RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-01373
BRANCH OF SERVICE:  ARMY 	SEPARATION DATE:  20050614

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E5, Admin Specialist, medically separated for “bipolar disorder, type I” rated 10%, and “chronic bilateral shoulder pain” rated  0%, with a combined disability rating of 10%.  

CI CONTENTION:  “Review 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 Medical Evaluation Board (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 - 20050506	VARD - 20070110	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bipolar Disorder, Type I 	9432	10%	Bipolar Disorder	9432	30%	20060906	
Chronic Bilateral Shoulder Pain	5099-5003	0%	Degenerative Disease Left Shoulder	5201	20%	20061010	
			Osteoarthritis Right Shoulder	5201	10%	20061010	
Obstructive Sleep Apnea	Not Unfitting	Obstructive Sleep Apnea	6847	50%	20060906	
Left Patellofemoral Pain	Not Unfitting	Chondromalacia, Tendonitis, Left Knee	5099-5010	10%	20061010	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  80% 	

ANALYSIS SUMMARY:  

Bipolar Disorder, Type I.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s bipolar disorder was initially documented in October/November 2003 after he reported “emotional extremes” since childhood, which worsened over the prior few months when he experienced depression, anger, irritability, impulsiveness, and poor energy.  He also had difficulty falling asleep and staying asleep, which was complicated by sleep apnea (see below).  He was originally diagnosed with a mood disorder, not otherwise specified, and was treated with sertraline (an antidepressant medication).  Over the next several months the sertraline dose was increased.  On 3 February 2004, the CI reported feeling less depressed and irritable and “more positive” with more energy.  He also reported brief episodes when he felt “hyper” since starting the treatment.  On 1 April 2004, he reported “definitely significant improvement” in his mood, and periods of depression were “less frequent and less intense.”  He brought up the issue of “hyperness” and described feeling anxiety and being overly vigilant for danger.  On 30 July 2004, he reported his mood as “a little higher than middle,” but continued to note irritability and occasional nightmares.  

At a psychological evaluation on 25 August 2004 he noted a history of mood changes going from depressed, then “normal,” then “skyrocket up,” cycling over about 2 weeks.  During the elevated periods of mood he would feel like ”bouncing off the walls,” would talk incessantly with rapid speed, and had racing thoughts.  Two to three years earlier, he recalled only sleeping about 5 hours over 4 days and not feeling tired.  During those times, he would also spend hundreds of dollars that he could not account for later.  He avoided stores and websites when his mood was elevated.  He was diagnosed with bipolar I disorder and was started on the mood stabilizer Depakote ER (valproic acid) in September 2004.  On 13 December 2004 he reported feeling “more upbeat” and “more stable.”  He was less irritable, but still had occasional nightmares.  He attended psychotherapy sessions in January and February 2005 and reported improvement in marital issues, but continued irritability and conflict at work.  The dose of Depakote was increased.  

During the 8 March 2005 MEB examination (recorded on DD Forms 2807-1 and 2808), 3 months prior to separation, the CI reported anxiety and paranoia, difficulty getting to sleep and staying asleep, and received counseling and treatment for depression and bipolar disorder.  The examiner checked normal psychiatric on the clinical evaluation.  On 13 April 2005 he denied a depressed mood or elevated mood and energy, but he seemed more on edge and felt “ready to snap.”  The examiner indicated the CI had shown improvement since starting treatment, but continued to exhibit irritability and seemed reluctant to fully engage in the treatment plan.  He opined that in a manic state the CI would be a significant risk to safety of himself or others if handling weapons or if engaged in activities such as driving during a manic state.  The examiner noted that the CI’s prognosis was fair for long-term control, depending on his motivation to follow his treatment plan, since the mood symptoms could be controlled (but not cured) with medication.  The Axis I diagnosis was bipolar I disorder, most recent episode mixed, manifested by manic episodes with greater than 1 week periods of elevated mood, decreased need for sleep, pressure to keep talking, racing thoughts, psychomotor agitation, and excessive spending.  There were also periods of depression greater than 2 weeks with insomnia and recurrent thoughts of death and mixed episodes with periods of irritability, increased energy, insomnia, and thoughts of death.  The degree of military/psychiatric impairment was considerable and impairment for social and industrial adaptability was definite.  The General Assessment of Functioning (GAF) score was 60 (moderate symptoms).  

