RECORD OF PROCEEDINGS PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXXXX		CASE: PD-2017-06032 BRANCH OF SERVICE: ARMY	SEPARATION DATE: 20041216

SUMMARY OF CASE: Data extracted from the available evidence of record reflects this covered individual (CI) was a Reserve E7, Motor Transport Operator, medically separated for “left elbow pain,” “left knee pain” and “PTSD,” rated 0% each, with a combined disability rating of 0%.

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 - 20041007	VARD - 20050323	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Left Elbow Pain	5099-5003	0%	Residuals Status Post Sub muscular Ulnar Nerve Transposition Left (Non-Dominant) Upper Extremity	8516	20%	20040929	
Left Knee Pain	5099-5003	0%	Patellar Recurrent Subluxation, Status Post Arthroscopic Lateral Release with Plica Resection; Left Knee	5299-5257	10%	20040929	
PTSD	9411	0%	PTSD	9411	50%	20041001	
COMBINED RATING: 0%	COMBINED RATING OF ALL VA CONDITIONS: 70%	
	
ANALYSIS SUMMARY:

PTSD. According to the STR and MEB behavioral health addendum, the CI’s PTSD began insidiously upon his return from a deployment in March 2004. He stated at his demobilization examination that he did not have any psychological or stress-related difficulties while deployed. However, while on convalescent leave, he claimed his wife said he was “acting differently.” He reported attacking his wife during sleep, and waking up at night with “panic symptoms.” He also

reported several episodes of sleep walking, nightmares, dissociation and being easily aggravated since his redeployment. He denied suicidal/homicidal ideation or hallucinations. He was attending weekly post-deployment groups. Medications included Celexa (anti-depressant). Two prior assessments by psychiatrists rendered diagnoses of PTSD and adjustment disorder NOS, respectively.

The MEB NARSUM examination noted complaints of “multiple acute stress symptoms.” Psychological testing in August 2004 was consistent with a diagnosis of PTSD and suggested a mild level of impairment with good coping mechanisms. Mental status examination (MSE) showed some evidence of depressed mood and anxiety associated with discussing certain topics. A diagnosis of PTSD was rendered with a Global Assessment of Functioning (GAF) score of 55 (moderate impairment). The examiner opined the CI met criteria for PTSD but noted that secondary gain could be playing a role in his presentation. The examiner also noted the psychiatrist who worked with the CI the most, stood by his diagnosis of adjustment disorder.

At the 1 October 2004 VA Compensation and Pension (C&P) mental disorders examination, 3 months before separation, the CI reported working in the medical hold unit since March 2004 and had lost no time from work due to his psychiatric symptoms. He was taking Ambien (sleep aide), Clonazepam (anti-anxiety) and mini press (nightmares). Upon release he hoped to find work in transportation or as a logistics supervisor. The MSE showed the CI smiled inappropriately at times when describing injuries incurred by other soldiers. He reported anger towards a psychiatrist who he felt insulted him and demeaned him in a group setting. He reported he checked locks 10 times per day to feel safe. He reported shaking, sweating, body chills and tachycardia while driving, triggered by seeing something in the middle of the road. He reported this happened a few times per week. He reported depression especially regarding his military service.  The examiner rendered a diagnosis of PTSD with a GAF score of 55.

During the 13 May 2005 mental health (MH) intake, the CI noted he had combat experience in Iraq. He endorsed sleep problems, claustrophobia, nightmares about the war and hitting his wife. He was taking medications (Clonzapam, Ambien and Prazocin) for sleep, nightmares and anxiety. He was a safety manager for a company and worked full time. A diagnosis of PTSD was rendered with a GAF score of 68 (mild impairment).

At the 24 June 2005 C&P PTSD examination, 6 months after separation, the CI endorsed dreams and nightmares almost nightly as well as avoidance, hypervigilance, decreased interest and lack of pleasure. Concentration and appetite were good but overall he slept well with the medication. The CI reported some guilt feelings, good mood on some days, occasional anxiety and irritability. He denied panic attacks. He continued to take the medications as described above. The CI reported good relationships with his wife and children and did well with others on a one-on-one basis. He had received a Bachelor’s degree in criminal justice. Since discharge he had worked  for his brother in sales but most recently was employed as a truck driver. He denied a history of hospitalizations or legal problems. There were no recorded visits to the emergency room (ER). He was able to handle activities of daily living. The MSE showed dysthymic mood, constricted affect and tangential thought production. Memory was good, sensorium clear and judgment good. A diagnosis of PTSD was rendered, with steady improvement and GAF score of 61 (mild impairment).

