RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-04118
BRANCH OF SERVICE:  army 	SEPARATION DATE:  20080711

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Military Police, medically separated for “bipolar disorder, type II” and “left knee pain,” each rated 10%, with a combined disability rating of 20%.  

CI CONTENTION:  “Review all 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 - 20080408	VARD - 20090108	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Bipolar Disorder, Type II	9432	10%	PTSD with Major Depressive Disorder and a History of Bipolar Disorder 	9432-9434	50%	20081014	
Attention Deficit Hyperactivity Disorder (ADHD)	Not Unfitting					
Left Knee Pain	5020	10%	Left Knee Medial Meniscal Tear 	5024-5260	10%	20081014	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

Bipolar Disorder, Type II.  According to the service treatment record (STR), MEB narrative summary (NARSUM) and addendum, the CI self-referred to mental health (MH) in June 2007 with symptoms of mood swings, racing thoughts, irritability, anger, insomnia, racing heart and anxiety.  She was diagnosed with bipolar disorder (provisional) and prescribed mood stabilizer and antidepressant medication.  At the time of the onset of symptoms, the CI had concerns about a deployment since she had problems with her knee and other ongoing issues.  The CI had no history of psychiatric hospitalization and her symptoms did not require emergency room (ER) intervention.  The STR indicated that the CI was prescribed five monthly refills of her mood stabilizing medication on 5 March 2008.  There was no evidence of MH treatment beyond the March 2008 visit.

The 21 March 2008 MEB addendum, 4 months prior to separation, noted complaints of impaired focus, irritability and problems concentrating.  There was no current report of elevated or depressed mood, sleep issues, mood swings, panic attacks, suicide or homicidal ideation, paranoia or grandiosity.  The CI did not endorse any symptoms of PTSD.  The CI was taking a mood stabilizer and a medication to treat symptoms of ADHD.  The examiner noted the CI had a history of medication non-compliance but had recently been compliant.  Mental status examination (MSE) was unremarkable.  There was no evidence of psychosis or thought disorder, and cognitive function and judgment were intact.  The diagnoses of bipolar disorder, type II, and ADHD, impulsive type were assessed, with a global assessment of functioning (GAF) score of 71-80 (slight or transient impairment).  The examiner opined that the CI’s capacity to return to full time duty within the next 12 months was good dependent on her compliance with treatment.  

The CI noted in a letter that she attended college in 2008 and graduated in 2009 as a registered nurse.  The January 2009 VA rating decision noted the CI underwent a VA Compensation and Pension (C&P) mental evaluation on 14 October 2008, during which, the CI complained of depressed mood, irritability, sleep difficulty, social isolation, anger outbursts and specific suicidal intent.  The CI denied being traumatized during her deployment to Afghanistan.  The MSE noted a history of sad and anxious mood, but was otherwise unremarkable.  The examiner diagnosed major depressive disorder, single episode and PTSD. 

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the MH disorder 10%, coded 9432 (bipolar disorder), citing occupational and social impairment due to mild or transient symptoms controlled by continuous medication.  The VA initially rated the MH disorder 50%, dual coded 9432-9434 (bipolar and major depressive disorder), effective 12 July 2008.  However, effective 14 October 2008, the MH disorder was rated 30%, dual coded 9432-9411 (major depressive disorder and PTSD), based on the C&P examination 3 months after separation.

Although the comorbid contended condition of ADHD may have existed prior to service or was found to be not unfitting by the PEB, the VASRD §4.130 rating is based on the CI’s overall MH status regardless of the number of independent MH diagnoses.  Therefore, IAW VASRD §4.14 the symptoms from the ADHD are properly subsumed under the rating for the bipolar disorder to avoid pyramiding.

Panel members agreed that the provision of VASRD §4.129 was not applicable in this case because there was no documentation of a highly stressful event.  The panel next proceeded with the rating recommendation.  There was an absence of ER treatment, hospitalization or evidence of any MH treatment after separation.  The MEB examiner indicated the CI’s symptoms were mild and responsive to medication, and impairment from her symptoms was slight or transient.  Her GAF score was in the slight-impairment range.  The MSE noted the CI was pleasant and cooperative, without symptoms of bipolar disorder.  The VA rating decision noted the CI’s MSE during the October 2008 examination, 3 months after separation, was unremarkable without any evidence of memory issues or symptoms of bipolar disorder.  There was no mention of treatment, and the examiner reportedly stated that the CI was capable of working on a full-time basis from a MH point of view.  The CI reported in a letter that she had completed a registered nursing program within a year.  There were no associated report of difficulty with school.  The commander’s statement noted that the CI was not physically capable of performing her military duties, but there was no mention of MH symptoms interfering with duty performance.  Therefore, based on the totality of evidence, panel members agreed the 10% PEB rating was justified for occupational and social impairment due to mild or transient symptoms controlled by continuous medication.  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 MH disorder.

Left Knee Pain.  According to the STR and MEB NARSUM, the CI underwent left knee surgery in March 2007 for lateral meniscus tear and mass of anterior knee.  Post-surgery, the CI continued to report knee pain and give way.  Post-surgical X-rays were normal and there was no significant soft tissue abnormalities.  The CI was assessed with patellar tendonitis.  An orthopedic clinic visit on 8 August 2007 showed normal left knee range of motion (ROM) without instability or tenderness on ambulation.

The 21 February 2008 MEB NARSUM examination, 5 months prior to separation, noted continued complaints of knee pain with increased activity.  The CI was unable to pass certain portions of the physical fitness test or continue activities in her MOS without significant knee pain.  Physical examination showed full ROM, but there was tenderness over the anterior and distal patella and joint line tenderness medially and laterally.  The knee was ligamentously stable.

At the 14 October 2008 VA Compensation and Pension (C&P) evaluation, 3 months after separation, the CI reported constant knee pain that traveled throughout the knee.  Physical examination showed tenderness, but she had a normal gait and there were no signs of edema, effusion, weakness or subluxation.  ROM was flexion of 140 degrees (normal) and extension of 0 degrees (normal).  There was no evidence of knee instability.  Joint function was not additionally limited by weakness, lack of endurance or pain after repetitive use.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left knee condition 10%, coded 5020 (synovitis), citing functional loss due to factors such as pain on repeated use and painful motion.  The VA rated the left knee condition 10%, analogously coded 5024-5260 (tenosynovitis causing limitation of flexion), based on the C&P examination, citing painful and limited 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).  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).  However, there was evidence of surgery to remove a meniscus (5259) and painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45).  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 knee condition.  

BOARD FINDINGS:  In the matter of the MH disorder and IAW VASRD §4.130, the panel recommends no change in the PEB adjudication.  In the matter of the left knee condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  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.

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20170419, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record  

AR20180006254, 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