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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 60% 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.

RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXX	CASE:  PD-2017-03393
BRANCH OF SERVICE:  Army	SEPARATION DATE:  20051013

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was a Reserve 03, Ordnance Officer, medically separated for “right shoulder instability [and] right knee medial compartment degenerative joint disease” with a disability rating of 10%.  Major depressive disorder (MDD) was determined to have existed prior to service (EPTS) and was not rated.  

CI CONTENTION:  “The military broke not just my body but my mind and spirit as well.  I believed that my mind, body, and spirit deserves more.”  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 - 20050630	VARD - 20060915	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Right Shoulder Instability and Right Knee Medial Compartment Degenerative Changes	5003	10%	Right Shoulder Hill-Sachs Lesion and Old Bankart Lesion	5203	0%	20051212	
			Right Knee Medial Meniscus Tear	5010	10	20051212	
Major Depressive Disorder	9434	EPTS	Major Depressive Disorder	9434	100%	20060601	
Patellofemoral DJD	Not Unfitting	Captured in the Rating for the Right Knee Condition Above	
Low Back Pain	Not Unfitting		
Bilateral Shin Splints	Not Unfitting	No VA Placement	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  100%	

ANALYSIS SUMMARY:  

Right Shoulder Instability and Right Knee Medial Compartment Degenerative Joint Disease (DJD).  The PEB combined the right shoulder and right knee conditions under a single disability rating, coded 5003 (degenerative arthritis) and rated 10%.  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 noted that “bundling,” the combining of two or more major joints, may be permissible under the VASRD 5003 rating requirements, and that this approach does not compromise the VASRD §4.7 directive to choose the higher of two valid ratings.  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 right shoulder and right knee conditions were separately profiled, adjudged to fail retention standards and implicated in the commander’s statement.  The panel concluded there was not a preponderance of evidence in the service records which overcame the panel’s presumption that each of the bundled conditions was reasonably considered separately unfitting.  The panel then considered its rating recommendation for the unfitting conditions at the time of separation.  The evidence for the right shoulder and right knee conditions are presented separately, with attendant recommendations regarding separate ratings if indicated.  

Right Shoulder Instability.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI sustained a right shoulder dislocation while navigating an obstacle course in 2003.  The shoulder was reduced with the help of field medics, and since then, she had several episodes of subluxation.  MRI arthrogram showed Hill-Sachs lesion with associated rounding and irregularity of the inferior labrum consistent with an old Bankart lesion and cartilage injury.  She had physical therapy (PT) for shoulder strengthening which improved her symptoms, but she remained unable to do pull-ups.  

During the 2 February 2005 MEB examination (recorded on DD Forms 2807-1 and 2808), 8 months prior to separation, the CI reported right shoulder pain and instability.  Physical examination revealed decreased right shoulder range of motion (ROM) with pain.  At the 14 February 2005 PT examination, the CI noted no recent subluxations or shoulder pain.  Right shoulder ROM was normal with minor pain and slight weakness (4+/5).  There was a positive O’Brien’s (test for labral tears) with 5/10 shoulder joint pain.  

The 11 March 2005 MEB NARSUM examination, 7 months prior to separation, noted complaints of right shoulder pain.  Physical examination of the right shoulder showed ROM with forward flexion of 180 degrees (normal) and abduction of 180 degrees (normal).  There was a positive apprehension relocation test with negative sulcus signs (instability).  The diagnosis was right shoulder mild instability.  The PT examination on 17 March 2005 revealed normal right shoulder ROM without pain.  

At the 12 December 2005 VA Compensation and Pension (C&P) examination, 2 months after separation, the CI reported 7/10 right shoulder pain occurring twice a month when reaching back.  Physical examination showed full ROM with flexion and abduction to 180 degrees, and no weakness.  There was no additional limitation on repetitive use due to pain, fatigue, weakness or lack of endurance.  

The panel directed attention to its rating recommendation based on the above evidence.  As noted above, the PEB rated the bundled shoulder and knee condition 10%, analogously coded 5003 citing “DJD without loss of motion, two or more major joints, without incapacitating episodes.”  The VA rated the right shoulder condition 0%, coded 5203 (clavicle or scapula, impairment of), based on the C&P examination, citing full ROM without additional limitations on repetitive use, episodic pain and diagnosed right shoulder Hill-Sachs lesion and old Bankart lesion (tears).  

There was no limitation of motion of the shoulder to support a rating under diagnostic code 5201 (arm, limitation of motion of).  The MEB and C&P examinations did not show swelling, muscle spasm, satisfactory evidence of painful motion or other evidence of functional loss to support a 10% rating IAW VASRD §4.59, §4.40 or §4.45.  There was no deformity or guarding of shoulder movement for rating under code 5202, and insufficient evidence of nonunion or malunion of the clavicle or scapula to warrant a 10% rating under code 5203.  Therefore, the panel agreed the findings of historical subluxations and positive apprehension test were closer to a 0% rating IAW VASRD §4.31.    

