RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-03334
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20080916

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Cannon Crewmember, medically separated for “posttraumatic stress disorder” and “limitation of motion of the left ankle,” rated 10% each, with a combined disability rating of 20%.   

CI CONTENTION:  He merits medical retirement.  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 - 20080530	VARD - 20081219	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Posttraumatic Stress Disorder	9411	10%	Posttraumatic Stress Disorder	9411	30%	20081103	
Limitation of Motion of the Left Ankle	5271	10%	Postoperative Residuals of the Left Ankle with Residual Scar	5271	20%	20081029	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  50%	

ANALYSIS SUMMARY:  

Posttraumatic Stress Disorder.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s mental health (MH) condition began following two deployments to Iraq (2003-2004 and 2005-2006).  He witnessed several traumatic events, and lost several friends due to enemy engagement.  Since witnessing these events, the CI complained of nightmares, flashbacks, irritability, sleep disturbance, difficulty with concentrating and avoidance behaviors.  In December 2007, he was diagnosed with chronic PTSD.  The STR demonstrated that the CI was never suicidal or homicidal and his condition did not require treatment in the emergency room (ER) or hospital.

During the 23 April 2008 NARSUM psychiatric examination, 5 months prior to separation, the CI complained of difficulty with sleep, concentration, and other PTSD symptoms, but noted he was less agitated and irritable.  He denied a history of psychosis or suicidal or homicidal thoughts. His medication had been of limited benefit.  He stated that he was having difficulty performing his military duties and his symptoms strained his relationship with his wife.  The mental status examination (MSE) was unremarkable with the exception of mood, affect and decreased rate and volume of speech.  The examiner opined there were “deficiencies in occupational functioning including difficulty in adapting to work with an inability to establish and maintain effective relationships.”  The Global Assessment of Functioning (GAF) score of 50 for moderate symptoms and or impairment was assigned.

At the 3 November 2008 VA Compensation and Pension (C&P) examination, 6 weeks after separation, the CI reported current treatment with the VA and medication therapy.  He had continued problems with sleep and irritability, and was easily startled, angered or irritated.  He complained of forgetfulness.  At the time of the examination, the CI was still married, but would yell at his kids if they irritated him.  He had a good relationship with an uncle.  He was not working because of his injured ankle and believed that he would also have trouble holding down a job because of his anger.  The examiner stated, “with continued therapy however the overall magnitude of his anger should diminish and he should be able to re-enter the work force.”  An MSE was not recorded.  A GAF score of 60 for mild-moderate symptoms and or impairment was assessed, and the diagnosis of PTSD was recorded.  The CI had not been hospitalized or treated in the ER for MH symptoms.  He had no history of panic attacks or suicidal ideation.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the PTSD 10%, coded 9411 (PTSD), and acknowledged “10A/C” was awarded for PTSD directly related to armed conflict in Iraq.  The VA rated the PTSD at 30%, coded 9411, based on the C&P examination.

The panel agreed the provisions of VASRD §4.129 were applicable in this case for “a mental disorder that develops in service as a result of a highly stressful event.”  Therefore, the panel recommends a minimum 50% rating for a retroactive 6-month period on the Temporary Disability Retired List (TDRL).  The panel next considered if a rating higher than the minimum 50% rating was warranted based on the evidence at constructive TDRL placement.  The panel considered the NARSUM addendum, the commander’s statement and the commander’s soldier evaluation memorandum.  The panel also considered the absence of psychiatric hospitalizations or visits to the ER for MH symptoms; and the absence of clinical evidence of impaired judgment, problems with thinking and suicidal or homicidal ideation.  The PTSD was not implicated in the commander's statement.  The soldier’s evaluation memorandum, prepared by the same commander, noted a normal memory, ability to maintain an acceptable level of attention and concentration to complete tasks in a timely manner, and civil relations with supervisors and other workers.  There was no indication that his MH condition had interfered with duty performance.  The panel agreed the record in evidence did not support a rating higher than 50% at TDRL placement.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 50% for the PTSD condition at TDRL placement.

The panel next considered whether the evidence at TDRL removal supported a rating higher than the 10% adjudicated by the PEB.  The C&P mental examination documented the CI was not working due to his ankle condition.  The CI was married and his anger and irritability was sometimes an issue; however, there was no report of domestic violence and he had no legal history.  He received medication and therapy but indicated he continued to have problems with sleep.  The STR in the months following separation indicated continued report of problems with sleep, anger and concentration; however, he was not treated in the ER or hospitalized for a MH issue.  The 4 December 2008 STR entry recorded the CI’s ability to concentrate and attend during the group session was within normal limits.  He was assessed with good judgment and normal cognitive functioning.  The January 2009 psychiatry note documented that the CI and his wife were expecting their baby “any day now,” and he had to put all of his appointments on hold for that reason.  The CI reported that things were going “very well at this point.”  The CI had no history of panic attacks, objective findings of issues with memory, and no visits to the ER or hospitalizations.  

