RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD1301682
BRANCH OF SERVICE:  Army	BOARD DATE:  20140605
SEPARATION DATE:  20070222

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SGT/E-5 (92A/Logistics Specialist) medically separated for chronic right knee pain.  The condition could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty or satisfy physical fitness standards.  He was issued a permanent L3 profile and referred for a Medical Evaluation Board (MEB).  The chronic right knee pain and mild right knee degenerative joint disease, characterized as “does not meet the retention standards” was forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other conditions were submitted by the MEB.  The PEB adjudicated “chronic right knee pain” as unfitting, rated 10% with likely application of the US Army Physical Disability Agency (USAPDA) pain policy.  The CI made no appeals and was medically separated.

CI CONTENTION:  “I requested to be seen several times for PTSD issues and believe I should have some percentage for this issue.”

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 those conditions identified but not determined to be unfitting by the PEB when specifically requested by the CI.  In addition, the CI was notified by the Army that his case may be eligible for review of the military disability evaluation of his mental health (MH) condition in accordance with Secretary of Defense directive for a comprehensive review of Service members who were referred to a disability evaluation process between 11 September 2001 and 30 April 2012 and whose MH diagnoses were changed during that process.  The rating for the unfitting chronic right knee condition and posttraumatic stress disorder (PTSD) are addressed below; no additional conditions are within the DoDI 6040.44 defined purview of the Board.  Any conditions or contention not requested in this application, or otherwise outside the Board’s defined scope of review, remain eligible for future consideration by the Board for Correction of Military Records.

RATING COMPARISON:

Service IPEB – Dated 20070105 | VA - (2 Mos. Post-Separation)
Condition | Code | Rating | Condition | Code | Rating | Exam
Chronic Right Knee Pain | 5099-5003 | 10% | Status Post Right Knee Reconstruction with Patellofemoral and Retropatellar Pain Syndrome and Degenerative Joint Disease | 5010-5260 | 10% | 20070409
PTSD | Not Addressed | Posttraumatic Stress Disorder | 9411 | 10% | 20070502
No Other Items in Scope | Other x 1 (Not in Scope) |
Combined:  10% | Combined:  30%
Derived from VA Rating Decision (VARD) dated 20070522 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:

Chronic Right Knee Pain Condition.  The narrative summary (NARSUM) notes that the CI injured his right knee while playing basketball in June 2005.  He tore the anterior cruciate ligament (ACL) and eventually underwent ACL reconstruction in January 2006.  Following surgery the knee was stable, but the CI continued to report knee pain and pain over the surgical hardware.  In November 2006, he had surgery to remove the hardware which did improve that pain.  At the surgery, the knee graft was stable and there was no cartilage damage noted.  Despite the second surgery and physical therapy, the CI continued to have knee pain.

At the MEB exam on 1 December 2006, approximately 3 months prior to separation, the CI reported chronic right knee pain.  The MEB physical exam noted the right knee was stable without swelling. Right knee range-of-motion (ROM) was [flexion-extension] 0-135 degrees (normal 140 degrees).  There was normal strength, sensation and reflexes (“neurovascularly intact”).  Radiographs of the right knee noted mild degenerative changes but were otherwise within normal.  The MEB examiner noted a pain rating of slight/frequent.

At the VA Compensation and Pension (C&P) exam performed 2 months after separation, the CI 
reported chronic right knee pain rated 2-3/10 with stiffness and swelling.  The VA examination noted a normal gait and stance.  On examination, there was tenderness about the patella.  There was no instability or evidence of cartilage damage.  Right knee ROM was 0-120 degrees with pain and there was no additional loss of ROM with repetition.  The examiner noted the CI was not taking any medications or using a brace, there were no dislocations, subluxations, incapacitating episodes and work was not affected by the condition.  Right knee X-rays showed degenerative joint disease.

The Board directs attention to its rating recommendation based on the above evidence.  The PEB rated chronic right knee pain status post ACL reconstruction at 10%, coded as 5099-5003 (analogous to degenerative arthritis) and cited the USAPDA pain policy with a pain rating of slight/frequent.  The VA rated status post right knee reconstruction at 10%, coded as 5010-5260 (analogous to traumatic arthritis with limitation of leg flexion).  The Board deliberated the rating of the right knee condition.  Following two surgeries, the CI had residual right knee pain without instability or evidence of cartilage damage, with painful ROM that did not meet the threshold for a compensable rating due to limited ROM.  The Board agreed that the CI’s disability due to the knee condition met the 10% rating coded as either 5099-5003 (for non-compensable limited ROM with degenerative arthritis established by X-ray findings) or as 5260 in accordance with the VA Schedule for Rating Disabilities (VASRD) §4.59 (painful motion) and there was no other ratable impairment of the right knee or any path to a higher evaluation.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the right knee condition.