Right Knee Medial Compartment DJD.  According to the STR and MEB NARSUM, the CI’s knee condition began in 2001 after a road march with a heavy ruck sack.  She underwent a knee arthroscopy with debridement of her medial meniscus.  The 11 March 2005 MEB NARSUM examination, 7 months prior to separation, noted complaints of right knee pain.  History indicated dramatic improvement of the knee following meniscal surgery.  Physical examination of the right knee showed a positive 1A Lachman’s (slight laxity) and there was mild medial joint line tenderness.  Right knee ROM testing showed 0-135 degrees of extension-to-flexion (normal 0-140).  At the 12 December 2005 C&P examination, 2 months after separation, the CI reported right knee pain.  Physical examination showed a normal gait and right knee ROM was from 0-140 degrees.  There was no limitation of motion on repetitive use due to pain, fatigue, weakness or lack of endurance.  

The panel directed attention to its rating recommendation based on the above evidence.  As noted above, the PEB rated the bundled shoulder and knee conditions 10%, analogously coded 5003 citing “DJD without loss of motion, two or more major joints, without incapacitating episodes.”  The VA rated the right knee condition, bundled with a low back condition, at 10%, coded 5010 (post-traumatic arthritis), based on the C&P examination, citing X-ray evidence of DJD of multiple joints with no limited or painful motion.  

There was no limitation of flexion or extension that supported a rating under the VASRD diagnostic codes for limitation of motion (5260 or 5261).  There was no history or evidence of dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258) to support a rating under that code.  There was no fracture, nonunion or malunion of the femur or tibia to support consideration under the respective codes for knee impairment related to long bone conditions (5255, 5262).  The analogous use of code 5259 (cartilage, semilunar, removal of, symptomatic) was potentially applicable in this case, and the panel deliberated if the CI’s disability picture more nearly approximated the 0% rating IAW VASRD §4.31 or a 10% rating.  In considering the final rating recommendation in the matter of the separated right shoulder and right knee conditions, the panel adjudged that there was insufficient evidence that both conditions were ratable individually at the 10% level, and separate ratings of 0% and 10% would be of no benefit to the CI compared to the combined 10% adjudicated by the PEB.  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 combined shoulder and knee condition.  

Major Depressive Disorder.  According to the STR and MEB NARSUM, the CI developed symptoms of depressed mood while in college with sleep disturbance and suicidal ideations in 1997.  The symptoms were accompanied by declining school performance and she needed additional time to complete her college degree.  She never received any form of treatment and after college graduation, joined the Army.  The 24 April 2001 enlistment examination and history (recorded on DD Forms 2807-1 and 2808), was negative for any mental health history or complaints.  Physical examination revealed a normal examination.  

In June 2004 the CI was referred for psychiatric testing to assist in a differential diagnosis of MDD versus adjustment disorder with depressed mood, versus borderline personality disorder.  Multi-day testing and evaluation in June 2004 led to assignment of both dysthymic disorder and recurrent major depression to reflect both her long term maladaptive tendency toward low mood and negative affect and her depressive episode, during which a marked decline in mood and functioning occurred.  

The 22 March 2005 MEB mental health (MH) NARSUM, 7 months prior to separation, indicated the CI first presented for care in October 2003 while stationed in Korea and had a brief voluntarily hospitalization for suicidal ideation.  There was no history of traumatic stress which may have caused her symptoms.  Symptoms worsened after starting Prozac, and the CI was subsequently hospitalized for three weeks and medically evacuated to CONUS for another week of hospitalization followed by two weeks of day treatment.  Upon reporting to her new assignment in Hawaii, the CI became depressed and was hospitalized for nine days.  Medication of Effexor was increased, however the CI was still having difficulty tolerating even minimal stress and responsibilities and was transferred to Medical Hold.  The mental status examination (MSE) was notable for a “nervous” mood with a slightly anxious and sad affect.  Judgement was felt to be poor by history and insight was deemed as fair.  There was no active suicidal or homicidal ideations, delusional or hallucinatory symptoms, speech disturbance, objective cognitive impairment or other symptoms suggestive of psychosis.  The diagnoses were dysthymic disorder and MDD, recurrent, moderate without psychotic features, with moderate to severe social/industrial impairment.  The global assessment of functioning (GAF) was 55 (in the moderate symptoms range of 60 - 51).  Present condition indicated that the CI was engaged in weekly psychotherapy and receiving medical management (daily Effexor, plus Risperdal as needed for anger or agitation).  The therapist reported the CI had little ability to tolerate even minimal work stress and essentially had no duties in the Medical Hold Company.  The CI had periodic emotional storms, sometimes associated with suicidal ideation, but had not required subsequent re-hospitalization.  

