RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXX	CASE:  PD-2017-04361
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20050515

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E4, Cavalry Scout, medically separated for “posttraumatic stress disorder[PTSD]” with a disability rating of 10%.  ”Chronic pelvic pain” was determined to have existed prior to service (EPTS) and was not rated. 

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 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 - 20050224	VARD - 20050818	
Condition	Code	Rating	Condition	Code	Rating	Exam	
PTSD	9411	10%	PTSD	9411	50%	20050527	
Chronic Pelvic Pain	5299-5236	EPTS	Pelvic Pain Syndrome, Status Post Urethral Stricture	7518	10%	20050629	
Bilateral Retropatellar Pain Syndrome	Not Unfitting 
	Lt Knee Retropatellar Pain Syndrome 	5003	10%	20050629	
		Rt Knee Retropatellar Pain Syndrome 	5003	10%	20050629	
Hypertension	Not Unfitting	Hypertension	7101	0%	20050629	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  70%	

ANALYSIS SUMMARY:  

PTSD.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI reported that trauma symptoms began in September 2003 while in Iraq.  The CI presented to the Behavior Health Department in August 2004 with symptoms of severe PTSD and depression following multiple traumatic events during his Iraq deployment.  He experienced avoidance symptoms, hyper arousal, depressed mood, transient suicidal thoughts, lower energy levels, and an intermittent alcohol consumption.  The 15 December 2004 MEB NARSUM examination, 6 months prior to separation, noted the complaint, “I still lose control sometimes.”  He reported frequent nightmares without Ambien, less when he took it.  Mood was improved though he was still depressed.  He reported occasional suicidal thoughts that he was able to dismiss and that his energy level was lower than normal.  PTSD symptoms persisted with prominent hyper arousal, including anger and hypervigilance; this was exacerbated by his chronic pain.  Mental status examination (MSE) showed the CI was mildly disheveled; mildly to moderately anxious, cooperative, and polite; speech was at a normal rate and amount with an increased volume at times, mood was depressed, and affect was sad.  He reported transient suicidal thoughts but denied he would kill himself.  A diagnosis of PTSD was rendered with a Global Assessment of Functioning (GAF) score of 51 (moderate symptoms, impairment.)  

The same-day psychiatric addendum noted the CI repeated the report, “I still lose control sometimes.”  The February 2005 commander’s statement noted the CI worked as an operations clerk with moderate to frequent contact with other soldiers.  He worked well with authority and others except on stressful days, i.e. when his workload increased or things happened outside of normal routine.  On these days he would be sent home as he often became borderline confrontational and disrespectful.  Work ethic was good, but he seemed to have more bad days than good, so it was hard to keep a constant line of work.  

At the 27 May 2005 VA Compensation and Pension (C&P) PTSD examination, 12 days after separation, the CI reported frequent and severe PTSD symptoms as described above.  He could become irritable, tense, and restlessness, and had nightmares about combat.  The CI reported depression related to physical pain in the genitourinary area.  He was living with his mother and stepfather and got along “great” with them.  He reported that he had friends in the military, that he watched television, and played with pets, but reported severe difficulties with irritability and anger that affected interpersonal relationships.  He reported isolation from everyone except immediate family.  

The MSE showed he was tense and restless with constricted affect and an anxious, depressed mood.  He had moderate sleep impairment and paranoid feelings that people were watching him.  He was rude out in public, he tapped his right foot and moved his right leg frequently, bit his nails, and had panic attacks when nervous.  He reported occasional suicidal thoughts and had fair impulse control with no episodes of violence.  He reported mildly impaired remote, recent and immediate memory.  A diagnosis of PTSD was rendered with a GAF score of 50 (moderate symptoms, impairment).  The examiner agreed that the CI was unable to work and was not employable at the time due to PTSD alone.  At the 29 June 2006 VA C&P examination, one month post-separation, the CI reported loss of control/violence; he became upset, threw a knife at another soldier, choked a soldier into unconsciousness in 2004, and at a store, he struck a person who called him a “baby killer.”   

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the PTSD condition 10%, coded 9411 citing symptoms of PTSD with slight improvement.  The VA rated the PTSD condition 50% based on the C&P examination, citing effects on employment, mood disorders, and sleep difficulties.  Impulse control was a problem.  The panel considered the provisions of VASRD §4.129 (mental disorders due to traumatic stress), and determined that the PTSD condition 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.  
Panel members agreed there was no evidence to support a rating higher than 50% at the time of TDRL placement.

