RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-02883
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060529

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Armor Crewman, medically separated for “posttraumatic stress disorder” and “low back pain,” each rated 10%, with a combined disability rating of 20%.  

CI CONTENTION:  The CI stated “conditions have gotten worse” and stated he was rated for PTSD with Major Depressive Disorder, low back pain, hearing loss with tinnitus, bilateral wrist pain, acid reflux, headaches and knee pain.  The CI also requested review of additional conditions not identified by the Medical Evaluation Board (MEB) and Physical Evaluation Board (PEB).  The CI 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 – 20060509	VARD - 20090920	
Condition	Code	Rating	Condition	Code	Rating	Exam	
PTSD with Major Depressive Disorder (MDD)	9411	10%	PTSD	9411	50%	20070828	
Low Back Pain	5237	10%	Low Back Pain	5237	10%	STR	
Hearing Loss w / Tinnitus	Not Unfitting	Tinnitus	6260	10%	20070813	
Bilateral wrist pain	Not Unfitting	Right wrist pain	5215	NSC	20070813	
Gastroesophageal Reflux Disease (GERD)	Not Unfitting	GERD	7399-7346	0%	20070813	
Headache	Not Unfitting	Headaches	8299-8100	0%	20070813	
Hemorrhoids	Not Unfitting	Hemorrhoids	7336	0%	20070813	
Bilateral pes planus	Not Unfitting	Bilateral pes planus	5276	0%	20070813	
Left Ganglion Cyst	Not Unfitting	Left Ganglion Cyst	7899-7819	0%	20070813	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

PTSD.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s PTSD began after exposure to an explosion and attack in May 2004 during his deployment to Iraq.  He received a Purple Heart in July 2004 and also received a Combat Action Badge.  After leaving Iraq in March 2005 he was sent to Korea.  After 3 months he developed a depressed mood, post-traumatic anxiety and suicidal ideation.  He received counseling for 1 month without medication, hospitalization or other treatment.  He reported a history of suicidal ideation at age 14 due to an emotionally abusive stepfather.  He was hospitalized in August 2005.

The 2 September 2005 hospital discharge summary, noted complaints of depression and suicidal intent to shoot himself with his own gun.  He reported depression with stressors of experiences in Iraq and being away from his family.  He reported he could not live with memories of Iraq with nightmares, flashbacks and auditory and olfactory (smell) hallucinations of an explosion in Iraq.  He reported additional symptoms of insomnia, exaggerated startle and hypervigilance.  He also developed neuro-vegetative symptoms of decreased appetite, energy and concentration.  He was treated with Celexa (depression) and Trazadone (sleep).  Mental status examination (MSE) showed moderately dysphoric affect, “down” mood, suicidal ideation with plan and intent, flashbacks and nightmares.  Diagnoses of depressive disorder and PTSD were rendered with a Global Assessment of Functioning (GAF) of 50 (moderate symptoms, impairment.)

The 17 February 2006 MEB NARSUM (psychiatric addendum), 3 months before separation, showed no change in medications since November 2005.  However, he reported worsening symptoms of nightmares, flashbacks, insomnia, irritability, hypervigilance, detachment from friends and family and avoidance of Iraq-associated things.  He also reported frequent dissociation through the day and mistook neon signs for flares he saw in Iraq.  Medications were changed with moderate improvement in symptoms.  MSE showed his mood was a little better and affect was sad.  Diagnoses remained the same.  The examiner noted symptoms had improved moderately in the past month but he still required significant medication and close psychiatric follow up.  

At the 28 August 2007 VA Compensation and Pension (C&P) examination, 15 months after separation, the CI reported depression, nightmares and waking up in cold sweats.  He had difficulty with attention and focus and constantly felt frustrated, aggravated, nervous and tense.  His wife said he struck out at her in his sleep.  He continued to endorse symptoms of PTSD.  He had yet to see a counselor or psychiatrist within the VA, but had seen his primary care physician who stopped the Celexa and started Cymbalta (depression), which did not work very well.  He quit a job as a correctional officer due to difficulty with handling stress of his wife working there and feeling like he had to protect her. He had not worked since and his marriage was strained.  He had one friend and wanted to be alone.  The MSE showed difficulty with remembering names and numbers, and he had sleep impairment with a depressed and anxious mood.  There was no history of panic attacks.  Diagnoses included PTSD and MDD with a GAF 60-65 (mild symptoms, impairment) due to PTSD and 55-60 (moderate symptoms, impairment) due to MDD.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the PTSD with MDD 10%, analogously coded 9411 (PTSD), citing mild industrial impairment.  The VA rated the PTSD 50%, analogously 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; impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. 

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 considered if there was evidence for a §4.130 rating higher than the §4.129 minimum mandated 50% at time of TDRL placement.  The panel agreed that the §4.130 criteria for a rating higher than 50% were not met near the time of separation and therefore the minimum 50% TDRL placement rating was applicable.

