RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-01966
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050220

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Combat Documentation Production Specialist, medically separated for “chronic bilateral knee pain” with a disability rating of 0%.  Posttraumatic Stress Disorder (PTSD) secondary to severe abuse when the soldier was a child” was determined to have existed prior to service (EPTS) and was not rated. 

CI CONTENTION:  Review of both the bilateral knees and PTSD 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 - 20041227	VARD – 20051005	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Bilateral Knee Pain	5099-5003	0%	Patellofemoral Syndrome, Right Knee	5010	10%	20050510	
			Patellofemoral Syndrome, Left Knee	5010	10%		
PTSD	9411	---%	PTSD	9411	NSC	20050511	
COMBINED RATING:  0%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

Chronic Bilateral Knee Pain.  The PEB combined the left and right knee conditions under a single disability rating, coded analogously to 5003 and rated 0%.  This 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 therefore directed at determining if 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 knees is presented together as the knees were seen together, but with attendant recommendations regarding separate unfitness, and separate rating if indicated.  

According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s bilateral knee pain began during the timeframe of 2000-2002 while ruck marching and continued to worsen despite rest and physical therapy (PT).  The 22 July 2004 MEB NARSUM addendum examination, 7 months prior to separation, noted complaints of severe bilateral knee pain that interfered with activities of daily living.  The pain worsened with running, prolonged standing and marching.  There was no report of either knee being worse than the other.  Physical examination showed full range of motion (ROM) with forward flexion of 140 degrees (normal), negative Lachman’s, negative posterior drawer and negative joint line tenderness.  There was no evidence of instability in either knee.  There was crepitus throughout the ROM and some pain with apprehension test. 

During the 28 September 2004 MEB examination (recorded on DD Forms 2807-1 and 2808), 5 months prior to separation, the CI reported his knees were painful when he ran or performed any strenuous work.  Physical examination noted “full ROM” bilateral knees, tenderness along patellar tendon bilaterally, and negative McMurray and drawer tests.

At the 10 May 2005 VA Compensation and Pension (C&P) evaluation, 3 months after separation, the CI reported daily pain in both knees.  Physical examination found his bilateral knee ROM measurements to be 110 degrees flexion (normal 140), and no evidence of instability or loss of motor strength or sensation.  The CI reported increased pain after repetitive use of the knees, but he was able to do deep knee bends, and walk on heels and toes without any problems.

The panel directed attention to its rating recommendation based on the above evidence. The panel first considered if each knee condition, when decoupled from the combined PEB adjudication, remained separately unfitting as established above.  Both knees were considered to fail retention standards and were implicated in the NARSUM.  The commander statement and other STR evidence did not provide any information which would permit the panel to discriminate the performance limitations attributable to either knee over the other.  Since undue speculation would be required to conclude that impairment from either knee would not have unacceptably interfered with MOS performance, members agreed that each knee was reasonably justified as separately unfitting.  The PEB rated the bilateral knee condition 0%, coded 5099-5003 (arthritis, degenerative), citing full ROM in both knees, no laxity, negative Lachman’s signs, posterior drawer and joint line tenderness and significant patellofemoral crepitus without significant effusion in the knees.  The VA rated each knee separately with patellofemoral syndrome condition at 10%, coded 5010 (arthritis, due to trauma, substantiated by x-ray findings), based on the C&P examination, citing painful or limited motion with slight pain on repetition for each knee.  

Panel members determined that the objective findings and associated disability for each knee were identical with minimal pathology.  The panel then considered its rating recommendation for the unfitting knee condition at the time of separation.  The CI’s profile allowed for walking, biking or swimming at own pace and distance, but did not allow for running.  The NARSUM, 7 months before separation, documented full ROM and pain in both knees during the apprehension test.  The C&P examination 3 months after separation was normal. ROM was full, there was no tenderness, but examination revealed increased pain with repetition, although he could heel and toe walk without pain.  The panel agreed that the condition was not compensable under ROM codes 5260 and 5261, or any other applicable VASRD code.  The Panel also agreed, there was insufficient evidence of objective painful motion with functional loss that would support a 10% rating IAW VASRD §4.59, §4.40, since neither was demonstrated during the C&P or NARSUM examinations.  Although the C&P examination documented the CI reported increase in pain with repetitive use of his knees, the CI was able to do deep knee bends, walk on his toes and heels without any problems. At the time of separation, both the NARSUM and the MEB H&P examinations recorded full ROM and painful motion was not found during ROM testing.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 0% for the right lower extremity condition and 0% for the left lower extremity condition.  As this results in no rating benefit to the CI, the panel recommends no recharacterization of the PEB adjudication for the bilateral knee condition. 
 
