam for insomnia, and Alprazolam for anxiety.  The mental status examination (MSE) was normal except for an apathetic mood and mildly depressed affect.  The examiner rendered a diagnosis of major depression with a Global Assessment of Functioning (GAF) score of 65 (some difficulty in social, occupational, or school functioning, but generally functioning pretty well).  The examiner opined that “it is expected that his depression will resolve once he is separated from the service and his leg heals, but the DSM-IV TR precludes this diagnosis if any other Axis I condition has its criteria met.”  The examiner further opined that the depressive disorder was not service disqualifying.  At the VA Compensation and Pension (C&P) mental disorders examination performed 5 months after separation, the CI reported a suicide attempt 2 months prior to the VA examination which resulted in an overnight psychiatric hospitalization.  During the exam, the CI revealed that while in service he had experienced the death of his mother and grandmother, and that after discharge he also received a diagnosis of HIV.  He reported symptoms of lack of motivation, problems sleeping, depressed mood, anhedonia, suicidal ideations, and social isolation.  The examiner noted that the CI was a nursing student, but left school after a syncopal episode which he reported resulted in problems with memory and concentration.  The MSE was significant for fatigued psychomotor activity, guarded attitude, constricted, blunted affect, dysphoric mood, suicidal ideation without a plan or intent, and impaired judgment and insight.  A GAF score of 49 (serious impairment in social, occupational, or school functioning) was assessed.  A diagnosis of MDD with anxiety was rendered.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB adjudicated the MDD as unfitting with a service disability rating of 10% for mild industrial impairment.  The VA rated the MDD with anxiety condition at 70% for deficiencies in most areas of functioning.  The Board considered whether the evidence supported a higher than 10% rating.  There were no pre-separation MH treatment notes available to the Board; therefore the Board placed high probative value on the psychiatric evaluation performed as part of the medical board process.  At the time of the examination, there was no evidence of total occupational and social impairment, deficiencies in most areas, reduced reliability and productivity, occasional decrease in work efficiency, or intermittent periods of inability to perform occupational tasks due to symptoms of a mental disorder.  The Board also determined that VASRD § 4.129 was not applicable in this case.  Considering the totality of the evidence and mindful of VASRD §4.3 (reasonable doubt), members agreed that a disability rating of 10% for MDD was appropriately recommended in this case.

Chronic Pain of Both Lower Extremities Condition.

Right Knee/Leg.  Treatment records evidence that the CI presented on 19 August 2006 with a 2-week history of right knee pain.  The physical examination demonstrated pain with motion and medial tibial plateau tenderness on palpation.  He was diagnosed with a tibial stress fracture and referred to PT.  The CI was subsequently placed in a full leg cast for 5 weeks due to progression of the stress fracture.  At an orthopedic evaluation dated 1 February 2007 the CI reported persistent 4/10 right leg pain despite physical therapy.  The narrative summary (NARSUM) 2 months prior to separation noted a history of 12 weeks of crutch ambulation with weight bearing as tolerated.  The examiner noted that after 24 weeks of light duty and conservative treatment the CI was “unable to walk very far or run.”  The left leg pain was rated 5/10 and increased to 7/10 with walking, running, climbing stairs, and prolonged standing.  The physical examination documented right leg tenderness to palpation with decreased flexion to 125 degrees (normal 140).  Testing for right knee instability was negative and the neurovascular examination was intact.  Radiographic evaluation was referenced as demonstrating “a healed stress fracture of the proximal right tibia.”  A diagnosis of chronic right leg pain secondary to stress fracture of the proximal tibia was rendered.  At the VA C&P examinations performed 3 and 5 months after separation, the CI reported right leg pain which increased at the end of walking and with prolonged standing.  The CI reported that he was able to stand more than an hour, but less than 3 hours and was able to walk more than one-quarter of a mile, but less than an mile.  The physical examination demonstrated tenderness to deep palpation without limitation of motion.  Radiographic evaluation of the right tibia was normal.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB combined the right leg pain and left foot pain conditions under a single service disability rating, coded analogously to 5022 (periostitis) and rated at 0% for no mechanical loss of motion.  The VA rated the right leg pain at 0%; coded 5262 (impairment of tibia and fibula).  In accordance with DoDI 6040.44, if the PEB combined adjudication is not compliant with the VASRD rating criteria, each condition subsumed under the single service disability rating must be reasonably justified as separately unfitting in order to remain eligible for service rating.  The Board’s initial charge in this case was directed at determining if the PEB’s combined adjudication was justified in lieu of separate ratings.  The right leg pain condition was profiled, considered to fail retention standards, and implicated by the NARSUM.  Members agreed that based on the clinical evidence and fitness performance-based criteria, the disability associated exclusively with the right leg could be reasonably justified as separately unfitting.  The Board then considered whether the evidence supported a higher than 0% rating for the right leg pain condition.  The Board noted that there was evidence of painful motion and pain with use for a 10% rating under VASRD code 5003 (arthritis, degenerative) and IAW VASRD§ 4.59 (painful motion) and § 4.40 (functional loss).  There was no evidence of moderate knee disability, leg extension limited to 15 degrees, or leg flexion limited to 30 degrees for a higher rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10%, coded 5003 for the right leg pain condition.

