RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03261
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060105

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (Chemical, Biological, Radiological, and Nuclear) medically separated for “chronic pain, right foot” and “major depressive disorder, single episode,” with a combined disability rating of 20%.

CI CONTENTION:  “Please consider all conditions.”  

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44.  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 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:  

IPEB - Dated 20051027	VA* - (~16 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Pain, Right Foot	5099-5003	10%	Right Foot Condition	5284	NSC	20070321	
MDD, Single Episode, Treated and Improved, Requiring Psychotropic Medication	9434	10%	MDD with Psychosis	9434	50%	20070418	
Other MEB/PEB Conditions x 0 (Not In Scope)	Other x 0 & 8	
RATING:  20%	RATING:  50% & 60%	
*Derived from VA Rating Decisions (VARDs) dated 20070928 & 20080222 (most proximate to date of separation [DOS]).  

ANALYSIS SUMMARY:  

Chronic Pain, Right Foot.  The first record in evidence for the right foot condition is an operative report dated 22 January 2003 for correction of a bunion (hallux valgus) and heel spur (which is usually secondary to plantar fasciitis).  The record shows that she was first symptomatic in 1997.  She did not recover from the surgery as expected and a neurological complication (reflex sympathetic dystrophy [RSD]) was suspected despite duty modifications, medications, and physical therapy (PT).  She was seen in physical medicine and rehabilitation (PMR) on 7 January 2004 and noted to have sensory and motor deficits of the right foot as well as decreased circulation as well as an abnormal gait due to pain (antalgic).  This was thought to be consistent with RSD.  She was placed on a different medication for nerve related pain (Neurontin) and a series of injections begun.  This proved to be unsuccessful and further intervention was not recommended in the PMR note dated 22 June 2004.  X-rays on 10 July 2004 showed good hardware placement and were otherwise unremarkable.  On 30 August 2004, she underwent hardware removal with mixed results as noted in a 10 November 2004 podiatry note.  She was then recommended for a Medical Evaluation Board (MEB).  The narrative summary (NARSUM) was dictated on 14 April 2005.  The CI reported that her feet hurt all the time at the site of the heel spur and of the bunion repair.  Her feet hurt with pressure, but manual palpation and passive range-of-motion (ROM) were not painful.  On examination, she had normal skin color and temperature, vascular supply, and neurological examination.  The findings previously recorded consistent with RSD had resolved.  She was thought to have a neurological cause of her pain, possible from a back condition.  At a neurological evaluation for migraine headaches on 29 June 2005, she was noted to have a normal neurological examination and to be able to hop on either foot without difficulty.  The Board noted that the CI later stated that she could not do this as it was contrary to her profile.  At the MEB examination on 22 August 2005, the CI reported bilateral foot pain.  The MEB physical examiner noted that the plantar fascia was (tender) bilaterally and pain was elicited with movement of the right great toe (dorsi- and plantar flexion [toe up and toe down]).  The gait was normal although she could not toe walk.  At the VA Compensation and Pension (C&P) examination performed 14 months after separation, the CI was not specifically evaluated for the foot condition.  However, her gait and neurological examination were normal.  The skin, extremities, and vascular supply were also normal.  

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the right foot pain condition at 10% with reference to the USAPDA pain policy, coded 5099-5003 (analogous to degenerative arthritis).  The VA initially adjudicated the right foot condition as non-service connected (NSC), but later rated the CI at 10% for residuals of right foot bunionectomy and removal of heel spur, coded 5280 (hallux valgus[bunion]), effective 25 October 2007, based on an examination 27 months after separation which was well outside the 12 month window assigned higher probative value.  The Board noted that the examinations proximate to separation documented a normal or near normal evaluation and gait.  It found no route to a rating higher than the 10% adjudicated by the PEB.  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 foot condition.  

