RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXX	CASE:  PD-2017-02276
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20080118

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Infantryman, medically separated for “PTSD” and “bilateral foot pain evaluated as metatarsalgia,” rated 10% each, with a combined disability rating of 20%.  

CI CONTENTION:  No specific contention was made.  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 - 20071022	VARD - 20080216	
Condition	Code	Rating	Condition	Code	Rating	Exam	
PTSD [Post Traumatic Stress Disorder]	9411	10%	PTSD	9411	50%	20071218	
Bilateral Foot Pain Evaluated as Metatarsalgia	5279	10%	Post Right Foot Surgery with Bunionectomy and Fusion with Residual Metatarsalgia	5279	10%	20071210	
			Post Left Foot Surgery with Bunionectomy and Fusion with Residual Metatarsalgia	5279	10%	20071210	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  80%	

ANALYSIS SUMMARY:  

PTSD.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s PTSD began insidiously after three deployments with exposure to a high number of extremely traumatic events. He was almost killed several times, and reported insomnia, nightmares, and irritability, apparently related to multiple combat exposures during his deployments to Iraq.  He had not previously sought care for symptoms, except for seeing a combat stress team member once during his first deployment.  During a psychiatry visit on 15 June 2007, he stated the past 2 months had been the worst.  He had become very irritable and angry, was having more nightmares, and felt like getting into physical fights with total strangers.  He was treated with an anti-depression medication and a sleep aid.  Psychological testing on 11 July 2007 showed over reporting of neurological and psychological difficulties, but endorsement of numerous symptoms consistent with anxiety and depression.  

The 18 July 2007 MEB NARSUM psychiatry consult, 8 months prior to separation, noted CI complaints of sleep difficulty due to nightmares and/or foot pain, impaired short-term memory, decreased appetite, and a weight loss of 10 pounds in the last 6-7 months.   He experienced nightmares, although they had decreased in frequency and intensity, and avoided reminders of his stressful military experience and anxiety.  He reported still feeling anxious and depressed with medication, but his temper was better with fewer crying spells.  His wife told him he was withdrawn and often inquired about his feelings about her, which he said, had not changed.  Mental status examination (MSE) showed depressed mood and affect.  The examiner noted the CI was close to tears numerous times, but did not cry, and showed many emotions while talking about experiences in Iraq; he appeared cognitively normal.  A diagnosis of PTSD was rendered with a Global Assessment of Functioning (GAF) score of 55 (moderate symptoms, impairment)  During a follow-up visit in November 2007, the CI reported that he was sleeping well and planning to go to school.  The MSE showed a bright mood and affect.  

At the 11 August 2008 VA Compensation and Pension (C&P) examination, 7 months after separation, the CI reported binge drinking 12 beers over a 2-day period every weekend, but  did not believe this was a problem.  He slept 6 hours per night, and at times he had difficulty with short-term memory, attention and concentration.  He had diminished interest in activities, depressed mood every couple of days, and often wanted to isolate himself.  He experienced insomnia and nightmares twice a week, and had some flashbacks which occurred as daydreams.  He also had high levels of irritability and anger with road rage, low frustration tolerance, hyper startle response, hypervigilance, and dissociative periods, which interfered with his functioning in class as a full-time student.  He reported his symptoms had not changed over the past year.  He commuted daily to school with friends, and helped care for his baby.  He had worked part-time, but stopped to focus on school, and hoped to eventually work as a mechanic.  He recently ran out of anti-depression and sleep medicines.  During the MSE, he reported poor sleep, and passive suicidal ideation but no plan or history of self-harm; he also often checked the windows at home.  The examiner noted a score of 29 out of 30 on cognitive testing, and no history of hospitalizations or legal problems, and opined that problems with concentration and short-term memory were likely related to PTSD.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the PTSD 10%, coded 9411 (PTSD), citing continuous medication required to control symptoms.  The VA rated the PTSD 50%, coded 9411, based on the C&P examination, citing occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships.  

The panel considered the provisions of VASRD §4.129 (mental disorders due to traumatic stress), and determined that the PTSD was due to a “highly stressful event,” and that application of §4.129 was appropriate in this case.  Therefore, a minimum 50% rating for a retroactive 6‐month period on the Temporary Disability Retired List (TDRL) is recommended.  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 panel turned to its rating recommendation at the time of TDRL placement and agreed that criteria for a 70% rating for “occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood” were not met near the time of separation; and therefore the minimum 50% TDRL rating prescribed by §4.129 is applicable.  Members adjudged that the most probative source of comprehensive evidence on which to base the permanent rating was the C&P examination.  The §4.130 criteria for a 10% rating require “symptoms controlled by continuous medication,” while a 30% rating stipulates “occupational and social impairment with occasional decrease in work efficiency and intermittent inability to perform occupational tasks.”  While the CI reported poor sleep and some hypervigilance and passive suicidal ideation, he was able to help care for his child, spend time with friends, attend school full-time, and even work part-time.  There was no evidence of visits to mental health since November 2007, when he was reportedly doing well, with no legal problems, hospitalizations or emergency room visits.  The last mental health evaluation for claims was in December 2007 when he was out of medications.  The panel concluded the CI’s symptoms were essentially controlled by continuous medication, thereby meeting criteria for a 10% rating at TDRL removal.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a retroactive 6-month period of TDRL with a rating of 50% (IAW with §4.129), and a permanent rating of 10% for PTSD, coded 9411. 