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the MH disorder 0%, coded 9411 (post-traumatic stress disorder), citing mixed opinion regarding diagnosis but consensus it was mild. The VA rated the MH disorder 50%, coded 9411, based on the C&P examination, citing occupational and social impairment with reduced reliability and productivity.

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. Members agreed the §4.130 criteria for a rating higher than 50% at the time of TDRL placement were not met; and, therefore the minimum 50% TDRL rating prescribed by §4.129 is applicable.

The most proximate source of comprehensive evidence on which to base the permanent rating is the C&P PTSD examination, performed 6 months after separation. The §4.130 criteria for a 10% rating is “symptoms controlled by continuous medication,” for a 30% rating is “occupational and social impairment with occasional decrease in work efficiency and intermittent inability to perform occupational tasks,” while criteria for a 50% rating requires “occupational and social impairment with reduced reliability and productivity.” The VA C&P PTSD examination noted continued report of PTSD symptoms and treatment with medication but good sleep, concentration and appetite; occasional anxiety and irritability and no panic attacks. The CI reported good family relationships and employment with two jobs since separation. He returned to his original work as a truck driver. He denied hospitalizations and legal problems and the STR did not record ER visits. The STR showed two MH visits post-discharge, one for MH intake in May 2005 and one for a C&P visit in June 2005. The STR did not show evidence of frequent follow-up MH visits but continued to take three psychotropic medications. The C&P examination noted mild disability and continued improvement. The panel concluded the CI’s symptoms were essentially controlled by continuous medication, thereby meeting the criteria for a 10% disability at TDRL removal. 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 10% for the PTSD, coded 9411.

Left Elbow Pain. According to the service treatment record (STR) and MEB narrative summary (NARSUM), the right-handed CI underwent a sub-muscular ulnar nerve transportation in June 2004 for cubital tunnel syndrome. He was seen and treated by occupational therapy (OT) and experienced some relief. His hand numbness resolved but he still experienced elbow pain. The 10 August 2004 MEB NARSUM examination, 4 months prior to separation, noted loss of movement and numbness to the left elbow. The elbow pain was aggravated by direct pressure. Physical examination showed a well-healed but tender incision over the posterior medial aspect of the elbow. Motor strength of the elbow and distal extremity was normal. Goniometric left elbow range of motion (ROM) was flexion of 115 degrees (normal 145) and extension of 10 degrees (normal 0). He also had 90 degrees of supination and 90 degrees of pronation. At the  16 August 2004 MEB examination (recorded on DD Forms 2807-1 and 2808), 4 months prior to separation, the CI reported left elbow numbness. Physical examination revealed limited rotation, flexion and extension of the left elbow and numbness of the lateral left elbow to the medial arm. The 20 August 2004 OT examination noted the CI was independent with self-care, but had difficulty reaching to pick things up or tucking in his shirt in the back. Examination showed left elbow extension of 30 degrees and flexion of 125 degrees. Left grip strength was 85 and right grip strength was 140. The decreased left grip strength was likely due to being tested after stretching and fitting for a night splint. Sensation was normal. At the 24 August 2004 OT follow- up, the CI reported his left elbow was feeling okay, but there was some sensitivity at the scar site.

At the 29 September 2004 VA Compensation and Pension (C&P) examination, 3 months before separation, the CI reported constant left elbow pain with swelling, fatigue, poor endurance and weakness. Physical examination showed decreased sensation to soft touch and pinprick of the left elbow. The left fourth digit flexion caused medial elbow muscle twitching and the left medial epicondyle was tender with guarding. Mild left biceps and triceps atrophy was noted. Deep tendon reflexes of the left triceps caused a body jerk, but all other reflexes were normal. The ROM study showed left elbow extension of 30 degrees and flexion of 105 degrees with pain. Left

upper extremity supination was 45 degrees with arm extended with pain at the elbow and tremors. Left upper extremity flexion and extension strength was decreased to 4/5 with elbow pain on resistance.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the left elbow condition 0%, analogously coded 5099-5003 (degenerative arthritis), citing moderate intermittent pain. The VA rated the left elbow condition 20%, coded 8516 (paralysis of the ulnar nerve), based on the C&P examination, citing limitation of motion, pain and functional impairment involving the left forearm, wrist and hand.