At the 1 June 2006 C&P examination, 8 months after separation, the CI reported negative thoughts and ruminations with symptoms of depression.  History was detailed and substantively similar to the NARSUM history.  The CI had a close, but guilt-ridden relationship with her husband, but reported having no friendships.  She stayed home most of the day, had intense doubts, was becoming immobilized by negative thoughts, had poor sleep and felt like a failure.  The MSE was notable for speech that was low in volume and a little slow, a mood that was severely depressed; a somewhat blunted affect, with crying and evident anxiety; negative ruminative thoughts; poor judgement and partial insight; there were no memory deficits, active suicidal ideation, delusional or hallucinatory symptoms, or other symptoms suggestive of psychosis.  Sleep impairment was adjudged as severe.  The diagnoses were recurrent MDD, dysthymia and personality disorder, NOS, with avoidant features.  The GAF was 45, indicative of severe symptoms and impairment.  The examiner opined that: “A chronic low-level depression appears to have been present at least since she was a freshman in college that was exacerbated to full major depressive episodes on at least 2 occasions if not more while she was in the military.”  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB did not rate the MH disorder, analogously coded 9434 (MDD), citing EPTS following a course of natural progression without permanent service aggravation.  The VA rated the MH disorder 100%, analogously coded 9434, based on the C&P examination, citing evidence of total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place and memory loss for names of close relatives, own occupation or own name.  

The panel’s first charge was an assessment of the fairness of the PEB’s determination the condition EPTS without permanent service aggravation.  The panel’s recommendation in that regard was premised on (and the PEB’s decision subject to) DoDI 1332.38 which is excerpted below.  
[E3.P4.5.2.3. Presumption of Aggravation] The presumption that a disease is incurred or aggravated in the line of duty may only be overcome by competent medical evidence establishing by a preponderance of evidence that the disease was clearly neither incurred nor aggravated while serving on active duty or authorized training.  Such medical evidence must be based upon well-established medical principles [E2.2.1 - Fundamental deductions consistent with medical facts that are so reasonable and logical as to create a virtual certainty that they are correct.], as distinguished from personal medical opinion alone.  Preponderance of evidence is defined as that degree of proof necessary to fully satisfy the board members that there is greater than a 50% probability that the disease was neither incurred during nor aggravated by military service.  
The panel considered there was no MH diagnosis prior to service entry, and the CI successfully earned a college degree and completed basic training and OCS without any MH diagnoses.  The STR was extremely scant and did not include any inpatient records or summaries; however, the June 2004 consultation led to the CI’s final diagnoses and indicated uncertainty in diagnosis prior to that timeframe.  The NARSUM examiner indicated the MDD EPTS with permanent service aggravation and the VA examiner indicate likely EPTS for dysthymia or personality disorder, but exacerbated to full major depressive episodes in the military.  After deliberation and consideration of the various issues raised above, members ultimately agreed that the above standards of DoDI 1332.38 were not satisfied in support of the PEB’s opinion that the natural course of the CI’s MH disorder was unaffected by events linked to the CI’s military service.  

The panel first addressed if the provisions of VASRD of §4.129 (mental disorders due to traumatic stress) were applicable.  The panel determined that the MDD was not due to a “highly stressful event” as used in the VASRD.  The panel agreed that the preponderance of evidence did not support the application of §4.129.  The panel next considered the §4.130 rating at the time of separation and the disparate medical evaluations in evidence.  The panel adjudged that the NARSUM evaluation had the highest probative value for rating at separation and the VA examination likely represented post-separation worsening.  

All members agreed that the §4.130 threshold for a 100% rating was not approached and that the criteria for a 30% rating were well‐exceeded.  The deliberation therefore settled on consideration of a 50% versus a 70% rating recommendation.  Regarding the 70% criteria for “occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood;” there were deficiencies in work and mood.  However, judgement was poor by history only, there was no deficit in thinking and the CI had a fiancé.  The panel adjudged the disability at separation most closely approximated social and occupational impairment consistent with a 50% evaluation “occupational and social impairment with reduced reliability and productivity.”  The lack of any MH diagnosis or therapy at service entry, and successful completion of OCS would support no higher than a 0% rating at service entry for any EPTS deduction.  After due deliberation, considering all the evidence and mindful of VASRD §4.3, the panel recommends a disability rating of 50% for the MH disorder, coded 9434.  

Contended PEB Conditions:  Patellofemoral DJD, Low back Pain and Bilateral Shin Splints.  The panel’s main charge is to assess the fairness of the PEB determination that the contended conditions were not unfitting.  Although all of the conditions were profiled, none were implicated in the commander’s statement or judged to fail retention standards.  The patellofemoral DJD was not separable from the unfitting right knee condition above and was subsumed in the rating of the right knee.  There was no performance-based evidence from the record that any of the contended 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 any of the contended conditions, so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the combined right shoulder and right knee condition, the panel recommends no change in the PEB adjudication.  In the matter of the contended low back pain and bilateral shin splints, the panel recommends no change from the PEB determination as not unfitting.  In the matter of the contended MH disorder, the panel recommends a disability rating of 50%, coded 9434 IAW VASRD §4.130.  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	
Right Shoulder Instability and Right Knee Medial Compartment Degenerative Joint Disease	5003	10%	
Major Depressive Disorder  	9434	50%	
COMBINED	60%