The commander’s statement, dated 14 April 2005, indicated the CI’s profile (P3U3L2S3) had a tremendous impact on his ability to perform.  He was unable to perform physical training or execute soldier actions and required the use of a CPAP [continuous positive airway pressure] machine (see below) and access to dependable source of electric power at night.  
  
The 21 April 2005 MEB psychiatric addendum, 2 months prior to separation, noted complaints of “depression, anger, frustration.”  Mental status examination showed the CI was neatly groomed and cooperative during the interview.  Eye contact was good.  There was no speech or psychomotor abnormality.  Mood was irritable and affect was congruent.  Thought process was linear, logical, and goal directed.  There was no suicidal or homicidal ideation, hallucinations, or evidence of psychosis.  Insight and judgment were good and estimated intelligence was average.  

At the 6 September 2006 VA Compensation and Pension (C&P) examination, 15 months after separation, the CI reported bipolar disorder with depression.  His behavior was adequate during the interview.  Mental status examination showed an alert male looking in accordance with his chronological age.  He was casually dressed, appropriately groomed, and maintained good personal hygiene.  Psychomotor activity was normal.  He made good eye contact and rapport was easily established and maintained.  His speech was spontaneous with a normal rate, volume, and tone.  There were no hallucinations, delusions, or phobic or ritualistic behavior.  Mood was reported as “neutral,” but assessed as mildly‑to‑moderately depressed.  He denied suicidal or homicidal ideation, intentions or plans, although there was a history of intermittent suicidality.  Affect was congruent to self-content and mood.  Thought processes were logical, coherent, and goal oriented.  Cognitive functions were fully oriented to person, place, time, and purpose.  There were no deficiencies in cognition or memory.  Concentration and attention were adequate and insight and judgment were well preserved.  The GAF score was 68 (some mild symptoms).  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bipolar disorder, type I 10%, coded 9432 (bipolar disorder), citing depression, irritability, increased energy and decreased sleep, and excessive spending, for which he took mood stabilizing and anti-depressant medications.  The CI had greater than 8 years of active duty, so 10 USC 1207a applied.  The VA rated the bipolar disorder condition 30%, coded 9432-9435 (bipolar disorder and unspecified depressive disorder) based on the C&P examination, citing depressed mood and constricted affect associated with period of mania and periods of depression.

Members discussed whether the CI warranted a 30% rating, which requires “occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events).”  Prior to separation, while taking medication, the CI felt better although he had irritability at work and at times felt as if he were about to “snap.”  Nevertheless, his work was not impaired by his mental health condition, but was related to other conditions.  When he was seen at VA examinations, symptoms such as depressed mood, anxiety, panic attacks, and sleep impairment were reported, but he was not taking the prescribed medications.  Therefore, panel members were in accord with the PEB that the 10% rating was not unreasonable.  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.  

Chronic Bilateral Shoulder Pain.  According to the STR and the MEB NARSUM, the CI’s right shoulder condition began in 2000 after he slipped on the ice and fell on his shoulder.  The CI underwent physical therapy for 2 years with no progress.  On 12 August 2003 he had a right arthroscopic labral tear repair, followed by more physical therapy.  At an orthopedic clinic visit on 30 September 2003 he reported achieving a range of motion (ROM) of 100 degrees and started strengthening, but developed severe pain which limited the ROM to 30 degrees forward flexion (normal 180) and 30 degrees abduction (normal 180).  Pain continued, and a note dated 2 April 2004 indicated an MRI showed postsurgical changes of the anterior labrum with an abnormal signal in the glenoid, making it difficult to tell if it was simply a postsurgical change or an acute tear.  There were also mild osteoarthritic changes of the acromioclavicular joint.  A 7 May 2004 examination revealed left shoulder flexion of 170 degrees and abduction of 165.  The right shoulder ROMs were the same as the left shoulder with pain for all motions except internal rotation.  Left shoulder strength was within normal limits and right shoulder strength was 4-4+/5.  O’Brien’s (test for glenohumeral joint labral tear), Speed’s (to test for superior labral tears or bicipital tendonitis), Neer’s (to test for subacromial impingement), and biceps tension (to test the integrity of the superior labrum) tests were positive and there was tenderness at the distal right clavicle at the acromioclavicular joint and at the anterior acromion.  In July 2004, the CI tripped over a child’s toy and landed on his left shoulder and was unable to move it.  As a result, he had persistent pain with reaching and overhead work and could not lift his arm with weight nor sleep on his left side.  Physical therapy did not help.  An MRI of the left shoulder showed an anterior labral tear without superior extension and mild to moderate degenerative changes of the acromioclavicular joint.  The rotator cuff muscles and tendons were normal.  

