RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2017-05168
BRANCH OF SERVICE:  Army 	SEPARATION DATE:  20060111

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 “post-traumatic stress disorder [PTSD] with depressive features and problems with anger management ” and “left foot pain,” rated 10% and 0%, respectively, with a combined  disability rating of 10%.

CI CONTENTION:  The conditions have affected his life and were not evaluated accurately for traumatic brain injury (TBI) and PTSD.  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 - 20051229	VARD - 20060719	
Condition	Code	Rating	Condition	Code	Rating	Exam	
PTSD…	9411	10%	PTSD	9411	50%	20060509	
Left Foot Pain	5099-5003	0%	Left Foot Surgery, Scar	7802	0%	20060509	
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’s mental health (MH) condition began after returning from a deployment to Iraq in March 2004.  He initially presented for MH treatment in April 2005 with depressed mood, insomnia, and social isolation, and after evaluation was prescribed medication for sleep, anxiety and depression.  In September 2005, he was diagnosed with PTSD and depression, not otherwise specified.  At that time, the CI reported having suicidal thoughts without a plan as well as marital conflict.  He was referred to deployment stress/anger management groups, but declined.  There was no history of emergency room visits for MH issues or psychiatric hospitalization during his military service.

The 6 December 2005 MEB psychiatric addendum examination, 1 month prior to separation, noted complaints of sleep disturbance and nightmares.  The CI reported his depression had improved significantly with medication, and that nightmares had turned into “regular dreams,” which he sometimes remembered.  He continued to have anxiety during the day, but was able to sleep with medication.  The mental status examination (MSE) revealed a mildly depressed mood and affect, and that he appeared to be fatigued, but was otherwise unremarkable.  The examiner noted that the CI had responded well to his antidepressant medication, showed a good sense of humor, and had fair insight and judgment.  Although the Axis I diagnosis included PTSD, “major depressive episode, moderate, with partial remission” was recorded.  No specific traumatic stressor was documented in the addendum.  

At the 9 May 2006 VA Compensation and Pension (C&P) examination, 4 months after separation, the CI reported his sleep was “pretty good now” with medication, and that he had fewer nightmares, with none in the past couple months.  He did experience irritability, a bad temper, and depressive symptoms, and avoided social situations.  He had been married for 3-1/2 years and had no children.  The CI had worked 3 days in a factory setting before being fired due to physical problems.  He was actively seeking employment, and had performed odd jobs for extra money.  He occasionally went fishing, but his overall social activity was limited.  The CI noted that during his deployment he had several frightening experiences, but the most frightening was being on a boat when it came under fire.  He thought he would be killed, but he and the other crew members were able to get away.  The MSE was unremarkable.

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 50%, coded 9411, citing occupational and social impairment with reduced reliability and productivity.  Members noted that in accordance with DoD guidance, VASRD section §4.129 (mental disorders due to traumatic stress) will be applied when PTSD is an unfitting condition.  Therefore, as a matter of policy, the PDBR must recommend the CI be placed on a constructive Temporary Disability Retired List (TDRL) with a minimum rating of 50% and reassessment after 6 months.  The panel next considered the §4.130 rating at TDRL placement, and noted that the STR showed the CI was stable and had responded well to medication with an unremarkable MSE; the commander’s performance statement also indicated he was “an above average soldier.”  There was no mention of an MH condition, and the panel concluded that criteria for a rating higher than 50% were not met at the time of constructive TDRL placement.  

The panel proceeded with the rating recommendation at the time of TDRL removal.  The STR documented three encounters during the TDRL period along with the C&P examination which was accomplished 2 months prior to TDRL removal.  These evaluations recorded a fairly normal MSE with the CI endorsing irritability and anger, but no depressive or PTSD symptoms.  His sleep had improved on medication with a few reported nightmares, and although he had limited social interactions, his marriage was intact and he was actively seeking employment.  

During a VA primary care intake visit on 18 July 2006, at the time of constructive TDRL removal (6 months), the provider noted that the CI was working construction and was still taking an antidepressant.  A social work contact note dated 11 August 2006, 1 month post-TDRL removal, noted the medication was working well and that he presented for a refill of his prescribed sleep medication.  During a social work visit 2 weeks later, the MSE revealed a euthymic mood and good affect, and no impairment in concentration, judgement, thinking or memory; all other aspects of the examination were normal.  The CI was not employed, but there was no mention of an MH condition interfering with the construction work reported during the July clinic visit. 

