RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-03957
BRANCH OF SERVICE: Army	BOARD DATE:  20150605
SEPARATION DATE:  20070307

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Longbow Apache Helicopter Mechanic) medically separated for anxiety disorder.  The anxiety disorder could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty.  He was issued a permanent L1/S3 profile and referred for a Medical Evaluation Board (MEB).  “Anxiety disorder, not otherwise specified (NOS),” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded one other condition (joint pain, localized in the knee) as meeting retention standards for PEB adjudication.  The Informal PEB adjudicated “anxiety disorder, NOS” as unfitting, rated 10%, citing application of AR 635-40.  The remaining condition was determined to be not unfitting.  The CI made no appeals and was medically separated.

CI CONTENTION:  “Please consider all conditions.”

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 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 20070119	VA* - (~3 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Anxiety Disorder, NOS	9413	10%	Anxiety Disorder	9413	30%	20070613	
Left Knee Pain	Not Unfitting	Lateral Collateral Ligament Strain, Left Knee	5260	0%	20070502	
Other MEB/PEB Conditions x 0 (Not in Scope)	Other x 5 	
RATING:  10%	RATING:  30%	
*Derived from VA Rating Decision (VARD) dated 20070822 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Anxiety Disorder, NOS.  According to service treatment records, the CI deployed to Iraq twice from January 2003 - July 2003 and February 2004 - February 2005.  On the post-deployment health assessment (PDHA) dated June 2003, the CI indicated he did not see anyone wounded, killed or dead during this deployment, did not engage in direct combat, and did not feel he was in danger of being killed.  He denied symptoms of anxiety.  No PDHA was in evidence after the second deployment.  He started mental health treatment at the Resiliency and Restoration Center in April 2006 due to anxiety symptoms that began during his deployments.  He had been in the care of a psychiatrist who prescribed medicine for depression and for sleep that did not respond to the initial dose, so the medicine was increased with minimal improvement of symptoms.  He attended group and individual therapy but this did not help his symptoms.  He received a permanent S3 profile and was referred for a MEB.

At the narrative summary (NARSUM) exam, dated 14 November 2006 (4 months prior to separation), the CI noted he had deployed twice and could not deploy again.  He was too anxious and was worrying “all the time” about IED explosions and mortar attacks and would get panic attacks.  Marital and financial strain was increasing his anxiety.  He reported low energy, poor sleep, decreased concentration, constant anxiety, nightmares and frequent panic attacks as related to another upcoming deployment.  He was ruminating about death and injury.  In addition to the medications and therapies he received, he attended anger and stress management classes but was still symptomatic.  He was working with helicopters, had a supportive relationship with his wife that was strained by his military situation, and was about to file for bankruptcy.  He denied previous psychiatric history, hospitalizations, suicide attempts or gestures.  The examiner noted his symptoms did not fit the criteria for posttraumatic stress disorder (PTSD).  A diagnosis of anxiety disorder NOS was rendered with a Global Assessment of Function (GAF) score of 60 (on the cusp of moderate to mild symptoms, impairment).  The examiner opined that the CI had an underlying anxiety disorder exacerbated by his combat stress experiences.

A rear detachment commander’s statement, undated, noted the CI maintained a great Soldier attitude.  He said the following: “Regarding his anxiety disorder, although he hides his discomfort very well, he has trouble focusing on simple tasks at hand which prevent him from reaching his full potential in the Army.”

At the VA Compensation and Pension (C&P) exam performed 3 months after separation, the CI reported feeling overwhelmed in crowds, avoidance of situations that trigger anxiety e.g. driving and shopping, worried a lot, had trouble waiting in lines, nightmares, sleep problems, isolation if there was a lot of noise, worsening peer relationships, and had frequent panic attacks, lasting 30 minutes to one hour.  He had been looking for a job in the correction system since he left the service and his relationship with the family was strained.  He was being seen as an outpatient by a civilian doctor and taking medication for sleep and anxiety.  Mental status examination was notable for an anxious mood and affect.  Despite medications he continued to have significant symptoms.  A diagnosis of anxiety disorder was rendered with a GAF score of 55 (moderate symptoms, impairment.)  The examiner opined the CI suffered a global level of anxiety that significantly and adversely affected his function on a social level and symptoms were severe and significant.  On a VA Psychosocial Assessment, dated August 2007, the CI denied direct combat exposures or personal injuries.  He was living in a supportive marriage with his wife and children.  He had recently quit his job to go back into the Army, stating he missed the structure.  He denied symptoms of depression or PTSD.

The Board directed attention to its rating recommendation based on the above evidence.  Application of VASRD §4.129 is considered by the Board for all cases of service-connected psychiatric conditions resulting in separation.  All members agreed that the “highly stressful event” requisite for §4.129 was not satisfied in this case.  The PEB and the VA rated the condition at 10% and 30%, respectively, coded 9413 (Anxiety Disorder).  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 to the PEB rating for the anxiety condition.

Contended Left Knee Condition.  The Board’s main charge is to assess the fairness of the PEB’s determination that left knee pain 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 CI reported he twisted his left knee in Iraq in November 2004 and developed pain, swelling and stiffness.  Magnetic resonance imaging (MRI) in April 2005 and a bone scan of the left knee in January 2006 were normal.  An MRI in February 2006 showed evidence of an old lateral collateral ligament injury and a small anterior horn of the lateral meniscus.  He was treated with physical therapy with good results.

On 27 December 2006, an addendum to the NARSUM appeared to erroneously reference the left knee as the right knee.  A full examination of the left knee revealed no effusion, no tenderness, no crepitus, no signs of instability, and no loss of motion.  Motor strength was 5/5.  The MEB orthopedics examiner opined the knee was completely normal, was stable and not unfitting.  The rear detachment commander’s statement noted “Concerning his (left) knee, he participates, ‘as tolerated’ in running events.”

At the VA C&P exam performed 2 month after separation, the CI reported locking in the left knee that occurred two times per month with residual aching and stiffness in cold damp weather.  He did not wear a knee brace.  Physical examination showed normal gait and posture.  Examination of the left knee revealed a normal appearance without heat, redness, swelling, or tenderness.  He could squat and rise without apparent discomfort, had a full range-of-motion and no instability.  The Orthopedics examiner noted a primary care physician had given a P2 profile for chronic left leg pain but the left knee was stable.

The left knee pain was not profiled or implicated in the commander’s statement and was not judged to fail retention standards.  There was no performance based evidence from the record that this 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 left knee condition and so no additional disability ratings are 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.  In the matter of the anxiety disorder NOS condition, the Board, by a majority vote, recommends a disability rating of 10%, coded 9413 IAW VASRD §4.130.  In the matter of the left knee condition and IAW VASRD §4.71a, the Board recommends no change in the PEB adjudication.  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 20140825, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

DEPARTMENT OF THE ARMY
ARMY REVIEW BOARDS AGENCY
251 18TH STREET SOUTH, SUITE 385
ARLINGTON, VA 22202-3531

SAMR-RB

MEMORANDUM FOR Commander, US Army Physical Disability Agency
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557

06 JUL 2016

SUBJECT: Department of Defense Physical Disability Board of Review Recommendation
for XXXXXXXXXX, AR20160003339 (PD201403957)

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