RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03479
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050323

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E6, AH-64D Armament/Electrical/Avionics System Repairer, medically separated for “panic disorder with agoraphobia,” “left ankle pain with lateral instability” and “chronic plantar fasciitis, left foot” rated 10%, 10% and 0%, respectively, with a combined disability rating of 20%.  

CI CONTENTION:  The CI asserts her initial rating was 20 percent and she feels the decision was not based on true facts.  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 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:  

SERVICE PEB - 20050216	VARD - 20051129	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Panic Disorder with Agoraphobia	9412	10%	Posttraumatic Stress Disorder(PTSD) and Panic Disorder	9411	50%
	20050620
	
PTSD	Not Unfitting					
Left Ankle Pain with Lateral Instability	5099-5003	10%	Left Ankle Sprain	5299-5271	0%	20050712	
Chronic Plantar Fasciitis Left Foot	5399-5310	0%	Plantar Fasciitis, Left Foot	5299-5276	0%	20050712	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

Panic Disorder with Agoraphobia.  According to the service treatment records (STR) and the Medical Evaluation Board (MEB) mental health (MH) narrative summary (NARSUM), the CI developed panic attacks after a mortar attack went off near her work area.  The mortar attacks continued and she continued to have panic attacks that lasted up to 15 minutes.  Initially, the CI was able to return to the mission after a panic attack; however, she began having severe attacks and was eventually medically evacuated from theater in July 2004.  The STR also indicated the CI was diagnosed with posttraumatic stress disorder (PTSD).

On 5 August 2005, the CI was transferred to the psychiatry inpatient unit from the emergency room after she reportedly took an overdose of medication and cut her wrist in a reported suicide attempt.  STR demonstrated multiple adjustments to the CI’s medications in response to undesirable side effects or lack of benefit.  She had discontinued medications on her own at various times and at times she did not fully adhere to treatment plans.  Despite treatment, the CI continued to have significant anxiety symptoms including panic attacks, and was referred to the MEB.  At the MEB NARSUM dated 20 October 2004, approximately 5 months prior to separation, the CI noted her panic attacks were stabilized at the time of the August hospitalization, but she continued to have daily nightmares.  After she was discharged she continued to have significant interpersonal problems at work and had marked difficulties with separating from her husband.  At the time of the NARSUM, the CI was taking psychotropic medications.  The CI reported that her panic symptoms reached clinically significant levels when she witnessed the explosion of a mortar by her workspace.  She related that she saw the fire and the damage it caused but did not see any loss of life.  Afterwards, every mortar attack provoked panic reaction.  The examiner noted that the CI had a prior MH history that included hospitalization in 2001 for depressive symptoms and suicidal ideations.  

The mental status examination (MSE) documented an anxious and constricted affect that was full range.  There was some psychomotor agitation (not described), and no evidence of a formal thought disorder or psychosis.  Judgment was not impaired, and cognition was intact.  The psychiatrist assessed panic disorder with agoraphobia and PTSD, and noted treatment had not improved her condition.  The Global Assessment of Functioning (GAF) score of 55 for moderate symptoms and or impairment was recorded, and it was noted that this represented a decrease in GAF score from the past year score of 75 (mild).  A memorandum dated a month before separation, was submitted to the PEB via the treating psychiatrist.  The psychiatrist noted the CI was in treatment and was compliant with her care, and that her psychotropic medications had improved her condition.

The VA Compensation and Pension (C&P) mental examination was accomplished 3 months after separation.  The CI reported she had about two panic attacks a week, and had other symptoms suggestive of PTSD.  Her attacks were triggered by loud noises.  Since discharge from the service she obtained employment; however, had missed 6 days in the 2 months of employment.  It was not clear if she had continued psychotropic medications after separation.  MSE noted that she was tearful during the interview and described her mood as depressed.  All other aspects of the examination were unremarkable.  The diagnoses of panic disorder without agoraphobia and PTSD were recorded.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB rated the panic disorder condition at 10%, coded 9412, noted that the CI was evacuated from Iraq due to panic attacks, and opined that the condition required psychotropic medication.  The PEB cited that the CI had “variable compliance and minimal engagement in outpatient therapy.”  It was also noted that PTSD was not ratable since it reflected pyramiding and the condition was not included on DA Form 3349 (physical profile).  Rating under §4.130 is based on overall occupational and social impairment due to mental health symptoms and not based on any specific mental health diagnosis, therefore, Board members agreed separate ratings for MH conditions would constitute pyramiding.

