RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXX	CASE:  PD-2013-01165
BRANCH OF SERVICE:  Army	BOARD DATE:  20150304
Separation Date:  20050913

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Aircraft Power Plant Repairer) medically separated for left hallux valgus.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS), however, his profile allowed for an alternate aerobic event to satisfy physical fitness standards.  He was issued a permanent L3/S1 profile and referred for a Medical Evaluation Board (MEB).  The left foot condition, characterized as “hallux valgus status post (s/p) surgery x 2, including bunionectomy with persistent left foot pain” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded six other conditions that did not fall below retention standards (posttraumatic stress disorder [PTSD] and cyclothymic disorder with anxiety and depression, hypertension, chronic intermittent neck and back pain, seasonal allergies, smoker, and dental problems) for PEB adjudication.  The Informal PEB adjudicated “left hallux valgus” as unfitting, rated 10% with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD).  The remaining conditions were determined to be not unfitting.  The CI made no appeals and was medically separated.

CI CONTENTION:  The CI elaborated no specific contention in his application.

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e.(2).  It is limited to those conditions determined by the PEB to be unfitting for continued military service and when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting.  Any conditions outside the Board’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/Naval Records.  Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The Board’s assessment of the PEB rating determinations is confined to review of medical records and all available evidence for application of the VASRD standards to the unfitting medical condition at the time of separation.  The Board 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, operating under a different set of laws.  The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation. 

In addition, the Secretary of Defense Mental Health Review Terms of Reference directed a comprehensive review of Service members with certain mental health (MH) conditions referred to a disability evaluation process between 11 September 2001 and 30 April 2012 that were changed or eliminated during that process.  The MH condition was reviewed regarding diagnosis change, fitness determination and rating in accordance with VASRD §4.129 and §4.130.

RATING COMPARISON:

Service IPEB – Dated 20050830 | VA - (2 Mos. Post-Separation)
Condition | Code | Rating | Condition | Code | Rating | Exam
Left Hallux Valgus | 5280 | 10% | S/P Left Foot Surgeries | 5284 | 10% | 20051110
PTSD /Cyclothymic disorder w/Anxiety & Depression | Not Unfitting | PTSD w/Mood Disorder | 9411 | 50% | 20051110
Other x 5 (Not In Scope) | Other x 5
Rating:  10% | Combined:  60%
Derived from VA Rating Decision (VARD) dated 20060407 (most proximate to date of separation [DOS])

ANALYSIS SUMMARY:  

Left Hallux Valgus Condition.  The CI developed left foot pain during road marches and marching activities during basic training in December 2002.  Initially he only had pain while wearing his Army boots; however, the pain worsened and he developed pain with street shoes as well.  The podiatrist, on 18 March 2003, noted pain in the first metatarsal phalangeal joint (MTPJ) of the left foot.  The physical exam findings were a left foot bunion on the first MTPJ with hallux valgus.  The examiner recommended conservative treatment and prescribed shoe inserts and a temporary profile.  A bilateral foot X-ray showed a moderate hallux valgus (bump on the side of the big toe) of the left foot with a bunion (changes in the boney framework on the front part of the foot), with the right foot showing only a small bunion.  The CI deployed to Iraq and remained on profile for his entire tour.  Once re-deployed, he sought podiatric care for the persistent foot pain.  He underwent a left great toe bunionectomy on 18 June 2004.  The CI was seen in Acute Care for numbness and tingling at the surgical site.  The podiatrist documented constant sharp to dull first left hallux pain with physical exam findings of tenderness to palpation over the first MTPJ.  A left foot X-ray showed no displacement of the screw.  The CI had persistent pain and underwent hardware removal and bone realignment on 4 April 2005.  A 4-week post-operative X-ray showed no left foot pathology.  The commander’s statement indicated the CI could not perform his basic MOS duties due to his physical limitations and he had a noticeable limp when walking.  A podiatry addendum approximately a month prior to separation documented chronic left foot pain with painful motion.  The MEB narrative summary (NARSUM) exam approximately a month prior to separation documented that although the second foot surgery increased the range of motion, the CI still had daily pain.  The minimum daily pain was rated at 3/10 intensity with an occasional increase in pain to 10/10 which would occur approximately three to four times every month.  The examiner referenced the MEB H&P DD Form 2807 for physical exam findings of numbness and tingling along with joint pain.  The VA Compensation and Pension (C&P) exam approximately a month prior to separation noted constant left foot pain when standing, sitting or lying down.  The CI reported severe pain if he walked any considerable distance and was unable to run for fear of provoking intense pain in the left toe.  He had flare-ups with weight bearing.  The physical exam findings were two scars on the volar foot surface that were purplish red in color, slightly swollen with exquisite tenderness, and an inability to stand on the left foot.

