RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXX	CASE:  PD-2014-04024
BRANCH OF SERVICE:  Marine Corps 	SEPARATION DATE:  20080630

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty, E4, Antitank Assault Guided Missileman, medically separated for “chronic knee pain of unknown etiology” and “PTSD, chronic, delayed;” “right ankle osteochondral defect of the talus, status post ankle arthroscopy with persistent right ankle pain” and “regional pain syndrome, right lower extremity,” with a combined disability rating of 0%.

CI CONTENTION:  CI contends his conditions do not allow him to remain in a state of normalcy and that he received a rating of 100% from the VA.  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 - 20080423	VARD - 20081126	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Right Knee Pain of Unknown Etiology	-	0%	No VA Placement	
PTSD, Chronic, Delayed	-		Posttraumatic Stress Disorder also Claimed as Anxiety, Depression, and Neuro-Psych	9411	50%	20080911	
Right Ankle Osteochondral Defect of the Talus, Status Post Ankle Arthroscopy with Persistent Right Ankle Pain	-		Status Post Arthroscopy of Right Ankle with Traumatic Degenerative Joint Disease with Painful Motion	5010-5271	10%		
Regional Pain Syndrome, Right Lower Extremity	-		Shrapnel Scar of Right Leg with Decreased Sensation	8520-7804	10%		
Traumatic Brain Injury	Cat III	Mild Traumatic Brain Injury with Headaches	8045-8100	10%	20080911	
Personality Disorder NOS with Antisocial and Narcissistic Traits	Cat IV	No VA Placement	
Alcohol Dependence, in Sustained Partial Remission		No VA Placement	
Opioid Abuse, in Sustained Partial Remission		No VA Placement	
Cannabis Dependence, in Full Remission		No VA Placement	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  70%	

ANALYSIS SUMMARY:  

Chronic Right Knee Pain.  The PEB combined the chronic right knee pain of unknown etiology, PTSD, chronic delayed, right ankle osteochondral defect (OCD) of the talus, and regional pain syndrome, right lower extremity together as unfitting; “The overall effect of the following diagnoses contribute to the unfit finding”; and provided an overall zero percent rating.  Not uncommonly this approach by the PEB reflected its judgment that the constellation of conditions was unfitting, but that individually each condition alone was not considered unfitting, hence the “combined effect”.  

The CI’s LIMDU dated 6 August 2007, approximately 10 months prior to separation, listed the condition of “right ankle OCD S/P arthroscope.”   The available record demonstrated absence of profile for the remaining conditions.  The CI was working out of his specialty due to medical condition.  The NMA dated 31 January 2008, 5 months prior to separation, noted that the CI was wounded during deployment, and as a result, he suffered “great physical and mental anguish.”  Following his injury, “his attitude and motivation deteriorated to the point that he was not mission capable.  Since his return from Iraq, his attitude was unchanged and work ethic was not suitable.”  No specific condition was implicated.  The Board considered each condition separately as discussed below.  

According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s right knee condition began in April 2007 as a result of an improvised explosive device (IED).  Radiographs of the right knee in April 2007 were unremarkable.  Despite treatment, his right knee pain persisted and he was referred to the MEB.

At the MEB NARSUM, dated 22 January 2008, approximately 6 months prior to separation, the CI continued to report that his right knee pained him.  Findings on physical examination recorded full range of motion (ROM) with pain along the arc of the knee.  There was no evidence of instability, but the knee was noted to be tender, without evidence of vascular compromise or inflammation.  He was assessed with chronic right knee pain of unknown etiology.  At the MEB examination in January 2008, 5 months prior to separation, the CI endorsed he had trouble with his knee; however, did not elaborate on the condition.  

At the VA Compensation and Pension (C&P) examination in September 2009, performed 2 months after separation, the CI reported he had pain in his right ankle, back and shoulder; however, right knee pain was not included in his documented complaint.  Physical examination documented right knee ROM as “full and totally pain free.”  Based on the evidence in the STR, the Board concluded at the time of separation, there was not a preponderance of evidence that the right knee condition cut short the CI’s military career.  After due deliberation and consideration of the totality of evidence, there is not reasonable doubt in the CI’s favor supporting addition of the right knee as unfitting condition for separation rating.  