Left Foot/Ankle Pain.  A treatment note dated 6 December 2006 documented the onset of left heel pain and that the CI was being followed by podiatry for a possible left calcaneal stress fracture.  The physical therapist noted a normal gait and plantar flexion of the ankles.  PT notes continued to document from December 2006 through February 2007 that the CI was followed by podiatry for a left calcaneal fracture.  There were no podiatry treatment notes on record.  At the MEB NARSUM examination the CI continued to report left foot pain, rated 5/10, and worse with activity.  The examiner documented that a bone scan performed on 24 January 2007 demonstrated a resolved left calcaneal stress fracture.  The examiner documented no obvious foot swelling, deformities, or tenderness to palpation.  At the VA C&P examination performed 3 months after separation, the CI reported that the left heel was very painful with standing.  He reported pain, stiffness, and instability of the left (calcaneo-navicular joint) foot.  The examiner noted pain to palpation and manipulation of the left heel.  X-ray evaluation demonstrated a fully healed old fracture of the left calcaneus.

The goniometric range-of-motion evaluations in evidence which the Board weighed in arriving at its rating recommendation, with documentation of additional ratable criteria, are summarized in the chart below.

Ankle ROM
(Degrees)	PT ~3 Mo. Pre-Sep	MEB ~2 Mo. Pre-Sep	VA C&P ~3 Mo. Post-Sep	
	Left	Right	Left	Right	Left	Right	
Dorsiflexion (20 Normal)	20	20	20	20	20	#	
Plantar Flexion (45)	50(45)	50(45)	50(45)	50(45)	35	#	
Comment	Non-tender	Non-tender	Non-tender	Non-tender	Tender to palpation	AO	
§4.71a Rating	0%	0%	0%	0%	10%	#%	

The Board directed attention to its rating recommendation based on the above evidence.  The PEB combined the right leg pain and left foot pain conditions under a single disability rating.  The VA rated the left foot pain at 10%; coded 5262 (impairment of tibia and fibula; slight ankle disability).  The Board considered whether the left foot pain could be reasonably justified as separately unfitting.  The left foot pain was not profiled, but was considered to fail retention standards and implicated by the NARSUM.  Members agreed that based on the clinical evidence and fitness performance-based criteria, the disability associated exclusively with the left foot could be reasonably justified as separately unfitting.  The Board then considered whether the evidence supported a higher than 0% rating for the left foot pain condition.  Minimal records pertaining to the left foot/ankle condition were available; therefore high probative value was placed on the MEB examination 2 months prior to separation.  Although the CI reported pain with use, there was no objective evidence of painful motion, pain limited motion, or pain on manipulation.  The Board also noted that radiographs demonstrated a healed calcaneal stress fracture.  Board members agreed that the left foot pain did not meet the criteria for a 10% rating IAW VASRD § 4.59 and § 4.40.  The Board noted X-ray evaluation demonstrated a healed foot stress fracture and IAW the VASRD the left foot pain in the absence of limitation of motion is subsumed in the 5003 rating.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board determined that the left foot pain condition was unfitting and, in the absence of separately ratable criteria, recommends a single rating in conjunction with the right knee condition under VASRD 5003.

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 right knee and left foot pain conditions, the Board unanimously determined that they were separately unfitting and recommends a disability rating of 10%, coded 5003 IAW VASRD §4.71a.  In the matter of the MDD and IAW VASRD §4.130, the Board unanimously recommends no change in the PEB adjudication.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  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	
Major Depressive Disorder 	9434	10%	
Chronic Right Knee and Left Foot Pain 	5003	10%	
COMBINED	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140702, 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-00), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557

06 JUL 2016

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation
for, AR20160002819 (PD201402720)

1. 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,
accept the Board's recommendation to modify the individual's disability rating to 20%
without re-characterization of the individual's separation. This decision is final.

2. I direct that all the Department of the Army records of the individual concerned be
corrected accordingly no later than 120 days from the date of this memorandum.

3. I request that a copy of the corrections and any related correspondence be provided
to the individual concerned, counsel (if any), any Members of Congress who have
shown interest, and to the Army Review Boards Agency with a copy of this
memorandum without enclosures.

BY ORDER OF THE SECRETARY OF THE ARMY:

CF:

( ) DoD PDBR
( ) DVA