Major Depressive Disorder (MDD), Single Episode, Treated and Improved, Requiring Psychotropic Medication.  The CI was first seen for mental health issues on 20 May 2002 when she noted persistent depressive symptoms since the death of her father the prior year with an increase in symptoms the past few months.  She had attended a bereavement group the previous year without benefit.  The CI was resistant to counseling, but was placed on medication.  The next mental health record in evidence is a request for a psychiatric evaluation from the physical examination section for the MEB on 4 December 2004 when she reported the history of depression and anxiety for which she had been treated.  She was evaluated 10 days later and reported depressive symptoms since the death of her father in 2001.  She was again placed on medications.  She showed fairly steady improvement and stated that she felt normal at the psychiatric appointment on 15 August 2005.  There were no further mental health clinical appointments in evidence until 19 December 2005, after the PEB (below).  The initial mental health (MH) NARSUM was on 17 August 2005.  It noted that she had improved since starting medications the previous December and she reported a normal libido and appetite.  She also noted that she cried less and slept better.  Her husband also reported that she was improved.  She was thought to show slight impairment with minimal duty restrictions.  The MEB examination was on 22 August 2005.  The psychiatric examination was checked normal.  The NARSUM was updated 6 weeks later on 27 September 2005.  It noted that while she had transient improvement, her symptoms had returned to “as before” despite continued treatment.  She was alert, oriented, and displayed good eye contact.  She reported sad mood, low energy, poor sleep, low libido, increased appetite, and decreased concentration.  She also reported panic attacks.  The commander of the Medical Holding Detachment noted on 20 October 2005 that the CI had been transferred to his unit on 1 September 2005, a period encompassing the NARSUM update.  She maintained a neat appearance and performed well at her current assignment.  She worked from 0730-1630 with a 90-minute lunch break.  The PEB adjudicated the MDD at 10% on 27 October 2005.  Another NARSUM update was dated 7 November 2005.  It noted that the CI had deteriorated since the initial dictation and that she was plagued with daily panic attacks.  The CI appealed the PEB findings in her letter dated 14 November 2005 and cited the 7 November 2005 update.  The appeal was denied as no new objective medical or performance evidence was contained in either document.  The CI cancelled an appointment in psychiatry on 18 November 2005 due to a migraine headache.  The last record prior to separation was an MH appointment on 19 December 2005 with a psychiatrist.  This was 4 months after her previous (kept) appointment and 2 weeks prior to separation.  She reported pseudo-seizures which had started on 18 October 2005 although she had unusual sensations for the previous 6 months (notes from June and August did not document these).  She reported one episode of suicidal ideation over a year previously and panic attacks three times a week.  On examination, she was frustrated and her attitude guarded.  She was passive and difficult to engage.  However, no behavioral abnormalities were present, eye contact normal, cognition normal, and she was cooperative.  She was diagnosed with a conversion disorder and major depression, recurrent.  No restrictions were levied.  At the VA C&P examination performed 18 April 2007, 15 months after separation, the examiner noted that the CI had been diagnosed with PTSD (post-traumatic stress disorder) and Cluster B personality traits (these include borderline, anti-social, narcissistic, histrionic, etc.).  She reported that she had begun drinking heavily around the time of her father’s death.  The CI also reported military sexual trauma (MST) which was not previously recorded.  She stated that she had been raped twice while on active duty, but was vague on details.  

The Board observed a significant disparity between the diagnoses assigned during the PEB process and the VA C&P as well the different histories.  The Board then considered the history of sexual assault.  It found no record that this was reported while the CI was on active duty nor did it find evidence to corroborate her history.  In February 1998, the CI was treated for facial scratches after she was in a fight; this was at her duty station prior to that of the reported assaults.  The assaults were alleged to have happened in 1998 in most encounters, but she stated that they were in 2001, once near the time her father died, at least twice. The Board noted that the CI specifically denied suicide attempts on the separation history.  She also reported multiple suicide gestures, but again with variability in the history.  The record demonstrates absence of treatment in the ER for panic attacks, suicidal attempts or gestures, and absence of psychiatric hospitalization both prior to separation and proximate to separation.  

The Board directed attention to its rating recommendation based on the above evidence.  It first considered the application of VASRD §4.129.  The Board observed that many victims of sexual assault do not report the incident(s) and that this was a known problem in the military during this time frame.  However, no evidence was found to support any type of assault during this period other than the fight which was at a different duty location.  No record exists for either incident until well after separation.  The history of the MST was not obtained until over 14 months after separation.  The Board noted that while the CI was active duty, she consistently reported the onset of depressive symptoms at the time of her father’s death and secondary to her loss.  The Board considered the totality of the evidence and determined that it does not support the application of VASRD §4.129.  It then considered the appropriate rating IAW VASRD §4.130.  The CI reported increased symptoms the final few months prior to separation.  However, her supervisor noted that she did a good job at her alternate duties in a report drafted after the second NARSUM which indicated a recurrence of symptoms.  Following separation, she found employment which she held until laid off due to an economic downturn several years later.  There is no evidence that she unable to perform her job either before or after separation other than the restrictions from her foot condition.  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 MDD condition.  

BOARD FINDINGS:  In the matter of the right foot condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the MDD condition 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.  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 20140614, 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 XXXXXXXXXXXXXXXXXXXX, AR20160004427 (PD201403261)

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