PTSD.  According to the STR and MEB mental health (MH) narrative summary (NARSUM), the CI reported a childhood history of physical, emotional and sexual abuse.  There was no documented history of pre-military treatment.  He was first seen by mental health (MH) in May 2004 for the report of anxiety, depression, and feelings of guilt over the past 3 years related to past abuse and family relationships.  He was diagnosed with anxiety disorder NOS, and was prescribed psychotropic medication and talk therapy.  In June 2004, he reported worsening irritability, anxiety, insomnia, and nightmares.  He reported that he began to have nightmares (there was no corroborating evidence of in-service traumatic events) about shooting members of Al Qaeda and then discovering that the people he killed were members of his own unit.  The CI reportedly stated that his symptoms worsened after seeing a video of a beheading in Iraq. 

During the 22 November 2004 MH NARSUM, 3 months before separation, the CI complained, “I relive my life every day.”  The CI reported that he disclosed the following in August and September 2004.  He “relived” an incident in childhood in which his grandfather picked him up by the throat and threw him across a room.  He remembered feeling terrified by the incident.   He also mentioned episodes of abuse by his mother’s boyfriends and sexual abuse by a babysitter.  He was reluctant to discuss these incidents and had avoided talking about them prior to August 2004.  He endorsed hypervigilance and startle response, and noted that his irritability was affecting his marital relationship.  In late September 2004, his diagnosis was changed to PTSD.  The mental status examination was unremarkable.

At the 11 May 2005 VA C&P mental evaluation, 3 months after separation, the CI reported he had never been hospitalized for mental health reasons, but had received outpatient therapy and medication.  He had not received MH treatment since 3 weeks prior to his discharge from the military, and was no longer taking psychotropic medication for treatment of anxiety symptoms.  The CI was working 40 hours a week in a job that he enjoyed, and his marriage was stable.  He had positive relationships with his daughter, and had an active social life with many friends.  A formal MSE was not recorded, but elements of the mental status was present throughout the interview and were unremarkable.  The examiner opined that the CI did not meet DSM-IV diagnostic criteria for PTSD since Criterion A was not satisfied.  Specifically, the examiner noted that there was doubt as to whether merely watching videos of someone being injured or killed, irrespective of how horrific the video could be considered trauma of the sort that would cause significant PTSD.  The examiner noted that the CI did not have significant social or occupational impairment due to his MH symptoms “at this time.”

The panel directed attention to its rating recommendation based on the above evidence.  The PEB did not rate the condition of PTSD and implied that the condition existed prior to service (EPTS).  The PEB noted the condition was secondary to severe abuse during childhood, and that it was improved with medications and talk therapy.  The VA did not service-connect the condition of PTSD, and noted that diagnostic criteria for PTSD were not met and significant social or occupational dysfunction related to MH symptoms were not present.  The panel first considered the nature of the condition.  The CI reported significant childhood abuse, family dysfunction, and military related trauma; however, no specific in service traumatic exposure was identified or corroborated.  Panel members agreed, it is more likely than not that his condition had existed prior to service, based on the CI’s report and the preponderance of evidence; however, the question of permanent service aggravation must be addressed.  The CI reported improvement in his condition with medication and therapy.  His condition did not require treatment in the emergency room or hospitalization.  At the time of the C&P examination, which was most proximate to separation, the CI’s condition had improved to the extent that he was considered no longer meeting DSM-IV diagnostic criteria for PTSD.  He was working full-time in a job he reportedly enjoyed, had good marital relationship and a good support system.

The panel acknowledges that IAW 1332.38 a presumption of service aggravation may only be overcome by clear and unmistakable evidence that the natural progression of a pre-existing condition was unaltered by any consequence of military service and unanimously agreed that in this case the evidence met that standard.  After due deliberation in consideration of the preponderance of the evidence, the panel concluded that there was insufficient cause to recommend a change in the PEB determination that the CI condition was not permanently service aggravated, and therefore this condition could not be recommended for disability rating.  After due deliberation, considering all of 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 PTSD condition.  

BOARD FINDINGS: In the matter of the bilateral knee condition and IAW VASRD §4.71, the panel unanimously recommends no change in the PEB adjudication.  In the matter of the contended PTSD condition, the panel unanimously recommends no change from the PEB determination as not unfitting.  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.  

AR20180011266, 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.

Sincerely,

Enclosure