RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX		CASE:  PD-2015-00271
BRANCH OF SERVICE:  Army	SEPARATIONDATE:  20060609

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E7, Cavalry Scout, medically separated for “posttraumatic stress disorder…” and “bilateral knee pain…” rated 10% and 0%, respectively, with a combined disability rating of 10%.   

CI CONTENTION:  The CI is “seeking correction of ratings for PTSD and bilateral knee conditions.” 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 based upon a 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 - 20060425	VARD – 20070405	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Posttraumatic Stress Disorder…	9412-9411	10%	Post Traumatic Stress Disorder (PTSD) w/Panic Attacks and Blackouts	9411	50%	20060929	
Bilateral Knee Pain…	5099-5003	0%	A Left Knee Condition	5260	10%	20060929	
			A Right Knee Condition	5260	10%	20060929	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDTIONS:  80%	

Posttraumatic Stress Disorder (PTSD).  According to service treatment records (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s PTSD condition began after a deployment to Korea and deployments to Kuwait and Iraq.  A visit to the emergency room (ER) in 1999 for chest pain resulted in the conclusion the episode may have been related to a panic attack. The CI was originally referred to mental health (MH) in May 2005 for chest pain, panic attacks and PTSD symptoms that were present by July 2004.  He reported developing nightmares about 3 months into his deployment to Iraq and was visited frequently by the combat stress team but this was not helpful.  In November 2004 he had chest pain, followed by “blackouts.” The chest pain persisted and negative cardiac work-up resulted in a diagnosis of panic disorder.  The MEB forwarded “post-traumatic stress disorder” and “panic disorder without agoraphobia” for PEB adjudication.  

The Psychiatric Addendum on 9 December 2005, 7 months prior to separation, noted complaints of episodic panic/anxiety, daily multiple panic attacks without agoraphobia, nightmares, social withdrawal, sleep disorder, hyper alertness, guilt over loss of soldiers in Iraq.  He was over-controlling with his daughters.  He and his wife had a loving and close relationship.  Mental status examination (MSE) showed a bright affect except when discussing the negative impact of his disorders on his career.  He initially denied and minimized the extent of his symptoms.  Diagnoses of PTSD and panic disorder without agoraphobia were rendered with a Global Assessment of Functioning (GAF) score of 50 (severe bordering on moderate symptoms, impairment.)  The examiner noted he was seriously impaired primary due to the panic disorder.  

At the MEB NARSUM examination on 23 March 2006, 3 months prior to separation, the CI reported frequent panic attacks which were associated with chest pains and frequent blackouts, without knowledge how long he was unconscious.  He had an episode while driving in March 2006 and has stopped driving.  He did not see much improvement in the panic attacks.  He was taking 2 anti-depression medications and one anxiolytic medication.  He had not worked in his primary MOS since August 2005.  He had blackouts with his panic attacks.  

At the 29 September 2006 VA Compensation and Pension (C&P) evaluation for PTSD, performed 4 months after separation, the CI reported nightmares 2 to 3 times per week, which awakened him, constantly intrusive thoughts of the war, constant anxiety, hypervigilance, sleep difficulty and sometimes passing out.  He continued to take a sleep medication, an anti-depression medication and an anti-anxiety medication 5 times per day.  He claimed he had not been able to get a psychiatry appointment since discharge.  He reported significant to severe difficulties despite these medications.  He had not been employed since discharge and was uncertain about prospects.  He was spending time with his daughters and building a house.  MSE showed him seemingly depressed and on the verge of tears through the interview.  He held back a great deal of emotion at times.  Affect was sluggish, under responsive and dampened to the point of being blunted.  He was withdrawn, socially distant, overwhelmed with anxiety and continued to have panic attacks.  Diagnoses of PTSD, panic disorder without agoraphobia, alcohol dependence, and iatrogenic benzodiazepine dependence were noted with a GAF score of 50.  The examiner opined the CI had severe PTSD accompanied by severe panic disorder that presented with episodes of “blacking out.” He was not able to function outside of the home and was overwhelmed most of the time.  

The PEB rated the PTSD (inclusive of panic disorder) condition 10%, coded 9411 (PTSD), citing mild industrial impairment, noting 10 A/C was awarded (result from a combat related injury).  The VA rated the PTSD with panic attacks and blackouts condition 50% coded 9412-9411 (PTSD with panic disorder), based on the VA C&P examination 4 months after separation, citing serious symptoms in occupational functioning.