PTSD, Chronic, Delayed.  According to the STR and the mental health (MH) NARSUM, the CI reported his PTSD symptoms began after the April 2007 IED blast.  He reported symptoms consistent with PTSD, as well as a few depressive symptoms.  The CI also had difficulties with his chain of command.  During the deployment, his condition was treated with medication, which was of limited benefit.  The discharge summary dated 20 June 2007, indicated he was admitted to the hospital during his Iraqi deployment, after he stated, “I may kill somebody in my chain.”  The discharge summary stated that the CI was angry with his chain of command “after struggle to be evacuated from theater”, and was upset about not being able to be home with his mother who was having significant medical challenges.  His treatment team decided to evacuate him to Germany for further treatment of his physical and mental issues.  After a brief stay in Germany, the CI was transferred to the naval hospital psychiatry inpatient unit.  

At the time of the NARSUM, dated 1 July 2007, the day of admission to the naval hospital, the CI complained of recurrent nightmares and flashbacks.  He reportedly denied suicidal, homicidal ideation, and psychotic symptoms.  The CI denied that he had any problems with PTSD symptoms since returning to the States.  He also noted that he didn’t need any medications and no longer wanted to continue the antidepressant or the anti-anxiety medication prescribed while deployed.  The psychiatrist noted that his hospital course was uneventful.  He interacted well with staff and other patients on the unit and did not display any signs of suicidal or aggressive behavior.  The following day (24 hours after admission), the CI was discharged.  At the time of discharge, his mental status examination (MSE) recorded the CI’s report that his mood was “good,” and his affect was documented as appropriate.  All aspects of the MSE were unremarkable.  The examiner assessed PTSD and recorded a Global Assessment of Functioning (GAF) score of 55 for moderate symptoms and or impairment.  The psychiatrist noted psychotropic medications were not required.  

The MH addendum was accomplished on 19 March 2008, approximately 3 months prior to separation.  The examiner noted the July admission and stated that the CI had been discharged against medical advice “because he denied any suicidal or homicidal thought.”  It was noted that the CI was seen at MH on 12 July 2007, and reported symptoms of PTSD, but denied suicidal or homicidal ideation.  It was also noted that he was referred to neuropsychology to evaluate a possible TBI; however, the validity of the results were in question, “as he was going through opioid withdrawal during the assessment.”  

The psychologist opined that the CI’s misuse of prescription pain medications had caused serious occupational and social impairments, and that he was at significant risk for relapse into drug dependence.  The diagnoses of PTSD, delayed, cannabis dependence, in full remission, alcohol dependence in sustained partial remission, and opioid abuse, in sustained partial remission were assessed with a GAF score of 68 for mild symptoms and or impairment.

The VA Compensation and Pension (C&P) mental examination was accomplished approximately 3 months after separation.  At the time of the examination, the CI reported that he was not taking medications for either physical or mental conditions, and noted that he was not receiving any form of MH treatment.  The examiner wrote, “In the veteran’s own words, he describes his PTSD symptoms as that he cannot sleep.”  The CI denied a legal history including DWIs, arrests, or time spent in jail.  He had plans for returning to school, and noted that he was not employed.  The CI reported he believed that he was unable to work as a “roadie” because there was too much lifting physical labor for which he experiences a good deal of physical pain and that it was difficult for him to be among crowds.  He was living with his fiancée and described a good relationship.  The examiner noted that the CI was involved in some substance abuse; he reported that he smokes marijuana daily (It was noted previously that the CI was a marijuana smoker prior to service).  It was noted that since discharge from the service, he had no outpatient care, nor was he hospitalized.  