The Board next considered whether the provisions of VASRD §4.129 (Mental disorders due to traumatic stress) was applicable.  The Board noted the CI had been treated in service for depression and anxiety prior to deployment.  However, her panic attacks did not occur until she was deployed and exposed to the several incidents experienced as traumatic which culminated in the PTSD diagnosis.  Due to her symptoms she was medically evacuated from theater.  Board members agreed the provisions of §4.129 were applicable in this case.  In accordance with VASRD §4.129, when a mental disorder that develops in service as a result of a highly stressful event is severe enough to bring about the CI’s release from active military service, the rating agency should assign an evaluation of not less than 50% and schedule an examination within the 6-month period following the veteran’s discharge to determine whether a change in evaluation is warranted.  

The Board next considered the §4.130 rating at the time of constructive TDRL placement. Available treatment records at the time of separation demonstrated some impairment in occupational and social functioning; however, there was no documented evidence to support impairment in judgment or thinking.  The NARSUM and C&P examination both recorded history of one psychiatric hospitalization related to suicide attempt.  The commander’s statement noted that the CI had several panic attacks while at work, and there was evidence of significant sleep impairment and panic attacks occurring more than once a week.  Both the NARSUM and C&P examination documented essentially normal MSEs with the exception of mood and affect.  The Board considered the record in evidence did not support a higher than 50% rating for TDRL placement. 

The Board next determined the most appropriate fit with VASRD §4.130 criteria at the end of TDRL for its permanent rating recommendation.  Treatment entry in December 2005, 9 months after separation noted that the CI had missed follow up appointments and had reduced her medication dose and became depressed; however, she had remained employed.  Panic attacks were not recorded.  Although the CI was hospitalized in February 2006, 11 months after separation, the record clearly demonstrated a pattern of symptoms occurring predominately in response to common stressors.  After considerable deliberation, Board members agreed, the evidence in totality was consistent with a 10% rating for transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress.  After due deliberation, and in consideration of all the evidence and VASRD §4.3 (reasonable doubt), the Board recommends a 50% disability rating at TDRL placement and a permanent 10% disability for the condition of panic disorder with agoraphobia.  

Left Ankle Pain with Lateral Instability.  According to STR and the MEB NARSUM, the CI sustained a left ankle sprain in 2000, while during training.  She was treated with immobilization and physical therapy.  Radiographic studies (X-ray) done in October and November 2000 were normal.  A treatment entry dated 27 June 2002, documented that the CI was able to run, march and ruck, and that she had full range of motion (ROM) in the left ankle.  The examiner indicated that her left ankle pain had resolved.  However, in 2004, the CI re-injured her ankle and her pain returned.  Despite treatment, the left ankle 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.  

At the MEB examination dated16 September 2004 approximately 6 months prior to separation, the CI reported episodes of left ankle give away.  Radiographic studies (X-Ray) showed absence of degenerative changes.  The physical examination noted some tenderness to palpation; however, the presence of ankle instability was not documented.  ROM recorded dorsiflexion of 15 degrees (NL=20) and plantar flexion to 35 degrees (NL=45).  The examiner assessed chronic plantar fasciitis and lateral ankle instability, and noted her left ankle condition was stable.  Pain was rated constant and moderate.

At the time of the physical therapy (PT) clinic appointment on 16 December 2004, approximately 4 months before separation, the CI reported left ankle and heel pain.  It was noted that she had recently re-injured the left ankle which had led to increased heel pain.  The physical examination showed a mild antalgic gait and noted that the CI was able to perform single leg stance; however, she was unwilling to bear weight on the left.  The CI was assessed with chronic left ankle pain and left plantar fascia pain.

At the VA Compensation and Pension (C&P) examination performed approximately 4 months after separation, the CI reported chronic pain and stiffness in her left foot which worsened with prolonged standing and walking.  However, there was no mention of any issues with her left ankle, but it was noted that she treated her ankle pain with rest and modification of activity.  The physical examination noted absence of tenderness to palpation of the left ankle and feet.  The CI was able to rise on heels and toes, heel to toe walk, and stand on one foot without evidence of discomfort.  ROM recorded dorsiflexion to 20 degrees (NL) and normal plantar flexion of 45 degrees.  Left ankle x-rays taken in July 2005 were normal.