The panel next considered the permanent rating recommendation and considered the 27 May 2005 C&P examination the most proximate source of comprehensive evidence on which to base the permanent rating recommendation.  The CI reported continued PTSD symptoms, particularly irritability and anger, which was affecting relationships.  He was isolated from all except family.  MSE showed anxiety, depression, mild memory loss, moderate sleep impairment, and occasional suicidal thoughts.  The commander had previously noted the CI could work well with authority and with other soldiers but when stressed, he had to be sent home because he became borderline confrontational and disrespectful.  He had more bad days than good days.  These observations were consistent with the CI’s report during the C&P examination that he had problems with irritability and anger.  The examiner noted he was unable to work and was unemployable due to PTSD alone.  Panel members agreed the CI’s condition most closely met the criteria for 30% disability.  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% (in accordance with §4.129), and a permanent rating of 30% for the PTSD condition.

Chronic Pelvic Pain.  According to the STR and MEB NARSUM, the CI’s urinary retention with spontaneous resolution began in the CI’s early teen years.  He experienced a second episode at age 19, one month before coming on active duty where he developed an inability to urinate for 20 hours.  He was seen in the emergency room, but attempts to pass a urinary catheter were unsuccessful due to urethral stricture and the urologist placing a suprapubic catheter releasing 1 ½ liters of urine output.  He was treated with antibiotics.  Urological testing (voiding cysto urethrogram and retrograde urethrogram) showed a normal bladder and urethra.  Over time, the suprapubic catheter was removed and the CI was able to void.  Assessment was a likely bladder over-distention as a cause of his acute urinary retention and a false (failed) passage of a catheter.  He was told he could resume normal activities and the urologist felt there was no problem with the CI coming onto active duty in August 1998 from a urologic standpoint.  

In April 2000, the CI complained of urinating blood for a week and a half (bloody urine one day and a week and a half later he had a return of 3 days of bloody urine and low back pain).  Urinalysis was normal.  Diagnosis was urinary tract infection versus stricture and he was treated with antibiotics.  The next episode of acute urinary retention for 24 hours was in May 2004.  They were unable to place a catheter into the bladder and retrograde urethrogram showed an obstruction at the level of the urogenital diaphragm so the prostatic urethra could not be visualized.  The CI underwent cystoscopy and a direct vision internal urethrotomy.  Diagnosis was acute urinary retention due to recurrent posterior urethral stricture.  Cystoscopy showed a normal urethra up to the bulbar urethra where a pinpoint opening was noted. No significant trauma from the previous catheterization was noted.  He was discharged in good condition. The initial follow-up visit revealed no complaints but in June 2004, the CI began to complain of right scrotal pain without swelling that increased with walking and heavy exercise.  A diagnosis of chronic prostatitis was rendered and he was treated with antibiotics however he continued to have chronic pelvic pain.  In September 2004 a testicular ultrasound showed a very small right hydrocele, but was otherwise normal.  He was diagnosed with chronic pelvic pain syndrome possibly due to chronic epididymitis and treated again with pain medication and antibiotics.  
 
The 8 November 2004 MEB NARSUM examination, 6 months prior to separation, noted complaints of “continuous pain all day and night with pain spasms through the day.  Lifting anything increased the pain and “doing physical activity caused more pain.”  The examiner noted the CI had chronic pelvic pain syndrome with right orchalgia and spasms of pain that radiated from the right testicle into the prostate and bladder.  These symptoms were a postoperative complication from a failed urethral catheter placement and a direct vision internal urethrotomy.  He currently took several medications, including a daily narcotic for pain that was constant, daily, and limited physical activities.  The CI had a post void residual of 147 cc and was treated with daily Flomax due to his elevated post void residual, as well as several pain medications, including a narcotic medication.  Physical examination of the genitals showed the CI was circumcised, testes were bilaterally descended and he was tender on the right worse than the left but there were no masses.  Testes were otherwise normal in all areas.  The examiner opined the CI was unable to perform his duties due to both the pain syndrome and PTSD.  He was unable to perform any aspect of the Army Physical Fitness Test.  The February 2005 commander’s statement noted the CI was able to work as an operations clerk in an office environment and worked well except when stressed.  

At the 29 June 2005 C&P examination, one month post- separation, the CI reported constant pain in the testicle, and pain in the prostate and bladder since his last surgical procedures.  He was treated with antibiotics in October-November for 8 weeks due to epididymitis.  The CI reported daily back pain, frequent pelvic pain, and weekly hematuria and nocturia two times per night.  The CI reported he voided daily every 3-4 hours.  He reported he was kicked in the testicle while detaining prisoners in Iraq in May 2003 and did not have any medical care.  The CI reported he was unemployed since his release from duty in May 2005.  He was currently treated with narcotic (Tylenol 3) and non-narcotic pain medication (Naproxyn).  There was no effect on routine activities of daily living and mild effect on instrumental activities of daily living.  