Board members agreed that the provisions of VASRD §4.129 were applicable in this case due to his combat experiences and the PEB acknowledgement of 10 A/C.  Disability associated with any psychiatric condition, regardless of the diagnosis or multiple diagnoses, is subsumed under a single rating using the same criteria IAW VASRD §4.130 general rating formula for mental health conditions.  The Board then considered if there was evidence for a §4.130 rating higher than the §4.129 minimum mandated 50% at time of TDRL placement.  A 70% rating requires impairment in most areas.  The Board agreed that the §4.130 criteria for a rating higher than 50% were not met near the time of separation, and therefore the minimum 50% initial TDRL rating is applicable.

The §4.130 criteria for a 10% rating is “symptoms controlled by continuous medication,” for a 30% rating is “occupational and social impairment with occasional decrease in work efficiency and intermittent inability to perform occupational tasks,” while criteria for a 50% rating requires “occupational and social impairment with reduced reliability and productivity.”  The most proximate source of comprehensive evidence on which to base the permanent rating is the C&P examination, 4 months after separation.  The examination noted persisting symptoms despite several medications, including an anxiety medication that likely resulted in addiction.  The CI was unemployed and not sure of prospects, spending time at home with his daughters and “building a house.”  He said he had not been able to secure follow-up psychiatric treatment.  The Board agreed the CI met criteria for a 30% disability rating at the time of separation.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board by majority recommends a disability rating of 50% for 6-months of constructive TDRL and a 30% permanent rating thereafter for the PTSD condition.

Bilateral Knee Pain Condition.  According to STR and the MEB NARSUM, the CI’s chronic bilateral knee pain condition began in November 1999 while he was ruck marching on a steep uphill slope.  Both knees locked and despite medication he had pain from that point on.  From 1990 to 2001, he had steroid injections without relief.  The pain persisted during his deployment and he had occasional swelling around his kneecaps.  Bilateral weight-bearing X-rays in January 2005 were normal.  Neuroimaging of the left knee in December 2005 showed a tear into the meniscus.  Orthopedics diagnosed chondromalacia in January 2006.  He then had physical therapy with little improvement.  The bilateral knee pain failed to respond to conservative therapy for at least 5 years.  The MEB forwarded “chronic bilateral knee pain/chondromalacia” for PEB adjudication.  

The MEB NARSUM examination on 23 March 2006, 3 months prior to separation, noted complaints of baseline minimal pain of 2/10 with baseline pain of 4 to 5/10 that could increase to 8 or 9/10 with increased activity or absent medication.  He had occasional swelling around the patella and occasionally took an over the counter pain medication.  He recently was told to stop running and not perform any biking or 2-mile run or alternate walk on the Army physical fitness test.  He was excluded from any unlimited running, walking, biking or swimming.  He passed his last fitness test in March 2005 with a perfect score.  He had difficulty completing long ruck marches, difficulty standing for prolonged periods and increased pain climbing on and off vehicles.  The commander noted that his condition was not exaggerated in any way.  
 
Physical examination of the knees was bilaterally abnormal.  He presented with stabilizing braces on both knees but without obvious bony deformity, palpable effusion and limitation in ambulation.  Range of motion (ROM) showed right knee flexion of 115 degrees, left knee flexion of 110 degrees and bilateral knee extension of 0 degrees.  All ROM was accompanied by severe pain at the extremes.  Neuroimaging of the left knee on December 2005 showed large medial meniscus with a tear into the meniscal body.  Bilateral X-rays in January 2006 showed narrowing in both medial tibial femoral compartments and possibly the patellofemoral compartments and some irregularity of the medial aspect of the right tibia suggesting previous injury.  Surgical repair of the meniscal tear in the left knee was recommended but it was not likely to affect his anterior knee pain.  A diagnosis of bilateral knee pain/chondromalacia was rendered.  

At the 29 September 2006 VA Compensation and Pension (C&P) General Medical evaluation, performed 3 months after separation, the denied swelling, stiffness or locking of the left knee.  There was some minimal discomfort around the infrapatellar area.  Imaging showed internal derangement of the left knee.  Pain was 4 to 5.  He was not taking any medication or using assistive devices.  He was unable to run.  Physical examination showed he had no difficulty with ambulation.  Flexion of the left knee was 120 degrees.  Right knee flexion was 130 degrees.  Extension bilaterally was 0 degrees.  The Lachman and McMurray were negative bilaterally.   Diagnoses of left knee internal derangement and right knee chondromalacia were rendered.   He did not appear to be in any distress.  
The Board directed its attention to its rating recommendation based on the above evidence.  The PEB combined the two knee pain conditions into a single unfitting condition characterized as “chronic bilateral knee pain”, coded 5099-5003 (analogous to degenerative arthritis) and rated at 0% citing full range of motion and no instability.  The VA coded the knees separately at 5260, (leg, limitation of flexion) and assigned a disability rating of 10% for each knee based on the VA C&P examination 3 months after separation, citing right and left leg flexion limited to 45 degrees.   

