RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2015-00775
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070117

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E2, Basic Trainee, medically separated for “chronic right leg pain…” with a disability rating of 0%. “Bipolar disorder…” was determined to have existed prior to service (EPTS) without permanent service aggravation (PSA) and was not rated.

CI CONTENTION:  The CI requested a review of all conditions. The complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The panel’s scope of review is defined in DoDI 6040.44.  It is limited to review of disability ratings assigned 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 or non-compensable.  Any conditions outside the panel’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 panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The panel’s assessment of the PEB rating determination is based on 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(s) at the time of separation.  The panel 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 panel 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 - 20070103	VARD - 20080630	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Right Leg Pain…	5399 -5314	0%	Right Iliotibial Band Syndrome	5099 -5024	NSC	20080227	
Bipolar Disorder	9432	EPTS	No VA Placement	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  NA	

ANALYSIS SUMMARY:  

Chronic Right Leg Pain.  According to the service treatment record (STR) and the Medical Evaluation Board (MEB) narrative summary (NARSUM), the CI’s right leg pain condition began in May 2006 during basic training without specific trauma.  The 11 October 2006 MEB NARSUM examination, 4 months prior to separation, noted complaints of chronic right hip and right leg pain.  It was noted that the CI underwent X-rays and a bone scan and both were normal.  She was placed in the Warrior Rehabilitation program and continued to have pain which was relieved with rest and exacerbated with increased activity.  Physical examination showed tenderness over the iliotibial band of the right lower extremity.  There was no instability of the hip or knee, and no snapping of the hips.  There was no tenderness of the femoral triangle of the hips.  Her gait was normal.  Neuromuscular strength and sensory function were normal, and there was no evidence of vascular compromise.  Range of motion (ROM) of the hip recorded extension to 15 degrees bilaterally (normal 30), flexion to 120 degrees bilaterally (normal 125), and abduction to 30 degrees bilaterally (normal 45).  Knee ROM was normal.  

At the 27 February 2008 VA Compensation and Pension (C&P) evaluation, 13 months after separation, the CI reported weakness after prolong standing, stiffness off and on, and lack of endurance.  Her hip and right leg pain was constant and she was not receiving any treatment for her condition.  Physical examination showed normal gait, absent of any signs of abnormal weight bearing or breakdown, and absence of use of any assistive device for ambulation.  There was some tenderness on the right knee but no signs of inflammation or infection, no locking pain or crepitus.  She had full knee ROM.  Hip ROM was not recorded; however, the examiner noted there was painful ROM in the right hip.  Lower extremity neurological examination showed normal motor and sensory function.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the chronic right leg pain 0%, analogously coded 5314 (Group XIV), citing slight injury to muscle Group XIV.  The VA did not service connect the chronic right leg pain, citing the evidence on file was not sufficient to demonstrate that the condition had its onset during active duty.  

The panel members agreed the evidence supports the 0% level of disability under the 5314 code for slight injury, as adjudicated by the PEB, and the higher rating of 10% for moderate disability was not justified.  There was no limitation of motion supporting a higher rating under the diagnostic codes for limitation of flexion or extension of thigh or leg (5251, 5252, 5253,5260, 5261), and painful motion was not recorded at the NARSUM or the C&P examinations. Evidence of functional loss was not present.  The condition was not compensable under the 5025 code since painful motion was not recorded, and physical examination was normal.  Therefore, there was no VASRD §4.71a route to a rating higher than the 10% adjudicated by the PEB under any applicable code, and no grounds for additional rating based on the presence of instability.

After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded that there was insufficient cause to recommend a change in the PEB adjudication for the chronic right leg pain. 
 
Bipolar Disorder.  According to the STR and MEB mental health (MH) NARSUM, the CI reported mood symptoms in April or May 2006 during basic training.  She noted that she had problems with irritability, sleep, depressed mood and lack of pleasure.  She also reported mood swings and interpersonal relationship issues.  The CI also indicated that she had a pre-service history of mood problems which had been diagnosed and treated as major depression and premenstrual dysphoria.  While in basic training, her symptoms re-emerged and she was again started on medication with good benefit.  However, it was determined that her bipolar diagnosis was not compatible with her continuance in the military.  

The 15 November 2006 MEB MH NARSUM examination, 3 months prior to separation, noted complaints of intermittent periods of mood swings, hyper-sexuality, impulsive spending, poor boundaries, decreased need for sleep, and poor relationships with peers.  Her episodes lasted for 3-4 days.  The examiner noted the CI had a good response to medication.  Mental status examination (MSE) documented rapid speech as the only abnormal finding.  The CI had remained on psychotropic medications and continuous use of the medications was recommended.  The diagnosis of bipolar disorder not otherwise specified (NOS) was recorded and the examiner noted her condition was EPTS.  It was noted that with adequate treatment she should be able to obtain employment commensurate with her training and education level, but that her bipolar diagnosis was not compatible with military service.  The 27 February 2008 VA C&P evaluation, 13 months after separation, did not mention the bipolar disorder. 

The panel directed attention to its rating recommendation based on the above evidence.  The PEB determined the bipolar disorder as EPTS, coded 9432 (bipolar disorder), citing the condition as pre-existing military entrance without PSA and as such it was not compensable.  The VA did not address the bipolar disorder, per the C&P examination 13 months after separation.  The panel reviewed the available evidence and noted the MH NARSUM documented the CI’s report of treatment for major depression and premenstrual dysphoric disorder prior to service, both were diagnosed and treated with medication by her primary care provider (PCP).  The NARSUM examiner noted that contact was made with the PCP who verified the CI’s premorbid history of mood lability and instability, as well as treatment for mood condition.  The examiner concluded per the history provided by the PCP and the examiner’s own assessment that the CI met criteria for the diagnosis of bipolar disorder NOS.  Based on this evidence, panel members agreed a determination of EPTS is upheld.

The panel next considered if the condition was PSA.  A presumption of service aggravation may only be overcome by a preponderance of competent medical evidence and accepted medical principles that the natural progression of a pre-existing condition was clearly unaltered by any consequence of military service.  The NARSUM examiner documented the absence of a history of inpatient psychiatric care pre-service and during service.  It was noted that the CI had an unstable occupational history prior to entering the military.  The CI’s condition was treated with medications, she had a history of good response to medication and at the time of separation, her condition was stable with medication.  The panel considered the evidence in its totality and was unable to find any justification to support a change in the PEB’s decision in this matter.  After due deliberation, and considering all of the evidence, the panel concluded the EPTS bipolar disorder NOS condition was not PSA beyond the natural progression of the condition and therefore recommends no change in the PEB’s adjudication.

BOARD FINDINGS:  In the matter of the chronic right leg pain and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the bipolar disorder and IAW VASRD §4.130 the panel recommends no change in the PEB adjudication.  There are no other conditions within the panel’s scope of review for consideration.  The panel, therefore, recommends that there be no modification or re-characterization of the CI’s disability and separation determination.  

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20150602, with attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

AR20170007026, XXXXXXXXXXXXXXXXXX. 

Dear XXXXXXXXXXXXXXXXXX:

	The Department of Defense Physical Disability Board of Review (DoD PDBR) reviewed your application and found your separation disability rating and your separation from the Army for disability with severance pay to be accurate.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed), and I accept its recommendation.  I regret to inform you that your application to the DoD PDBR is denied.  

	This decision is final.  Recourse within the Department of Defense or the Department of the Army is exhausted; however, you have the option to seek relief by filing suit in a court of appropriate jurisdiction.

Sincerely,