The Board considered its rating recommendation for the recommended placement on TDRL, which is the date of separation (in light of the mandatory TDRL period described in the analysis of the panic disorder condition above) and removal.  The PEB assigned a 10% rating under an analogous 5003 code (Arthritis, degenerative).  The VA assigned a 0% rating using an analogous 5271 code (Ankle, limited motion of) based on the VA C&P examination approximately 4 months after separation, citing a lack of evidence for a 10% rating of moderate limited ankle motion.

The Board agreed that the ROM examination at both the NARSUM and C&P examinations detailed above did not support a rating higher than 10% for moderate limitation of motion under diagnostic code 5271.  The Board considered additional coding options to include ankylosis (5270), nonunion or malunion (5262), and VASRD code for other foot injuries (5284); however, there was no path to a higher rating at TDRL placement, and there was no additional evidence justifying a rating greater than 10% at TDRL removal.  After due deliberation, and 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 left ankle condition at TDRL placement and at permanent separation.

Chronic Plantar Fasciitis Left Foot.  The CI’s left foot fascia pain condition developed in June 2001.  At the time of the PT clinic appointment on 19 June 2001, the CI reported numbness in her toes with prolonged ambulation and foot pain.  The physical examination showed tenderness over the left plantar fascia.  The examiner diagnosed plantar fasciitis and recommended a plantar fascia night wrap.  At the MEB examination dated 16 September 2004, approximately 6 months prior to separation, the CI had functional impairments of an inability to run for her APFT and march with a rucksack due to left foot pain and because her “foot gives out.”  Radiographic studies (X-Ray) demonstrated absence of degenerative changes.  The physical examination showed tenderness in the lateral ligaments, but no foot/ankle instability.  Her condition was recorded as stable with good prognosis with modification of activity level.

At the VA C&P examination performed approximately 4 months after separation, the CI reported chronic pain along the plantar aspect of her left foot which worsened with prolonged standing and walking.  She continued to use shoe inserts.  The physical examination showed full ankle/foot ROM and no evidence of tenderness.  

The Board considered its rating recommendation for the recommended placement on TDRL (in light of the mandatory TDRL period described in the analysis of the panic disorder condition above) and removal.  The PEB assigned a 0% rating under an analogous 5310 code (Group X. Function).  The VA assigned a 0% rating using an analogous 5276 code (Flatfoot, acquired: (pes planus) based on the VA C&P examination approximately 4 months after separation, citing absence of evidence of pain on manipulation to warrant a compensable rating.  The Board found no evidence to justify a compensable rating under any applicable VASRD code at TDRL placement and at the time of permanent separation.
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 plantar fasciitis left foot condition for TDRL placement and at permanent separation.  

BOARD FINDINGS:  In the matter of the panic disorder with agoraphobia condition, the Board unanimously recommends an initial TDRL rating of 50% in retroactive compliance with VASRD §4.129; and a 10% permanent rating IAW VASRD §4.130.  In the matter of the left ankle pain with lateral instability condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication at TDRL placement and at permanent separation.  In the matter of the chronic plantar fasciitis left foot condition and IAW VASRD §4.73a, the Board unanimously recommends no change in the PEB adjudication at TDRL placement and at permanent separation.  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 the prior medical separation 

CONDITION	VASRD CODE	RATING	
		TDRL	PERMANENT	
Panic Disorder with Agoraphobia	9412	50%	10%	
Left Ankle Pain with Lateral Instability	5271	10%	10%	
Chronic Plantar Fasciitis Left Foot	5399-5310	0%	0%	
COMBINED	60%	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140630, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

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 AR20160014205 (PD201403479)

1.  Under the authority of Title 10, United States Code, section 1554(a), I approve the enclosed recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) pertaining to the individual named in the subject line above to  constructively place the individual on the Temporary Disability Retired List (TDRL) at 
60% disability for six months effective the date of the individual’s original medical separation for disability with severance pay and then following this six month period no recharacterization of the individual’s separation or modification of the permanent disability rating of 20%.

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 as follows:

	a.  Providing a correction to the individual’s separation document showing that the individual was separated by reason of temporary disability effective the date of the original medical separation for disability with severance pay.

	b.  Providing orders showing that the individual was separated with a permanent combined rating of 20% effective the day following the six month TDRL period with no recharacterization of the individual’s separation.

	c.  Adjusting pay and allowances accordingly.  Pay and allowance adjustment will provide 60% retired pay for the constructive temporary disability retired six month period effective the date of the individual’s original medical separation and adjusting severance pay as necessary to account for the additional TDRL time in service.

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