The panel determined the most proximate source of comprehensive evidence was the pre- separation C&P examination. There was evidence of mild biceps and triceps atrophy and slightly decreased grip strength. Although there was insufficient limitation of motion (LOM) to support a rating under the 5206, 5207, or 5208 codes, panel members agreed that a 10% rating was justified with application of VASRD §4.59 (painful motion). Although there was some decrease  of sensation in the elbow, mild grip weakness and abnormal left triceps reflex, finger movements were full and normal, so there was no evidence of moderate disability in support of a higher 20% rating under code 8516. After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a rating of 10% for the left elbow condition, coded 5099-5003.

Left Knee Pain. According to the STR and MEB NARSUM, the CI’s left knee condition began in 1988 after he turned his knee. He had numerous subluxations with treatment by the emergency room. He ultimately had surgery but problems persisted with his left knee. The MEB NARSUM examination noted complaints of left knee pain that was aggravated by climbing stairs. Physical examination showed no effusion, but he exhibited some patellar apprehension (test for likeliness of subluxation and dislocation) and patellar crepitus. The left knee was stable to varus, valgus, anterior and posterior stress. Goniometric left knee ROM measurements following repetitive movement was flexion of 130 degrees (normal 140) and extension of 0 degrees (normal). Painful motion was not mentioned. During the MEB examination the CI reported left knee pain and swelling with a history of chronic recurring dislocations. Physical examination showed left knee tenderness of the lateral patella and pain with resistance to ROM.

At the C&P examination the CI reported chronic left knee pain, stiffness, swelling, fatigue, locking, give-way, heat, redness, grinding and instability. He used a brace for physical activity but denied current use of assistive devices. On examination, there was pain with varus and valgus stress testing (damage to ligaments) and also left lateral greater than medial knee joint line tenderness with guarding. Left lower extremity flexion and extension strength was 4/5 with pain on resistance to the knee. There was no joint deformity, discoloration, warmth, swelling or effusion. Gait, coordination and position sense was normal and he toe walked with a slight left leg limp. Tandem walk was normal. Left knee ROM testing showed flexion of 135 degrees with pain and extension of 0 degrees with no pain. There was no additional limitation due to pain, fatigability, weakness or lack of endurance following repetitive use.

The panel directed attention to its rating recommendation based on the above evidence. The PEB rated the left knee condition 0%, analogously coded 5099-5003 (degenerative arthritis), citing degenerative arthritis without X-ray changes or loss of motion. The VA rated the left knee condition 10%, analogously coded 5299-5257 (knee, other impairment of), based on the C&P examination, citing painful motion during flexion and valgus and varus stress testing. The panel determined the most proximate source of comprehensive evidence to evaluate the CI was the C&P examination. 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) to support a rating under that code. There was 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, there was evidence of painful motion with functional loss supporting a 10% rating (based on §4.59, §4.40 and §4.45). After due deliberation, considering all the evidence and mindful of VASRD §4.3 (reasonable doubt), the panel recommends a rating of 10% for the left knee condition, coded 5099-5003.

BOARD FINDINGS: In the matter of the PTSD, the panel recommends an initial TDRL rating of 50%, coded 9411 in retroactive compliance with VASRD §4.129 and a 10% permanent rating at 6 months IAW VASRD §4.130. In the matter of the left elbow condition, the panel recommends an initial TDRL rating of 10%, coded 5099-5003 and a permanent 10% rating at TDRL removal IAW VASRD §4.71. In the matter of the left knee condition, the panel recommends an initial TDRL rating of 10%, coded 5099-5003 and a permanent 10% rating at TDRL removal IAW VASRD §4.71. 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	
Left Elbow Pain	5099-5003	10%	10%	
Left Knee Pain	5099-5003	10%	10%	
Posttraumatic Stress Disorder	9411	50%	10%	
	COMBINED	60%	30%	

ARXXXXXXXXXXX

Dear XXXXXXXXXXXXXX:

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 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 permanent 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 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), 2900 Crystal Drive, Suite 300, Arlington, VA 22202-3557.

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

Sincerely,

Enclosure