RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-04479
BRANCH OF SERVICE:  Air Force 	SEPARATION DATE:  20080104

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was an active duty E5, Security Forces Craftsman, medically separated for “chronic left ankle pain” and “major depressive disorder [MDD],” rated 10% each, with a combined disability rating of 20%.  

CI CONTENTION:  “Please 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 - 20071119	VARD - 20080507	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chronic Left Ankle Pain	5262	10%	S/P Left Ankle Arthrodesis with Bone Graft	5262	10%	20080321	
MDD	9434	10%	MDD	9434	50%	STR	
COMBINED RATING:  20%	COMBINED RATING OF ALL VA CONDITIONS:  60%	

ANALYSIS SUMMARY:  

Chronic Left Ankle Pain.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI underwent left ankle surgery in March 2005.  Postoperatively, she experienced pain when running or performing impact activities involving her left lower extremity.  
During the 14 December 2006 MEB NARSUM examination, 13 months prior to separation, the CI’s chief complaint remained as “chronic left ankle pain.”  Her physical examination (PE) revealed tenderness about the left ankle and atrophy of the lower left leg.  Additionally, although not quantified, there was altered sensation (paresthesia) over the distribution of both the left sural and superficial peroneal nerves.  

At the 21 March 2008 VA Compensation and Pension (C&P) examination, 2 months after separation, the CI reported constant 7/10 left ankle pain relieved by rest and over the counter medication (Tylenol).  Additionally, she endorsed left ankle weakness, swelling and lack of endurance, all worsened with activity.  She denied having stiffness, heat, give way, locking, fatigability or frequent dislocations.  The PE of the left lower extremity and ankle revealed the presence of the expected surgical scars.  Left ankle range of motion (ROM) and gait were normal.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left ankle condition 10%, coded 5262 (tibia and fibula impairment of).  Utilizing the same code, the VA also rated the left ankle condition 10%, based on the C&P examination, citing “slight” ankle disability.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel agreed the VA examination, being closest to separation, held more probative value than the NARSUM examination.  Evidence of 7/10 painful symptoms being relieved by rest and over the counter medication (Tylenol) lent sufficient support for no greater than “slight” impairment with the maximum of a 10% rating under code 5262 as set by the PEB.  Therefore, there was insufficient cause to recommend a change in the PEB’s adjudication for the left ankle condition.  

Major Depressive Disorder.  According to the STR and MEB NARSUM, the CI was first referred to mental health (MH) in August 2006 as part of an MEB evaluation that was related to a chronic pain condition.  Throughout 2007, the CI’s diagnosis was revised from post-partum depression to major depression, recurrent and moderate.  A psychology clinical encounter dated 4 September 2007, (4 months prior to separation) specifically noted that the CI’s primary stressor was related to the MEB process and her newborn baby.  Additionally, the encounter documented a normal mental status examination (MSE) without suicide or homicide ideation, intent or plan.  The CI was not taking any medication.  

The 14 December 2006 MEB NARSUM psychiatric addendum, 1 month prior to separation, noted complaints of “continuous low-grade depression between exacerbation with isolating and social anxiety, with no suicide ideation, intent or plan.”  Although there was no documented MSE at this encounter, her MDD diagnosis was coupled with a “marked” impairment assessment for military service and “definite” impairment assessment for civilian social and industrial adaptability.  Other clinical documentation during 2007 indicated that the CI’s depressive symptoms were exacerbated due to single parent stress and severe job dissatisfaction.  Her symptoms included fatigue, overeating/binging, psychomotor retardation, guilt, anhedonia (loss of pleasure), insomnia and fatigue.  She denied suicide ideation, intent or plans.  The commander’s letter specifically noted that the CI’s MH condition did “not affect her duty requirements and she [could] work full shifts.”  

The panel directed attention to its rating recommendation based on the above evidence.  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 MH conditions).  The VA utilized the STR to evaluate and rate the CI’s mental health diagnosis.  Both the PEB and VA applied the clinically appropriate code of 9434 (MDD) and arrived at different ratings (10% and 50% respectively) under VASRD §4.130.  The PEB cited the CI’s social and industrial adaptability impairment as “mild” for its rating level; whereas, the VA cited a mental condition being severe enough to be discharged from active military service for its 50% rating. 

Panel members first considered if the definition of VASRD §4.129 was met (a mental disorder that develops in service as a result of a highly stressful event).  All panel members agreed the requisite §4.129 link that the condition occurred “as a result of a highly stressful event” was not adequately satisfied.  The panel therefore, will consider only the VASRD §4.130 impairment present at or near separation for a single rating recommendation.  Members considered if there was evidence for a §4.130 rating higher than the PEB’s current 10%.  The NARSUM addendum indicated the CI was not on medication; and, thus that particular criterion in the 10% rating level was not applicable and the rating must be based upon the degree of occupational and social impairment.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel concluded that the psychology encounter at 4 months prior to separation held the greatest probative value due to a documented MSE which was absent from the “reviewed” NARSUM one month later.  Such findings of a normal MSE coupled with the absence of medications would not support any rating higher than that of the PEB’s current 10%.  Therefore, there was insufficient cause to recommend a change in the PEB’s adjudication for MDD.

BOARD FINDINGS:  In the matter of the left ankle condition and IAW VASRD §4.71a, the panel recommends no change in the PEB adjudication.  In the matter of the MDD and IAW VASRD §4.130, 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 20170526, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Record 

SAF/MRB
1500 West Perimeter Road, Suite 3700
Joint Base Andrews, MD 20762

XXXXXXXXXXXXXXXXXX

Dear XXXXXXXXXXXXXXXXXX:

		Reference your application submitted under the provisions of DoDI 6040.44 (Section 1554, 10 USC), PDBR Case Number PD-2017-04479.

After careful consideration of your application and treatment records, the Physical Disability Board of Review determined that the rating assigned at the time of final disposition of your disability evaluation system processing was appropriate.  Accordingly, the Board recommended no re-characterization or modification of your separation.

I have carefully reviewed the evidence of record and the recommendation of the Board.  I concur with that finding and their conclusion that re-characterization of your separation is not warranted.  Accordingly, I accept their recommendation that your application be denied.

						Sincerely,

		

Attachment:
Record of Proceedings