The 23 February 2005 MEB NARSUM examination, 4 months prior to separation, noted shoulder complaints.  ROM measurements were flexion of 155 degrees and abduction of 155 degrees bilaterally.  Impingement signs were moderately positive bilaterally.  Instability signs were not present.  O’Brien’s sign for labral pathology was positive bilaterally, more so on the right.  Lift off test for anterior capsular pathology was positive on the left.  During the MEB examination the CI reported constant pain in both shoulders.  The examiner checked normal upper extremities on the clinical evaluation.

At the C&P examination the CI reported discomfort in both shoulders, right worse than left, aggravated by lifting heavy weight or doing above shoulder activity.  He had not been absent from work due to a flare up or incapacitation of any joint condition.  Physical examination of both shoulders showed no localized tenderness, swelling, deformity, or instability present.  Right shoulder ROM measurements were forward flexion 170 degrees, abduction 170 degrees, external rotation 70 degrees, and internal rotation 60 degrees.  Left shoulder measurements were flexion 170 degrees, abduction 170 degrees, external rotation 80 degrees, and internal rotation 80 degrees.  There was no pain on ROMs or loss of motion on repetition in either shoulder.     There was no evidence of adverse impact on activities of daily living, personal grooming, hygiene, transportation, or his occupation.  X-rays of both shoulders revealed no evidence of fracture or dislocation, and no significant degenerative disease changes were identified.  The examiner’s diagnosis was bilateral shoulder impingement syndrome.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral shoulder pain condition 0%, coded 5099-5003 (analogous to arthritis, degenerative), citing positive impingement signs bilaterally, abduction 155 degrees each shoulder, and positive O’Brien’s signs bilaterally.  The VA rated the osteoarthritis right shoulder condition 10%, coded 5201 (arm, limitation of motion of), based on the C&P examination, citing radiological evidence of degenerative changes and slight loss of range of motion.  The VA also rated the degenerative disease left shoulder condition 10%, coded 5201, also based on the C&P examination, citing radiological evidence of degenerative changes and slight loss of range of motion.  

The PEB combined the chronic bilateral shoulder pain conditions as a single unfitting condition coded 5099-5003 and rated 10%. The approach by the PEB not uncommonly reflected its judgment that the constellation of conditions was unfitting, and there was no need for separate fitness adjudications.  The panel’s initial charge in this case was directed at determining if the PEB’s approach of combining conditions under a single rating was justified in lieu of separate ratings.  When considering a separate rating for each condition, the panel considers each bundled condition to be reasonably justified as separately unfitting unless a preponderance of evidence indicates the condition would not cause the member to be referred into the DES or be found unfit because of physical disability.  When the panel recommends separate fitness recommendations in this circumstance, its recommendations may not produce a lower combined rating than that of the PEB.  The evidence for the bilateral chronic shoulder pain conditions was presented together above.  In this case, bilateral shoulder pain was profiled and the conditions were implicated by the NARSUM and were referred to in the commander’s statement based on the profile.  Members agreed that each shoulder condition is separately unfitting and that identical coding and ratings are applicable.  Although the ROMs of each shoulder were within normal limits, each shoulder had positive impingement signs and a positive O’Brien’s sign for labral pathology.  Panel members agreed that a 10% rating was justified for each shoulder with application of VASRD §4.59 (painful motion).  There was no malunion or recurrent dislocation of the humerus and no dislocation or nonunion of the clavicle or scapula to justify a higher rating under the 5202 (humerus, other impairment of) or 5203 (clavicle or scapula, impairment of) codes.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the chronic right shoulder pain condition, coded 5099-5003, and a disability rating of 10% for the chronic left shoulder pain condition, coded 5099-5003.  