The panel considered the record in totality, and the panel majority concluded, at the time of separation, the CI’s disability was most reflective of the 10% level for “occupational or social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress.”  After due deliberation, considering the totality of 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% (in accordance with §4.129), and a permanent rating of 10% for PTSD. 

Limitation of Motion of the Left Ankle.  According to the STR and the MEB NARSUM, the CI underwent left ankle arthroscopy with modified Brostrom repair surgery in May 2007.  At the time of the 17 September 2007 physical therapy visit, 4 months post-surgery and 12 months before separation, the CI reported 4/10 pain.  He noted that in the morning he “feels pretty good” and felt about the same through the day but had occasional sharp pain to ankle at night.  On examination, left ankle range of motion (ROM) showed dorsiflexion of 5 degrees (normal 20) and plantar flexion of 45 degrees (normal) with painful motion.  The 28 January 2008 podiatry clinic visit, 8 months before separation, noted the CI was doing well ambulating in an ankle brace and with minimal pain.  The surgical wound was well healed and the ankle was stable on examination. 

During the 26 April 2008 MEB NARSUM examination, 5 months before separation, the CI complained of daily pain in his left ankle, worse with increased activity.  He was unable to run and was not capable of performing physical activity required of his MOS due to having to lift heavy equipment.  Physical examination showed no evidence of an inflammatory process.  There was normal motor strength in all leg compartments and intact sensation.  However, muscle strength was slightly reduced (4+/5) in the left ankle during dorsi and plantar flexion.  The left ankle ROM evaluation recorded dorsiflexion of 5, 8 and 8 degrees with weakness limiting additional motion.  Plantar flexion was 35, 32 and 32 degrees with pain and weakness limiting additional motion.  The right ankle averaged 12 degrees of dorsiflexion on three trials and had normal plantar flexion.

At the 29 October 2008 C&P evaluation, 6 weeks after separation, the CI reported chronic pain, stiffness, weakness and instability in the left ankle, worse with prolonged walking, standing or any type of climbing movements.  He ambulated with a cane for support.  Physical examination showed a well-healed surgical scar with pain over the lateral malleolus, extending into the dorsal aspect of the foot.  There was no instability present, and no bony deformities noted.  The ROM evaluation showed left ankle dorsiflexion of 15 degrees with pain and plantar flexion of 20 degrees also with pain.  Repetitive motion testing revealed increased pain and fatigue over the left ankle; however, there was no decrease in ROM.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left ankle condition 10%, coded 5271 (limitation of motion of the ankle), citing moderate limitation of motion.  The VA rated the left ankle condition 20%, coded 5271, based on the C&P examination, citing “the provisions of the criteria governing functional loss due to pain on use or flare-ups have been considered, and a 20% evaluation is assigned in this case because following repetitive testing you had increased pain and fatigue over the left ankle.”
As noted above, the CI was placed on the constructive TDRL.  Therefore, the panel considered the left ankle rating at the time of constructive TDRL placement.  The panel agreed the ROM examinations proximate to separation were consistent with the “moderate” limitation of motion required for the 10% rating under this code.  A higher rating of 20% was not indicated in the absence of “marked” limited ROM of the ankle.  Because there was no ankylosis, nonunion or malunion, VASRD §4.71a offers no applicable joint code which would yield a rating higher than the 10% adjudicated by the PEB.  At the time of TDRL removal, the CI continued to complain of left ankle pain.  X-rays of the left ankle taken in October 2008 and April 2009 were unremarkable.  Panel members agreed, there was insufficient evidence supporting a rating higher than 10% at the time of separation.  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 left ankle condition at constructive TDRL placement or separation.  

BOARD FINDINGS:  In the matter of the PTSD, the panel majority recommends an initial TDRL rating of 50% in retroactive compliance with VASRD §4.129 as DOD directed; and a 10% permanent rating at 6 months IAW VASRD §4.130.  The single voter for dissent recommends a 30% rating at final disposition, but elected not to submit a minority opinion.  In the matter of the left ankle condition and IAW VASRD §4.71, the panel recommends no change in the PEB adjudication.  There were no other conditions within the panel’s scope of review for consideration.  

The panel recommends the CI’s prior determination be modified as follows, effective as of the date of the prior medical separation:  

CONDITION	VASRD CODE	RATING	
		TDRL	PERMANENT	
PTSD	9411	50%	10%	
Limitation of Motion of the Left Ankle	5271	10%	10%	
COMBINED	60% 	20%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170403, w/attachments
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record

AR20180008928, 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] [Reserve retirement] and then following this six month period no re-characterization of your separation or modification of the permanent disability rating of 20%.  Enclosed is a copy of the Board’s recommendation and record of proceedings for your information.

	The constructive TDRL period 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 no re-characterization of your separation or modification of the permanent disability rating of 20% following the constructive six month TDRL period. 

	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.  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), XXXXXXXXXXXXXXXXXX.

	A copy of this decision has also been provided to the Department of Veterans Affairs 

Sincerely,					      
Enclosure