Bilateral Foot Pain.  According to the STR and MEB narrative summary (NARSUM), the CI’s bilateral foot condition began in November 2000 after completion of basic training.  Mild asymptomatic bilateral hallux valgus was noted at the time of enlistment with no waiver required.  During basic training, he developed a left leg stress fracture/shin splints and later a spiral fracture of the left tibia during a road march.  He experienced foot problems shortly thereafter and was issued boot inserts for pes planus, but had no significant relief.  Symptoms increased significantly following a 12-mile march, and he was diagnosed with stress fractures in his feet.  He was able to deploy to Iraq in 2003, however midway through the deployment he had significantly increased pain in the left foot after excessive walking.  The CI underwent left foot surgery in September 2004 which included a bunionectomy with metatarsal and phalangeal osteotomy; shortening of the second through fifth metatarsal osteotomies; and application of a posterior splint.  

He had right foot surgery in February 2005, which included a bunionectomy with metatarsal phalangeal osteotomy; second and third metatarsal shortening with internal fixation; hammertoe correction; tenotomy and capsulotomy of the fourth and fight metatarsal phalangeal joints; and application of a below-knee splint, resulting in decreased pain in the right foot.  The CI deployed in December 2005, but had significantly increased pain in the left foot and also had a fracture of the immobile second toe.  He re-deployed in October 2006 and was referred to podiatry for further evaluation.  His second toe fracture on the left foot healed, but he was eventually taken for a repeat surgery in April 2007 (arthroplasty to distal interphalangeal joint, second toe, left foot).  Despite the surgeries, the CI continued to have limiting bilateral foot pain. 

The 13 June 2007 MEB NARSUM examination, 7 months prior to separation, noted complaints of bilateral foot pain rated at 5/10 in intensity.  He frequently had cramping throughout both feet, especially after increased activity, due to permanent immobility of the foot bones.  He also had significant pain when he walked on an upward incline.  He rated his maximum pain at 7-8/10, and stated that this occurred 2 or 3 times a week.  Physical examination revealed no significant abnormalities other than post-surgical changes of both feet.  

The VA Rating Decision revealed a diagnosis of “status post right foot surgery with bunionectomy and fusion with residual metatarsalgia” and “status post left foot surgery with bunionectomy and fusion with residual metatarsalgia.”  Examination of the right foot revealed plantar tenderness over the first and third metatarsal joints.  The right fifth toe was mildly deformed, with a callus at the tip of the toe, and was curled under the fourth toe.  Examination of the left foot revealed plantar tenderness over the first and third metatarsal joints.  The third toe was mildly deformed with a callus at the tip of the toe.  The examiner noted the CI had hammertoes on both feet.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the bilateral foot condition 10%, coded 5279 (metatarsalgia), unilateral or bilateral.  The VA rated the left and right foot conditions 10% each, and coded both 5279 based on the C&P examination, citing “maximum evaluation permitted in the Scheduling for Rating Disabilities for metatarsalgia.”  The VA also assigned a 10% rating for hammer toe of all toes on one foot.  Members noted that both feet were separately unfitting and not inappropriately bundled under 5279, which specifies a 10% rating for unilateral or bilateral feet.  The panel considered other VASRD rating options, but there was no evidence of claw foot (5278); weak foot, bilateral (5277); or fractures with malunion or nonunion (5283) in either foot to justify a rating under the respective codes.  Members also considered whether the VASRD code for “foot injuries, other” (5284) provided for a higher rating (§4.7), but agreed that the condition was best characterized as “moderate,” warranting a 10% disability rating for each foot.  Alternatively, there was evidence of bilateral hallux valgus to meet the criteria for a 10% rating of each foot.  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 right foot, and a disability rating of 10% for the left foot, each coded 5284.    

The panel then determined the rating recommendation for each foot condition at TDRL removal.  The closest examination was not until the C&P examination on 7 April 2009 which was 15 months after TDRL placement and 9 months after the projected TDRL removal.    There was no evidence to show the severity increased for either foot, and members agreed that a 10% rating for each foot remained appropriate, coded 5284.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a TDRL placement rating of 10% and permanent disability rating of 10% for both the right and left foot conditions.  

BOARD FINDINGS:  In the matter of the PTSD, the panel recommends an initial TDRL rating of 50%, coded 9411, in retroactive compliance with VASRD §4.129 as DoD directed; and a 10% permanent rating at 6 months IAW VASRD §4.130.  In the matter of the bilateral foot pain, the panel recommends a disability rating of 10% for each foot, coded 5284 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% for each foot.  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	RATING	
		TDRL	PERMANENT	
PTSD	9411	50%	10%	
Chronic Bilateral Foot Pain Evaluated as Metatarsalgia	5284	10%	10%	
	5284	10%	10%	
COMBINED	60%/30%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170408, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

[AR Number], XXXXXXXXXX

XXXXXXXXXX
XXXXXXXXXX
XXXXXXXXXX

Dear XXXXXXXXXX:

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] [Reserve retirement].  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, (TAPD-ZB / XXXXXXXXXX), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557.

	A copy of this decision has also been provided to the Department of Veterans Affairs [and to the counsel you listed on your application; [name and address]].

Sincerely,					      
						      					
Enclosure