RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-01227
BRANCH OF SERVICE:  ARMY	SEPARATION DATE:  20080909

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E2, Trainee, medically separated for “right inferior pubic ramus stress fracture” rated 10%. “Bipolar disorder not permanently service aggravated (PSA),” was determined to have existed prior to service (EPTS) and was not rated.” 

CI CONTENTION:  Pelvic fracture rating should be higher. Review of an additional condition not identified by the Medical Evaluation Board (MEB) and Physical Evaluation Board (PEB) was also requested. 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 PEB to be unfitting for continued military service, and when specifically requested by the CI, those conditions identified by the MEB, but determined by the PEB 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.  The panel’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections when appropriate.  The panel’s assessment of the PEB rating determination is based on review of medical records and all available evidence relevant to application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards for 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, which operates 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 disability at the time of separation.  

RATING COMPARISON:

SERVICE PEB - 20080811	VARD - NA	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Rt Inferior Pubic Ramus Stress Fracture	5299-5255	10%	No VA Examination Proximate to Separation in Evidence	
Bipolar Disorder	9432	EPTS		
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  NA	

ANALYSIS SUMMARY:

Right Inferior Pubic Ramus Stress Fracture.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s pelvic stress fracture condition began in May 2008 without specific trauma or injury.  A right pelvic MRI showed inferior pubic ramus stress fracture.  She was placed on 30 days of convalescent leave 30 May 2008 and subsequently diagnosed as pregnant.

During the 12 July 2008 MEB NARSUM addendum examination, 2 months prior to separation, physical examination revealed bilateral “full“ range of motion (ROM) with no immediate pain; however, painful motion was present with passive ROM.  The 21 July 2008 MEB NARSUM examination, noted complaints of an unhealed pelvic stress fracture.  Physical examination showed the CI walked with crutches due to the pelvic stress fracture.  The remainder of the examination was normal.  There was no VA examination proximate to separation in evidence.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the right hip ramus stress fracture condition 10%, analogously coded 5299-5255 (femur, impairment).  The panel agreed there was no limitation of right hip motion to support a 10% rating under codes 5250, 5251, 5252, or 5253.  However, there was satisfactory evidence of painful motion to support a 10% rating IAW VASRD §4.59.  There was no evidence of a femur impairment (code 5255) or other coding option to support a rating higher than the PEB’s adjudication.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded there was insufficient cause to recommend a change in the PEB adjudication for the right inferior pubic ramus stress fracture condition.

Bipolar Disorder.  According to the STR and MEB NARSUM, the CI’s bipolar disorder condition was EPTS.  The CI reported outpatient counseling from ages 17-20, at least three inpatient psychiatric care admissions, self-mutilation between the ages of 8-18, being prescribed psychotropic medications, and heavy alcohol use prior to enlistment, but denied drug or alcohol abuse.  The service entry Report of Medical Examination and History (DD Forms 2807-1 and 2808) were not in evidence.

The 25 June 2008 permanent S1 physical profile did not indicate psychiatric impairment or limitation. The 30 June 2008 psychiatric evaluation, performed before MEB initiation, rendered a diagnosis of adjustment disorder with depressed mood and a Global Assessment of Functioning (GAF) score of 60 (moderate symptoms).  On 21 July 2008, after MEB initiation, the CI was given an S3 profile which indicated at least one psychiatric condition that may require significant limitations.  The MEB psychiatric addendum, conducted the same day and 2 months prior to separation, noted complaints of sleep difficulty, poor concentration and energy, depressed mood with intermittent visual and auditory hallucinations, and racing thoughts and irritability.  The CI reported the aforementioned prior to the service mental health history.  

The mental status examination showed poor eye contact, “depressed” mood, affect congruent with inappropriate laughter and smiling, auditory and visual hallucinations, high impulsivity, along with poor judgment and insight.  A bipolar disorder diagnosis was rendered with a GAF score of 55 (moderate symptoms).  The examiner opined the CI’s bipolar disorder condition was EPTS and was temporarily aggravated by service.  The CI’s social and industrial impairment was mild.  

The 29 July 2008 commander’s statement implicated the CI’s bipolar disorder as one of three conditions (bipolar disorder, right hip, and pregnancy) which rendered the CI incapable of completing basic training.  The commander also documented that the CI adjustment disorder with depressed mood was diagnosed in July 2008.  The panel noted both bipolar disorder and adjustment disorder diagnoses occurred after MEB initiation.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB did not rate the bipolar disorder condition, coded 9432 (bipolar disorder), citing the condition as EPTS and not PSA.  The panel first determined if the CI’s condition was EPTS.  The CI initially reported her bipolar disorder diagnosis and treatment during the MEB psychiatric addendum examination.  Although the service entry medical examination and history were not in evidence there was no STR evidence to disprove the CI’s testimony.  The panel agreed with the PEB’s determination that the CI’s bipolar disorder condition was EPTS.
The panel then deliberated if the CI’s bipolar disorder condition was PSA.  On 26 June 2008 the CI completed the MEB-required Report of Medical Assessment (DD Form 2697) where she only identified her right pelvic fracture and pregnancy conditions as impediments to military duty; a mental health condition was not listed.  During the MEB psychiatric addendum examination, initiated after the MEB, the CI reported the aforementioned bipolar disorder diagnosis and treatment (including hospitalizations and medications) as EPTS.  The commander’s performance statement implicated the CI’s bipolar disorder condition as duty-limiting and also identified the CI’s adjustment disorder with depressed mood; both diagnoses were rendered after MEB initiation. There was no STR evidence indicating the CI had psychiatric symptoms, received psychiatric treatment, or psychotropic medications during her pre-MEB time in service.  

The panel determined the bipolar disorder condition was not PSA; additionally, based on the preponderance of evidence the bipolar disorder condition was not unfitting.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded there was insufficient cause to recommend a change in the PEB adjudication for the bipolar disorder condition.

BOARD FINDINGS:  In the matter of the right inferior pubic ramus stress fracture condition 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.   
Therefore, the panel, recommends 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 20170213, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record

AR20180007412, XXXXXXXXXXXXXXXXXX

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.

A copy of this decision has been provided to the counsel you listed on your application, XXXXXXXXXXXXXXXXXX.

Sincerely,					      
Enclosure