The Board first considered whether the PTSD condition was unfitting for continued military service.  There was no indication from the record that any MH condition was profiled and no MH condition was implicated in the non-medical assessment, except the commander stated the CI’s injury had caused him “physical and mental anguish.”  There was no indication from the NARSUM that any MH condition failed retention standards.  The Board noted the CI engaged minimally in MH treatment, and he took psychotropic medications inconsistently after returning from Iraq.  However, he had no recorded visits to the ER for MH issues, nor was he hospitalized psychiatrically in the 11 months before separation, and evidence of consistent outpatient treatment was absent.  The record demonstrated a 24-hour admission related to his MH condition after returning to the US.  Furthermore, the PTSD symptoms reported at the MH addendum were not judged to be the cause of occupational or social impairments; he was assigned a GAF score in the very mild range.  

The C&P examination 3 months after separation, recorded he was not in any form of MH treatment, had no visits to the ER, and he was not admitted to the hospital.  His only reported symptoms were memory issues and sleep disturbance.  There was not a preponderance of evidence that his MH condition cut short the CI’s military career.  After due deliberation and consideration of the totality of evidence, there is not reasonable doubt in the CI’s favor supporting addition of PTSD as unfitting condition for separation rating.  

Right Ankle.  According to STR and the MEB NARSUM, the CI’s right ankle condition began in April 2007 after as a result of an improvised explosive device (IED).  In May 2007, he underwent arthroscopy while in-theater.  However, his right ankle pain persisted and he was referred for an MRI.  At the MEB NARSUM the CI reported right ankle pain.  Physical examination of the ankles showed 15 degrees of dorsiflexion in the right ankle (NL=20 degrees) and 20 degrees of dorsiflexion in the left ankle.  He had good subtalar motion, and tenderness to palpation was noted.  There was no evidence of neurovascular compromise.  The diagnosis of chronic right ankle pain status post ankle arthroscopy for osteochondral lesion of the talus was recorded.  The examiner did not make any statements regarding retention standards, but stated “It is the opinion of the board that the member’s current medical condition interferes with the reasonable performance of his assigned duties in the US Marine Corps.”  The statement was not specific for any of the listed conditions (TBI, PTSD, chronic right ankle pain, chronic right knee pain, regional pain syndrome, and right lower extremity).

At the VA Compensation and Pension (C&P) examination in September 2008, performed 2 months after separation, the CI reported he has continued to have right ankle pain with motion, such as running and with prolonged walking.  He was not using a walking aid and generally did not have a limp.  He can climb some stairs, was able to drive, and walk reasonable distances.  His ankle tended to give out under him if he placed it on uneven surfaces.  Physical examination documented that the CI was able to walk on his heels and his tiptoes, and his gait was normal.  Motor strength of upper and lower extremity muscles was normal and sensory function was intact with the exception of slight sensory impairment in front of the right leg below the scar from shrapnel injury.  ROM recorded right ankle dorsiflexion of 20 degrees and 50 degrees of plantar flexion.  There was pain on motion and motor strength during dorsiflexion was decreased due to pain.

Based on the evidence in the STR, the Board concluded at the time of separation, there was not a preponderance of evidence that the right ankle condition cut short the CI’s military career.  After due deliberation and consideration of the totality of evidence, there is not reasonable doubt in the CI’s favor supporting addition of the right ankle as unfitting condition for separation rating.  

Regional Pain Syndrome.  The CI’s pain syndrome condition began in April 2007 as a result of an improvised explosive device (IED).  The CI sustained a deep laceration on the right leg and puncture wound on left leg.  There were no fractures; however, he was found to have a contaminated right pretibial wound that required debridement and closure.  After the surgery in June 2007, follow-up visit noted that his condition had improved; however, he continued to have pain that limited his ability to do PT, despite having oral narcotic analgesics and a narcotic patch.  The wound on the leg was healing well.  In August 2007, the CI presented to the emergency room due to right leg pain and was diagnosed with right tibia cellulitis which was treated, but did not resolve his pain complaint.  Therefore, he was referred to the pain specialist, who evaluated and treated him for the diagnoses of right lower extremity pain and right lower extremity battle wound with subsequent surgery.  The follow-up pain management visit on 16 January 2008 recorded the CI continued to have severe pain in the right lower extremity, which was now moving into the knee joint.  The CI reported that he had seen orthopedist and was told that his pain was too complicated for orthopedist to manage.  The examiner noted that the CI had been successfully weaned off of the analgesic patch (self -weaning), but was still taking other medication for pain to include narcotic medications.    