Contended Mental Health Conditions.  The Board considered the appropriateness of changes in the MH diagnoses, PEB fitness determination; and if unfitting, whether the provisions of VASRD §4.129 were applicable, and a disability rating recommendation in accordance with VASRD §4.130 under the Terms of Reference of the MH Review Project.  The Board noted that the CI contended a PTSD diagnosis and reviewed to see if there was evidence of inappropriate elimination or change of a diagnosis of PTSD or any MH condition during processing through the Disability evaluation System.  The DD Form 2808, Report of Medical Examination, included a diagnosis of insomnia, the NARSUM did not address any MH condition and the MEB did not forward any MH condition to the PEB.  Therefore, this case did not appear to meet the inclusion criteria in the Terms of Reference of the MH Review Project.  The Board next reviewed to see if there was evidence to support that any MH condition was unfitting for continued military service and therefore eligible for service disability rating.  The CI’s post-deployment health assessments in March and October of 2005 noted that he had been in combat and felt in danger while deployed.  The CI reported some emotional concerns and requested additional counseling for symptoms of nightmares, intrusive thoughts, feeling on guard, feeling numb and having decreased interest in activities he used to enjoy and indicated he was under care.  There is one page referencing MH in the service treatment record (STR) dated 24 July 2006, 7 months prior to separation, which noted standardized testing indicated anxiety and depression and an antidepressant was prescribed.  However, there are no other records pertaining to MH evaluation or treatment in the STR before the Board.  The automated problem list for non-MH visits between 30 January 2006 and November 2006 noted diagnoses of adjustment disorder with anxiety and depressed mood and the MEB examination visit in the STR listed adjustment disorder with disturbance of emotions.  The DD Form 2808 listed insomnia and noted the CI was prescribed sleeping medications and on the DD Form 2807, Report of Medical History, the examiner noted that the CI reported treatment for depression and anxiety symptoms from November 2005 to August 2006.  The last performance evaluation report in the records dated June 2006 indicated that the CI performed successfully and was rated as superior.  The commander’s performance statement does not mention any MH condition and cites physical limitations as impairing the CI’s duty performance.  The psychiatric profile was S-1 throughout service.

At the initial VA Compensation and Pension (C&P) PTSD examination on 2 May 2007, 2 months after separation, the CI reported he had treatment for depression and anxiety at the military treatment facility and also off-post.  He reported being treated with antidepressants for several months, but was not on any medication at the time of the VA C&P examination.  He had attended eight MH counseling sessions, but stopped because that was all that was financially covered by the military.  The VA examiner noted that the CI was deployed for a year to Iraq (between 2004 and 2005) and received a Combat Action Badge.  The CI reported that he had always had problems with mood swings of anxiety and depression, but that there was an increase in the severity of symptoms in the last 2 weeks.  He reported depression and anxiety, with sleep difficulties and occasional vivid memories of combat related events, awake or asleep, triggered sometimes by war movies.  He reported irritability and temper outbursts, but no physical violence, but admitted recent thoughts of harming himself, without a plan or intent.  The CI reported being married for 7 years with a child, but there was marital strain.  The CI was employed since separation from the military and reported that he liked his job and the people he worked with and went to the gym daily.  On the mental status examination, the CI had a depressed mood and some decreased concentration was noted, but the examination was otherwise normal, without abnormalities of thought, or speech, or evidence of delusions or hallucinations.  The examiner indicated that DSM-IV PTSD criteria were met and the Axis I diagnosis was PTSD with a Global Assessment of Functioning of 60 (on the cusp of moderate and mild impairment range).  The VARD on 22 May 2007 rated PTSD 10%, 5 months after separation.

The evidence in this case demonstrates that MH diagnoses of adjustment disorder were made in service and insomnia was noted on the DD Form 2808, but there is no evidence for a diagnosis of PTSD during service.  Although ideally the MH condition would have been addressed directly and forwarded by the MEB, there is no evidence that the acuity was such that it was not a reasonable judgment call on the part of the MEB physician to not do so; nor, is there any indication that the CI desired such action.  Although there was evidence of PTSD symptomatology arising soon after separation, all members agreed that there was insufficient evidence which could support a recommendation for adding PTSD as a service diagnosis.  It was likewise agreed that even if another Service diagnosis (anxiety or depression) was conceded for consideration; there would be insufficient evidence for recommending it as unfitting and eligible for rating; noting the S1 profile, the lack of indication by the commander that there were MH limitations on performance and the lack of any performance-based evidence in the service record suggesting that such limitations existed.  After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend the addition of any MH diagnosis for service disability rating.

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.  As discussed above, PEB reliance on the USAPDA pain policy for rating the right knee condition was operant in this case and the condition was adjudicated independently of that policy by the Board.  In the matter of the right knee condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended MH condition, the Board unanimously agrees that it cannot recommend any MH condition for additional disability rating.

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

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20130929, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

		
XXXXXXXXXXXXXXXXXX
President
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 XXXXXXXXXXXXXXXXXX, AR20140016131 (PD201301682)

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						     XXXXXXXXXXXXXXXXXX
						     Deputy Assistant Secretary
						         (Army Review Boards)

CF: 
(  ) DoD PDBR
(  ) DVA

PD1301682