RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-04492
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20070728

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects this covered individual (CI) was a Reserve E5, Infantryman, medically separated for “PTSD” and “left knee degenerative arthritis,” rated 10% and 0%, respectively, with a combined disability rating of 10%. 

CI CONTENTION:  No specific contention was made.  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 - 20070515	VARD - 20080305	
Condition	Code	Rating	Condition	Code	Rating	Exam	
PTSD	9411	10%	PTSD	9411	0%	STR	
Left Knee Degenerative Arthritis	5003	0%	Left Knee, Early Degenerative Changes	5260	10%	20070925	
COMBINED RATING:  10%	COMBINED RATING OF ALL VA CONDITIONS:  20%	

ANALYSIS SUMMARY:  

PTSD.  According to the service treatment record (STR) and MEB narrative summary (NARSUM), the CI’s mental health (MH) disorder began during deployment to Iraq from 2005-2006 after several combat exposures.  The 1 February 2007 MEB psychiatric addendum, 6 months prior to separation, noted complaints of nightmares, hypervigilance, increased anger, and ruminations about events in Iraq.  He was visibly upset when describing a recurring flashback of a small child being hit by a mortar round and trying to collect her remains as he saw her family crying.  Loud noises triggered memories of Iraq, and he had homicidal thoughts but no plan or intent.  He was attending individual therapy and took medications for sleep. The mental status examination showed a depressed affect with mood described as “not good, not better,” and no suicidal ideation.  Diagnoses of PTSD, major depressive disorder, and insomnia were rendered with a Global Assessment of Functioning (GAF) score of 40 (major impairment in several areas).  

At the 1 April 2008 VA Compensation and Pension (C&P) examination, 8 months after separation, the CI reported symptoms of PTSD, including severe sleep impairment exacerbated by shift work, but no panic attacks.  He worked full-time in security, had married the previous year, and lived with his wife and several family members.  A doctor had prescribed anti-depression medication and he was waiting for it in the mail.  Physical examination showed blunted affect, depressed mood, and suicidal ideation without a plan.  A diagnosis of PTSD was rendered with a GAF score of 60 (moderate bordering on mild symptoms, impairment).  

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the PTSD 10%, coded 9411 (PTSD), citing mild industrial impairment.  The VA rated the PTSD 0%, coded 9411, based on the STR, citing failure to report for an MH examination on 30 October 2007.  The panel considered the provisions of VASRD §4.129 (mental disorders due to traumatic stress), and determined that the PTSD 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.  

The panel turned to its rating recommendation at the time of TDRL placement, and agreed the §4.130 criteria for a rating higher than 50% were not met; and, therefore the minimum 50% TDRL rating prescribed by §4.129 is applicable.  Panel members agreed that the most proximate source of comprehensive evidence on which to base the permanent rating was the C&P examination.  The §4.130 criteria for a 10% rating is “symptoms controlled by continuous medication,” and a 30% stipulates “occupational and social impairment with occasional decrease in work efficiency and intermittent inability to perform occupational tasks.”  Although the CI reported continued symptoms, he was working full-time and lived with his wife and family.   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% IAW with §4.129, and a permanent rating of 10% for the PTSD, coded 9411. 

Left Knee Degenerative Arthritis.  According to the STR and MEB NARSUM, the CI suffered a left knee inversion injury in November 2005 while running, and developed persistent medial and posterior knee pain and an anterior knee effusion.  He completed deployment on a no-running profile, and imaging in January 2006 indicated complete disruption of the anterior and poster cruciate and medial collateral ligaments.  There was also evidence of a partial tear of the lateral collateral ligament, complex tear of the lateral meniscus, and swelling around the popliteal tendon and muscle belly.  He underwent arthroscopic repair and reconstruction, but the pain worsened, and he continued to have medial sided knee pain and instability.  A left knee MRI on 1 December 2006 showed post-surgical changes within the medical collateral ligament and articular cartilage loss involving the femoral condyle and patella, but no medial meniscus tear.  