The panel then considered its permanent rating recommendation at TDRL removal.  The most proximate source of comprehensive evidence on which to base the permanent rating was the 28 August 2007 C&P examination.  The §4.130 criteria for a 10% rating is “symptoms controlled by continuous medication,” the 30% rating requires evidence of “occupational and social impairment with occasional decrease in work efficiency and intermittent inability to perform occupational tasks” while the criteria for a 50% rating specifies “occupational and social impairment with reduced reliability and productivity.”  The C&P examination noted the CI was still symptomatic, had three jobs since separation and quit all of them for various reasons and was currently unemployed.  His marriage was strained.  He was isolating after engaging in fights, was angry and inactive at home and in the community despite daily psychotropic medications.  The MSE noted memory impairment for names and numbers, depress/anxious mood and sleep impairment.  Therefore, the panel concluded the 30% rating most accurately depicted the CI’s mental health disorder at TDRL removal.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a TDRL placement rating of 50% and permanent disability rating after removal from TDRL of 30% for PTSD.

Low Back Pain.  According to the STR and MEB NARSUM, the CI’s back condition began in May 2004 after an IED explosion rolled his HUMVEE and he was thrown on his back.  X-rays were negative.  Range of motion (ROM) per the 26 October 2005 MEB examination (recorded on DD Forms 2808) showed flexion to 85 degrees (normal 90), and combined ROM of 210 degrees (normal 240) with right lumbosacral pain.    

The 23 November 2005 MEB NARSUM examination, 6 months prior to separation, noted complaints of low back pain.  Pain increased with prolonged ambulation.  He had not received any physical therapy and there was no surgical indication.  Physical examination showed tenderness to the right paraxial lumbosacral spine but no midline tenderness.  Neurovascular examination was within normal range.  The 30 March 2006 NARSUM addendum, 2 months prior to separation, showed intact heel-to-toe walk.  The ROM evaluation measured by goniometer was 85 degrees of flexion and combined ROM of 210 degrees.  There was no applicable VA examination proximate to separation in evidence.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the back condition 10%, analogously coded 5237 (lumbosacral strain), citing tenderness and thoracolumbar combined ROM of 235 degrees.  The VA also rated the back condition 10%, analogously coded 5237 (lumbosacral strain), based on the STR, citing forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees.  

The panel agreed that a 10% rating, but no higher, was justified for limitation of flexion greater than 60 degrees but not greater than 85 degrees and/or combined ROM greater than 120 degrees but not greater than 235 degrees, as reported on the MEB NARSUM addendum examination.  There was no muscle spasm or guarding severe enough to result in an abnormal gait or spinal contour, thus the next higher 20% rating was not justified on this basis.  There was no evidence of intervertebral disc syndrome which resulted in incapacitating episodes requiring physician-prescribed bed rest to warrant consideration of rating under the alternate VASRD formula for that condition.  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 back condition at TDRL placement.  The panel then consider its rating recommendation for the back condition at TDRL removal, but noted there were no subsequent examinations proximate to TDRL removal for consideration.  Therefore, the panel agreed the same 10% rating was appropriate for rating at TDRL removal.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3, the panel recommends a 10% rating for the back condition at TDRL placement and removal.

Contended PEB Conditions:  Hearing Loss with Tinnitus, Bilateral Wrist Pain, GERD, Headache, Hemorrhoids, Bilateral Pes Planus and Ganglion Cyst.  The panel’s main charge is to assess the fairness of the PEB’s determination that the contended conditions were not unfitting.  None of the conditions were profiled, specifically implicated in the commander’s statement or judged to fail retention standards.  There was no performance-based evidence from the record that the conditions significantly interfered with satisfactory duty performance at separation.  After due deliberation, the panel concluded there was insufficient cause to recommend a change in the PEB fitness determination for the contended conditions, so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the PTSD with comorbid MDD, the panel recommends a disability rating of 50%, coded 9411 IAW VASRD §4.129 for 6 months from the time of discharge consistent with a constructive period of TDRL and then a permanent rating of 30% IAW VASRD §4.130.  In the matter of the back condition, the panel recommends a 10% rating at both TDRL placement and TDRL removal.  In the matter of the contended bilateral wrist pain, hearing loss with tinnitus, GERD, headache, hemorrhoids, bilateral pes planus and ganglion cyst, 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	RATING	
		TDRL	PERMANENT	
Posttraumatic Stress Disorder 	9411	50%	30%	
Chronic Low Back Pain	5299-5237	10%	10%	
	COMBINED	60%	40%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170425, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record

AR20180008789, XXXXXXXXXXXXXXXXXX

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX

I accept the recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) to constructively place you on the Temporary Disability Retired List (TDRL) at 60% disability for six months effective the date of your original medical separation for disability with severance pay and then following this six month period re-characterize your separation as a disability retirement with the combined disability rating of 40%.  Enclosed is a copy of the Board’s recommendation and record of proceedings for your information.

	The constructive TDRL period and the re-characterization of your separation as a disability retirement will result in an adjustment to your pay providing you 60% retired pay for six months from the date of your original medical separation and then 40% disability retired pay effective the date following the constructive six month TDRL period, 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