The MH addendum noted that it was during this timeframe (January 2008), that the CI had been prescribed multiple narcotic medications to address his lower extremity pain condition, and was “apparently abusing these medications.”  He had been seen in the emergency room (ER) on four occasions from 8-14 February 2008, each time “he was highly intoxicated during duty hours and had been discovered passed out or nearly unconscious in his work area.”  Therefore, he was referred to substance abuse treatment and was recommended for admission into the intensive inpatient substance abuse treatment program.  On 29 February 2008, he was admitted to the program and discharged on 14 March 2008, without completing the program.  The CI was considered a rehab failure due to poor motivation, non-compliance with the program rules and fraternization.

The NARSUM dated in January 2008 recorded the diagnosis of regional pain syndrome and noted that the CI continued to have chronic right lower pain, despite surgery, activity modification, extensive physical therapy, non-steroidal anti-inflammatory medications, and extensive narcotic medications.  It was noted that the CI’s “current medical condition interferes with the reasonable performance of his assigned duties.

The Board first considered whether the regional pain syndrome condition was unfitting for continued military service.  The evidence demonstrated that he had right leg pain, but was able to bear weight, heel and toe walk, and was not using a cane.  He could climb stairs, was able to drive, and walk reasonable distances.  There was no evidence of lower extremity weakness, vascular issues, and no sensory loss that resulted in impairment.  Considering the record in its totality, the Board was unable to find objective evidence that the condition was unfitting.  After due deliberation and consideration of the totality of evidence, there is not reasonable doubt in the CI’s favor supporting addition of regional pain syndrome as a separately unfitting condition for separation rating.

Contended PEB Conditions. Traumatic Brain Injury (TBI); Personality Disorder NOS with Antisocial and Narcissistic Traits; Alcohol Dependence, in Sustained Partial Remission; Opioid Abuse, in Sustained Partial Remission and Cannabis Dependence, in Full Remission.  The TBI insert condition 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 at separation.  The PEB determined that the conditions of Personality Disorder NOS with Antisocial and Narcissistic Traits; Alcohol Dependence, in Sustained Partial Remission; Opioid Abuse, in Sustained Partial Remission and Cannabis Dependence, in Full Remission are conditions which do not constitute physical disabilities and therefore are not compensable.  IAW DoDI 1332.38, personality disorders, and alcohol or other substance use disorder do not constitute a physical disability, and are therefore, not compensable or ratable After due deliberation, and in consideration of the 
recommend a change in the PEB fitness determination for the contended conditions and so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the chronic right knee pain of unknown etiology, post-traumatic stress disorder, chronic, delayed,, right ankle osteochondral defect of the talus, regional pain syndrome conditions and IAW VASRD § 4.71a, 4.130, 4.71a, and 4.124a, the Board recommends no change in the PEB adjudication.  In the matter of the contended traumatic brain injury; personality disorder NOS with antisocial and narcissistic traits; alcohol dependence, in sustained partial remission; opioid abuse, in sustained partial remission and cannabis dependence, in full remission conditions, the Board recommends no change from the PEB determinations 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 20140919, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

MEMORANDUM FOR DIRECTOR, SECRETARY OF THE NAVY COUNCIL OF REVIEW
               BOARDS 

Subj:  PHYSICAL DISABILITY BOARD OF REVIEW (PDBR) RECOMMENDATIONS
 
Ref:   (a) DoDI 6040.44
       (b) CORB ltr dtd 15 Nov 16

      In accordance with reference (a), I have reviewed the cases forwarded by reference (b), and, for the reasons provided in their forwarding memorandums, approve the recommendations of the PDBR that the following individual’s records not be corrected to reflect a change in either characterization of separation or in the disability rating previously assigned by the Department of the Navy’s Physical Evaluation Board:

		- XXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXX, former USMC
		- XXXXXXXXXXXXXXXXXXX, former USMC