Physical examination showed tenderness of the testicle and epididymis/spermatic cord/scrotum bilaterally, the prostate and the site of the suprapubic catheterization insertion.  There was normal perineal sensation, normal penis, no abdominal tenderness but very mild tenderness at the site of the temporary suprapubic catheter insertion.  The urethra was normal and there was no sign of infection.  The examiner noted the chronic pelvic pain syndrome was a postoperative complication from a failed urethral catheter placement and requirement for a direct vision internal urethrotomy for a urethral stricture.  It was likely he had a chronic smoldering UTI/epididymitis due to urethral stricture due to the above.  The urology follow-up dated 13 December 2005, noted the CI had no voiding difficulty, and no dysuria or hematuria.  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB determined the chronic pelvic pain was EPTS, and analogously coded 5299-5236 (sacroiliac injury and weakness.)  The VA rated the pelvic pain syndrome condition 10%, coded 7518 (stricture of urethra, rate as voiding dysfunction) based on the C&P examination, citing daytime voiding intervals between 2 or 3 hours, or awakening to void two times per night and also if there is a showing of marked obstructive symptoms.  

Regarding the EPTS determination, the STR documents a reported history of genitourinary problems.  Urology noted there was no problem with the CI entering the service in August 1998 and the military entrance processing system did not document any urological problems or use of associated medications at entry.  There was no evidence he had urinary issues on active duty until April 2000, about 20 months after entry when he presented for the first time with hematuria.  There were no further symptoms until May 2004, when he presented with urinary retention.  Without symptoms or medications at entry, a urinary condition would have been rated 0%.  Additionally, there was no evidence of a chronic pain syndrome historically.  Both the NARSUM and the C&P examinations noted pelvic pain syndrome was a complication of a second urology surgery, rather than a natural progression of a urological condition.  In addition, service aggravation should be considered.  Therefore, the panel concluded the EPTS assignment should be disallowed.  

Based on the diagnosis of PTSD and the §4.129 constructional TDRL requirements outlined above, the panel must determine a rating recommendation for the chronic pelvic pain at TDRL placement and removal.  The NARSUM examination noted an elevated voiding residual of 147 cc but a residual of 150 cc is required for a 10% rating under the 7518 code.  The commander’s statement noted the CI was able to work at a sedentary job while on medical hold.  Therefore, the panel agreed that a 0% rating, but no higher, was justified prior to constructive TDRL placement under the 5299-5236 code.  

The panel then determined the rating recommendation for the pelvic pain at TDRL removal assigned at the 6 months TDRL interval.  The panel determined the most proximate source of comprehensive evidence, to evaluate the CI at TDRL removal, was the December 2005 urology outpatient examination.  At that time there was no evidence of voiding difficulty.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends the chronic pelvic pain be rated 0% at TDRL placement and the same as a permanent disability rating after removal from TDRL. 

Contended PEB Conditions:  Bilateral Retropatellar Pain Syndrome and Hypertension.  Neither of the conditions were profiled or implicated in the commander’s statement, and they did not fail retention standards.  There was no performance-based evidence from the record that either of 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 either of the contended conditions, so no additional disability ratings are recommended.  

BOARD FINDINGS:  In the matter of the post-traumatic stress disorder, the panel recommends an initial TDRL rating of 50%, coded 9411 in retroactive compliance with VASRD §4.129 as DoD directed; and a 30% permanent rating at 6 months IAW VASRD §4.130.  In the matter of the chronic pelvic pain, the panel recommends an initial TDRL rating of 0%, coded in retroactive compliance with VASRD §4.129 as DoD directed; and a 0% permanent rating at 6 months IAW VASRD §4.71.  In the matter of the contended bilateral retropatellar pain syndrome and hypertension, the panel recommends no change from the PEB determination 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	
Post-Traumatic Stress Disorder	9411	50%	30%	
Chronic Pelvic Pain Syndrome	5299-5236	0%	0%	
COMBINED	30%	

The following documentary evidence was considered:

AR20200002318

DearXXXXXXXXXXXXXXXXX:

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 50% disability for six months effective the date of your original medical separation for disability with severance pay and then following this six month period recharacterize your separation as a permanent disability retirement with the combined disability rating of 30%.  Enclosed is a copy of the Board’s recommendation and record of proceedings for your information.

	The constructive TDRL period and the recharacterization of your separation as a disability retirement will result in an adjustment to your pay providing you 50% retired pay for six months from the date of your original medical separation and then 30% 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).

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