The Board, IAW VASRD §4.7 (higher of two evaluations), must consider separate ratings for PEB bilateral joint adjudications; although, separate fitness assessments must justify each Service disability rating.  In this case, both knees were considered to fail retention standards; both were implicated by the NARSUM and in the commander’s statement; and, both were profiled.  Members agreed therefore that each knee should be conceded as reasonably separately unfitting.  

The Board must determine rating recommendations for the bilateral knee condition on §4.129 constructional TDRL requirements cited in the anxiety disorder above.  The MEB NARSUM, conducted 3 months prior to separation is the most proximate source of comprehensive evidence of evaluation the CI had at TDLR placement.  Each knee had radiographic evidence of narrowing of the femoral compartments and flexion less than the 140 degrees normal ROM and pain, and the left knee showed evidence of a torn meniscus for which surgery was recommended but declined.  There was no evidence of frequent episodes of locking, pain and effusion into the left joint so therefore a higher 20% rating was not indicated and identical ratings for each knee was warranted.  The Board agreed that there was sufficient evidence of painful motion to warrant a 10% rating for each knee IAW VASRD §4.59 (painful motion) and §4.45 (the joints).  Other pathways to a higher rating were considered, but there was no ankylosis or objective instability, no meniscal removal and no limitation of motion sufficient to warrant any rating higher than 10% for each knee.  Surgery to repair the left meniscus had been recommended but declined.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 10% for the right knee condition and 10% for the left knee condition, each coded 5099-5003 at TDRL placement.  

The Board then determined the rating recommendation for the right knee and the left knee conditions at TDRL removal assigned at the 6 months TDRL interval.  The Board determined the most proximate source of comprehensive evidence, to evaluation the CI at TDLR removal, was the VA C&P examination performed 3 months post-separation. There were no subsequent examinations for Board consideration.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a TDRL placement rating of 10% and permanent disability rating after removal from TDRL of 10% for the right knee pain condition and a TDRL placement rating of 10% and permanent disability rating after removal from TDRL of 10% for the left knee pain condition. 

BOARD FINDINGS:  In the matter of the PTSD condition, the Board recommends a disability rating of 50%, coded 9411 IAW VASRD §4.129 for 6 months from the time of discharge consistent with a constructive period of TDRL and then a permanent separation rating of 30% IAW VASRD.  In the matter of the right knee pain condition and IAW VASRD §4.71a, the Board unanimously recommends a disability rating of 10%, coded 5271 IAW VASRD §4.71 for 6 months from the time of discharge consistent with a constructive period of TDRL and then a permanent separation rating of 10% IAW VASRD §4.71.  In the matter of the left knee pain condition and IAW VASRD §4.71a, the Board unanimously recommends a disability rating of 10%, coded 5271 IAW VASRD §4.71 for 6 months from the time of discharge consistent with a constructive period of TDRL and then a permanent separation rating of 10% IAW VASRD §4.71.  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; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective as of the date of his prior medical separation:  

CONDITION	VASRD CODE	RATING	
		TDRL	PERMANENT	
PTSD	9411	50%	30%	
Left Knee Pain	5099-5003	10%	10%	
Right Knee Pain	5099-5003	10%	10%	
RATING	60%	40%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150413, 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  

06 MAR 2017

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for 
XXXXXXXXXXXXXXXXXX, AR20170000664   (PD201500271)

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 re-characterize the individual’s separation as a permanent disability retirement with the combined disability rating of 40%.

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:

	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 retired with permanent disability effective the day following the six month TDRL period.

	c.  Adjusting pay and allowances accordingly.  Pay and allowance adjustment will account for recoupment of severance pay, provide 60% retired pay for the constructive temporary disability retired six month period effective the date of the individual’s original medical separation and then payment of permanent disability retired pay at 40% effective the day following the constructive six month TDRL period.  

	d.  Affording the individual the opportunity to elect Survivor Benefit Plan (SBP) and medical TRICARE retiree options.

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