At the 21 December 2006 MEB examination (recorded on DD Forms 2807-1 and 2808), 7 months prior to separation, the CI reported chronic ligament pain.  The examiner documented medial and collateral ligament tenderness, swelling, and pain elicited with valgus stress.  Left knee flexion was to 110 degrees (normal 140) and extension to 0 degrees (normal), limited by pain. The 11 January 2007 MEB orthopedic consultation noted the CI had recurrent effusions postoperatively, and that he had some pain relief after a steroid injection and when using his brace.  Physical examination revealed effusion, “good” ROM, findings consistent with anterior cruciate ligament (ACL) deficiency, pain with patellofemoral motion, and tenderness along the medial and lateral compartments.  The provider diagnosed left knee pain and instability status post ACL reconstruction with arthritic changes and recommended a more stable “ACL-style” brace for wear with activities.  

The 31 January 2007 MEB NARSUM examination, 6 months prior to separation, noted CI complaints of left anterior knee pain that lasted all day and was exacerbated by walking more than one mile, and sitting or standing more than 5 hours.  He had some instability and giving way going up stairs but no falls, and he denied locking.  Although he had some fatigue with exercise or walking, he was able to work and perform activities of daily living even when pain was severe.  He reported weakness and stiffness in the morning and evening with some swelling, and awoke from knee pain twice a night.  His pain was relieved by wearing his knee brace (not worn during the examination) and he did not take pain medications.  Physical examination showed a normal gait and tenderness of the medial and lateral aspect of left knee at the joint line.  There was a slight left drawer (Grade I Lachman) sign and slight medial laxity with pain.  Goniometrically measured ROM showed flexion to 110 degrees and extension to 0 degrees (normal), with endpoint pain.  The 29 June 2007 orthopedics memo to the PEB noted bilateral knee ROM of 0-120 degrees with pain at extreme limits of left knee motion.  

At the 25 September 2007 VA C&P examination, 2 months after separation, the CI reported intermittent left knee pain rated at 4/10, and that could walk 2 miles with the brace and 1 mile without it.  His knee occasionally locked in the morning, but did not give way, and he denied flares.  Bending and stooping caused pain, and he was unemployed.  Physical examination showed left knee flexion to 80 degrees, with pain, and extension to 0 degrees.  There was pain with three repetitions and he was unable to toe walk.  Lachman, drawer and McMurray testing was negative.  Left knee X-rays in October 2007 noted hardware in place with early degenerative changes and medial joint space narrowing and spurs.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left knee condition 0%, coded 5003 (degenerative arthritis), citing degenerative arthritis without mechanical loss of motion.  The VA rated the left knee condition 10%, coded 5260 (limitation of leg flexion), based on the C&P examination, citing objective evidence of degenerative changes.  Based on the PTSD and §4.129 constructional TDRL requirements outlined above, the panel must determine a rating recommendation for the left knee condition at TDRL placement and removal.  There was no report or evidence of dislocated meniscus or loose body causing frequent locking with recurrent effusions (5258) prior to separation; and no fracture, nonunion or mal-union of the femur or tibia to support consideration under the respective codes for knee impairment related to long bone conditions (5255, 5262).  However, the NARSUM examination showed evidence of painful motion with functional loss for a 10% rating at TDRL placement.  The panel then determined the rating recommendation at TDRL removal, and agreed that a 10% rating, but no higher, was justified for painful motion.  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 10% for the left knee condition, coded 5003, at TDRL placement, and a 10% permanent disability rating after TDRL removal.  

BOARD FINDINGS:  In the matter of the PTSD, the panel recommends an initial TDRL rating of 50%, coded 9411in retroactive compliance with VASRD §4.129 as DoD directed; and a 10% permanent rating at 6 months IAW VASRD §4.130.  In the matter of the left knee degenerative arthritis, the panel recommends an initial TDRL rating of 10% in retroactive compliance with VASRD §4.129, as DOD directed, and §4.71a; and a 10% permanent rating at 6 months.  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, effective the date of medical separation:  

CONDITION	VASRD CODE	RATING	
		TDRL	PERMANENT	
Post-Traumatic Stress Disorder 	9411	50%	10%	
Left Knee Degenerative Arthritis	5003	10%	10%	
	COMBINED	60%	20%	

The following documentary evidence was considered:

AR20190007299, 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 and then following this six month period your disability rating should be modified to 20% rather than 10% but not to the degree that would justify changing your separation for disability with severance pay to a permanent retirement with disability.  I have reviewed the Board’s recommendation and record of proceedings (copy enclosed) and I accept its recommendation.  

The constructive TDRL period and the recharacterization of your separation as a disability retirement 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 discharge with severance pay with a combined 20% disability rating effective the date following the constructive six month TDRL period, minus the amount of severance pay you were previously paid at separation.

	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. 

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