Contended PEB Conditions:  Obstructive Sleep Apnea (OSA) and Left Patellofemoral Pain.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  Both of the conditions were profiled and implicated in the commander’s statement, based on reference to the profile and notation the CI used a CPAP machine requiring access to a dependable source of electric power.  

The CI underwent a polysomnogram on 3 April 2003 for a history of excessive daytime somnolence and snoring.  The test showed the CI had severe OSA with a respiratory disturbance index (RDI) of 37/hour.  The sleep apnea was abated with use of a CPAP machine.  Weight loss and alcohol avoidance were also recommended.  The commander’s statement noted that he was unable to perform physical training and perform soldier actions.  However, there was no indication that he was unable perform his primary duties as an administrative specialist, which require a source of electricity that could be made available for the CPAP machine.  At the C&P examination the CI said his symptoms improved significantly and he was very happy with the CPAP machine and had no further complaint.  

In 1998, the CI complained of approximately 2 years of left knee pain with several episodes of locking of the knee.  Pain persisted despite physical therapy for 4 months.  In August 1998 the CI underwent an examination under anesthesia which showed chondromalacia grade II/IV of the patella, a medial plica, and chondromalacia of the medial femoral condyle.  Debridement of the medial plica and a partial synovectomy were performed.  In April 2004 the CI complained of left lower leg pain in the area of the shin due to a 2½-mile walk 5 days earlier.  Examination on 26 April 2004 revealed a normal left tibia with an exaggerated response.  The NARSUM noted the CI continued to have pain in the knee especially going up and down stairs and with running.  Examination of both knees revealed normal alignment and there was pain with manipulation of the left patellofemoral joint.  ROM of each knee was normal.  There was no instability and McMurray’s test (to determine a meniscal tear) was negative.  X-rays of the knees were normal.  At the C&P examination the left knee revealed no localized tenderness, swelling, deformity, or instability.  ROM was 0-105 degrees (normal 0-140) with crepitus.  There was no adverse impact on activities of daily living or occupation.  X-rays of the knees showed no significant joint space narrowing with no evidence of fracture, dislocation, or effusions.  

There was no performance-based evidence from the record that either of the conditions significantly interfered with satisfactory duty performance at separation.  The CI was an administrative specialist at the time of separation, and a reliable source of electricity was more than likely available if he were to deploy.  After due deliberation, the panel concluded there was insufficient cause to recommend a change in the PEB fitness determination for either of the contended conditions, so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the bipolar disorder, type I and IAW VASRD §4.130, the panel recommends no change in the PEB adjudication.  In the matter of the chronic bilateral shoulder pain condition, the panel recommends a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a for the right shoulder pain condition, and a disability rating of 10%, coded 5099-5003 IAW VASRD §4.71a for the left shoulder pain condition.  In the matter of the contended obstructive sleep apnea and left patellofemoral pain conditions, the panel recommends no change from the PEB determinations as not unfitting.  There are no other conditions within the panel’s scope of review for consideration.  

The panel recommends 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 the date of medical separation:  

CONDITION	VASRD CODE	PERMANENT RATING	
Bipolar Disorder, Type I	9432	10%	
Chronic Shoulder Pain, Right	5099-5003	10%	
Chronic Shoulder Pain, Left 	5099-5003	10%	
COMBINED w/ BLF	30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20160206, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

AR20180008270, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

I accept the recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) to re-characterize your separation as a disability retirement with the combined disability rating of 30% effective the date of your medical separation for disability with severance pay.  Enclosed is a copy of the Board’s recommendation and record of proceedings for your information.

	The re-characterization of your separation as a disability retirement will result in an adjustment to your pay providing retirement pay from the date of your original medical separation minus the amount of severance pay you were previously paid at separation.
 
	The accepted DoD PDBR recommendation has been forwarded to the Army Physical Disability Agency for required correction of records and then to the U.S. Defense Finance and Accounting Service to make the necessary adjustment to your pay and allowances.  These agencies will provide you with official notification by mail as soon as the directed corrections have been made and will provide information on your retirement benefits.  Due to the large number of cases in process, please be advised that it may be several months before you receive notification that the corrections are completed and pay adjusted.  Inquiry concerning your correction of records should be addressed to the U.S. Army Physical Disability Agency, (AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557.

	A copy of this decision has also been provided to the Department of Veterans Affairs.
Sincerely,					      
Enclosure