The 11 April 2007 C&P examination, 9 months after TDRL removal, noted CI complaints of poor sleep and intrusive thoughts that made him feel depressed and angry.  He was also irritable, and had difficulties with his temper and problems with his marriage.  Contrary to all previous accounts of symptoms controlled by medication, he stated that his prescriptions were not helpful, and therefore, he discontinued them.  The MSE was unremarkable with the exception of “down mood and energy.”  Although he claimed problems with his temper, there were no reports of domestic violence, or violence in the community.  Symptoms were stable and his condition did not require emergency care or hospitalization.

Panel members concluded that, at the time of constructive TDRL removal, the preponderance of evidence supports that the CI’s disability was most reflective of a 10% rating for occupational and social impairment “due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or; symptoms controlled by continuous medication.”  After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a disability rating of 50% for 6 months of constructive TDRL, and a 10% permanent rating thereafter for the PTSD, coded 9411. 

Left Foot Pain.  According to the STR and MEB NARSUM, the CI’s left foot condition began in January 2005, and he underwent surgery to remove bone spurs from the top of his foot in June 2005.  He continued to have foot pain, and X-rays showed post-surgical changes consistent with removal of bone spurs from the dorsal aspect of the first metatarsocuneiform joint.

During the 18 October 2005 MEB examination (recorded on DD Forms 2807-1 and 2808), 3 months prior to separation, the CI reported left foot pain and that he used a cane for walking. Physical examination revealed a healed scar and tenderness. The 2 November 2005 MEB NARSUM examination, 2 months before separation, noted complaints of left foot pain, rated at 2/10.  Midfoot pain was worse with wearing of military footgear as well as increased weight bearing activities.  Physical examination showed mild pain at the first metatarsocuneiform joint, minimal tenderness of the incision scar, and no signs of inflammation or infection.  There was no compromise of neurovascular function. 

At the 9 May 2006 C&P examination, the CI reported that he was diagnosed with flat feet upon entering the military.  He continued to have left foot pain after prolonged standing or walking more than 100 yards, but did not use an assistive device brace or orthotics and took no medication for pain.  Physical examination showed he was able to rise to his toes and heels without difficulty.  Bilateral foot and toe range of motion (ROM) was normal with sensation intact.  Foot X-rays showed no bone or joint abnormalities.

The panel directed attention to its rating recommendation based on the above evidence.  The PEB rated the left foot pain 0%, analogously coded 5099-5003 (degenerative arthritis), citing the US Army Physical Disability Agency pain policy.  The VA did not rate the left foot pain, but assigned a 0% rating, coded 7802 (scar), citing absence of criteria for a compensable rating.

The panel considered the rating at constructive TDRL placement and removal.  The NARSUM documented mild pain and tenderness at the first toe joint, but no other abnormality, and noted the CI walked using a cane.  The C&P examination recorded the absence of a cane or any other assistive device, and full ROM with no pain on motion.  Members agreed there was insufficient evidence of painful motion with functional loss to support a 10% rating (based on §4.59, §4.40 and §4.45) at the time of TDRL placement and removal. 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 left foot condition.

BOARD FINDINGS: In the matter of the PTSD, the panel recommends a disability rating of 50%, coded 9411 IAW VASRD §4.129 for 6 months from the time of discharge consistent with a constructive TDRL period, and then a permanent separation rating of 10% IAW VASRD §4.130.  In the matter of the left foot condition, the panel recommends no change in the PEB adjudication at the time of constructive TDRL placement and removal.  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 Foot Pain	5099-5003	0%	0%	
COMBINED	50%	10%	

AR20190005619, XXXXXXXXXXXXXXXXXX

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 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 no recharacterization of your separation or modification of the permanent disability rating of 10%.  Enclosed is a copy of the Board’s recommendation and record of proceedings for your information.

	The constructive TDRL period 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 no recharacterization of your separation or modification of the permanent disability rating of 10% following the constructive six month TDRL period. 

	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.