The Board directed attention to its rating recommendation based on the above evidence.  The PEB coded 5280 (left hallux valgus) condition, unilateral hallux valgus, rated 10%, the only available compensable rating for this code.  The VA coded the status post left foot surgeries condition as 5284 (foot injuries) other rated 10%, moderate.  The record in evidence demonstrated that all exams proximate to separation documented pain with ambulation.  The Board considered an alternate coding of 5003 with application of painful motion and 5284; however, neither coding schema would result in a higher rating.  After due deliberation, considering all of the evidence, and mindful of VASRD §4.3 (reasonable doubt), the Board concluded there was insufficient cause to recommend a change in the PEB adjudication for the left hallux valgus condition.

Contended PTSD/Cyclothymic Condition.  The Board reviewed the records for evidence of inappropriate changes in diagnosis of the MH condition during processing through the Disability Evaluation System.  The evidence of the available records shows a diagnosis of PTSD/cyclothymic disorder was rendered and no change in diagnosis was made at any time; therefore, this case did not meet the inclusion criteria in the Terms of Reference of the MH Review Project.  The MH condition adjudicated as not unfitting by the PEB was PTSD/cyclothymic disorder with anxiety and depression.  The Board’s first charge with respect to this condition is an assessment of the appropriateness of the PEB’s fitness adjudication.  The Board’s threshold for countering fitness determinations is higher than the VASRD §4.3 (reasonable doubt) standards used for its rating recommendations, and require a preponderance of evidence.  

The psychiatric addendum to the MEB approximately a month prior to separation documented that the CI’s symptom of anxiety began during his 2003 deployment to Iraq.  He began having panic attacks frequently, reported suicidal ideation, and other symptoms suggestive of depression and PTSD.  While on mid-tour leave, he presented to the MH clinic and was diagnosed with depression.  He returned to Iraq with medication but after 2 months he ran out of medicine, however, his symptoms had improved and he had done well.  He completed his tour and returned stateside in March 2004.  Treatment records were silent until the July 2005 NARSUM.  The NARSUM indicated the CI did not deploy with his unit in 2005 because he had foot problems.  He reported his nightmares had recurred, and he once again presented to MH and was diagnosed with cyclothymia and PTSD.  He was treated with medication that helped his sleep and terminated his nightmares.  His panic attacks were infrequent and “seemed to be related to stimuli associated with being in Iraq”.  At the NARSUM exam, the examiner stated, the CI “had no psychotic symptoms, no behavioral problems, legal trouble, or difficulty with work as a result of his symptoms.”  Although the CI was taking medications for the mood disorder, the examiner noted that he was motivated for treatment and recovery and was doing well.  The examiner documented his prognosis as good with continued treatment.  The CI was diagnosed with cyclothymic disorder, mild to moderate, and PTSD, both with minimal impairment for military duty and a mild impairment for social and industrial adaptability.  The Global Assessment of Functioning was 61 (connoting some mild difficulty in social, occupational, or school functioning, but generally functioning pretty well).  He also had some meaningful interpersonal relationships.  

The VA C&P exam approximately a month after separation documented continued nightmares, other symptoms of PTSD and mood disorder.  Additionally, the CI reported episodes of auditory hallucinations of hearing a voice call his name.  However, his mental status examination was unremarkable and active psychosis was not identified.  There was no evidence of psychiatric hospitalizations or visits to the emergency room for MH symptoms.  The CI was married and working full-time as an air frame contractor.  Although symptoms recorded at the C&P exam were significantly more than during the NARSUM, 2 months after separation, the record reflected minimal symptoms in the year prior to separation, and indicated that his symptoms were responsive to medication.  The PTSD and cyclothymic conditions were not profiled or implicated in the commander’s statement as causing any duty impairment.  Additionally, the CI did not endorse any MH-related symptoms or significant events associated with the development of MH symptoms on the Post-Deployment Health Questionnaire he completed upon his return from Iraq.  The MH conditions were not judged to fail retention standards.  There was no indication from the record that any MH condition significantly interfered with satisfactory duty performance.  After due deliberation, and in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the PTSD/cyclothymic conditions and therefore, no additional disability ratings can be recommended.
BOARD FINDINGS:  IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication.  The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised.  In the matter of the left hallux valgus condition, and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended PTSD/cyclothymic condition, the Board unanimously recommends no change from the PEB determination as not unfitting.  There were no other conditions within the Board’s scope of review for consideration.

RECOMMENDATION:  The Board, therefore, recommends that there be no re-characterization of the CI’s disability and separation determination.

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20130814, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record

XXXXXXXXXXXXXXX
President
DoD Physical Disability Board of Review

SAMR-RB									

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXX, AR20150010408 (PD201301165)

I have reviewed the enclosed Department of Defense Physical Disability Board of Review (DoD PDBR) recommendation and record of proceedings pertaining to the subject individual.  Under the authority of Title 10, United States Code, section 1554a,   I accept the Board’s recommendation and hereby deny the individual’s application.  
This decision is final.  The individual concerned, counsel (if any), and any Members of Congress who have shown interest in this application have been notified of this decision by mail.

 BY ORDER OF THE SECRETARY OF THE ARMY:

Encl		     XXXXXXXXXXXXXXX
			     Deputy Assistant Secretary of the Army
			          (Review Boards)
						         
CF: 
(  ) DoD PDBR
(  ) DVA

PD-2013-01165