RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD1302174
BRANCH OF SERVICE:  Army	BOARD DATE:  20140710
SEPARATION DATE:  20090125

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty SPC/E-4 (88M/Motor Transport Operator) medically separated for chondromalacia patellae of the left knee and little finger of the left hand.  The left knee and left little finger conditions could not be adequately rehabilitated to meet the physical requirements of his Military Occupational Specialty (MOS) or satisfy physical fitness standards.  He was issued a permanent U3L3 profile and referred for a Medical Evaluation Board (MEB).  “Chronic left knee pain and fracture 5th finger left hand” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  The MEB also identified and forwarded six other conditions for PEB adjudication, one being adjustment disorder with anxiety and depressed mood.  The Informal PEB adjudicated “chondromalacia patellae, left knee and little finger/left hand, limitation of motion” as unfitting, rated 10% and 0%, with likely application of the VA Schedule for Rating Disabilities (VASRD).  The adjustment disorder with anxiety and depressed mood was determined to be non-compensable, although may be administratively unfitting.  The remaining conditions were determined to meet retention standards and found to be not unfitting by the PEB.  The CI made no appeals and was medically separated.

CI CONTENTION:  The applicant makes no contentions.

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 applicant.  The ratings for conditions meeting the above criteria are addressed below.  In addition, the Secretary of Defense directed a comprehensive review of Service members with certain mental health conditions referred to a disability evaluation process between 11 September 2001 and 30 April 2012 that were changed or eliminated during that process.  The applicant was notified that he may meet the inclusion criteria of the Mental Health Review Terms of Reference.  The mental health condition was reviewed regarding diagnosis change, fitness determination and rating in accordance with VASRD §4.129 and §4.130.  Any conditions or contention not requested in this application, or otherwise outside the Board’s defined scope of review, may be eligible for future consideration by the Board for Correction of Military Records.

RATING COMPARISON:

Service IPEB – Dated 20081203	VA - (2&3 Mos. Post-Separation)	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Chondromalacia Patellae, Left Knee	5099-5003	10%	Left Knee Chondromalacia	5260	10%	20090331	
Little Finger, Left Hand	5230	0%	S/P Left Hand Fracture, Fifth Digit	5230	0%	20090331	
Adjustment Disorder with Anxiety and Depressed Mood	Not Compensable	PTSD	9411	30%	20090427	
Other x 0 (Not is Scope)	Other x 10		
Combined:  10%	Combined:  40%	
Derived from VA Rating Decision (VARD) dated 20090528 (most proximate to date of separation [DOS]).

ANALYSIS SUMMARY:  IAW DoDI 6040.44, the Board’s authority is limited to making recommendations on correcting disability determinations.  The Board’s role is thus confined to the review of medical records and all evidence at hand to assess the fairness of PEB rating determinations, compared to VASRD standards, based on ratable severity at the time of separation.

Chondromalacia Patellae, Left Knee Condition.  This condition began in 2006 when a heavy object fell on the knee.  Persistent pain with activity led to arthroscopic debridement of damaged patellar (kneecap) cartilage in June 2008.  Despite aggressive physical therapy (PT) and medication, pain persisted.  A magnetic resonance imaging study in October 2008 showed chondromalacia of the patella, but no meniscal or ligamentous abnormalities were present.  The MEB separation physical exam on 26 August 2008 (5 months prior to separation) noted decreased range-of-motion (ROM) due to pain, but ROM was not measured.  At the narrative summary (NARSUM) exam on 7 October 2008 (3.5 months prior to separation) the CI complained of pain, stiffness and swelling.  Physical examination noted a gait that was affected by the presence of a long left knee brace.  A left patellar reflex was not performed because of the presence of knee pain.  At the MEB PT evaluation on 20 October 2008, the CI reported left knee pain that was constant and dull.  Examination showed a normal gait and no knee swelling or ligament instability.  Painful motion occurred throughout 115–140 degrees of flexion.  There was no additional limitation after three repetitions.  Left knee ROM, flexion, was normal at 140 degrees.  At the VA Compensation and Pension (C&P) exam on 31 March 2009 (2 months after separation), the CI reported stiffness, but denied pain, giving way or instability of the knee.  He also reported locking episodes 2-3 times per month, but denied swelling or subluxation.  Weather changes or overuse exacerbated symptoms.  He experienced a flare-up every 2-3 weeks that lasted 2-3 days.  During a flare-up he had difficulty playing with his children or picking up heavy items.  Examination showed swelling but no crepitation, instability or grinding.  Painful motion was absent and there was no additional limitation with repetition.  The left patellar reflex was accomplished without reported difficulty, and was normal. ROM was normal, 140 degrees for flexion.

The Board directs attention to its rating recommendation based on the above evidence.  The PEB and VA chose different coding options for the condition, but this did not bear on rating.  The PEB’s 10% determination was consistent with §4.71a standards.  Although there was no limitation of motion, there was ample evidence of pain with use (§4.40) or painful motion (§4.59) to warrant a 10% rating.  The Board agreed that a route to a higher rating under 5257 (knee, other impairment of) was not supported by the evidence.  There was likewise no history of dislocated semilunar cartilage to warrant a rating under the 5258 code.  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 left knee chondromalacia condition.

Little Finger Condition.  In January 2008 the CI sustained a fracture of the proximal phalanx of the left little finger that required medical evacuation from Iraq for surgical treatment.  After open reduction and internal fixation of the fracture on 30 January 2008, the CI was treated aggressively with occupational therapy.  Although the fracture healed successfully, he experienced persistent swelling, pain and stiffness.  At the NARSUM exam the CI reported that the finger would occasionally lock-up in a partially flexed position.  Examination revealed a finger that was sausage shaped due to the surgery.  Testing showed mildly reduced ROM of the middle and distal finger joints.  The proximal joint (metacarpophalengeal joint – at junction of hand and finger) ROM was normal formal grip and pincer strength testing was normal.  At the C&P exam the CI reported that the finger locked-up once per month for seconds to a couple of minutes.  Examination showed no evidence of painful motion or of pain after repetitive motion.

The Board directs attention to its rating recommendation based on the above evidence.  The PEB and the VA assigned a 0% rating under the same 5230 code (ring or little finger, limitation of motion).  Because the maximum rating under 5230 or 5227 (ankylosis of little finger) is 0%, Board members agreed there was no route to a higher rating. 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 little finger condition.

Contended PEB Condition of Adjustment Disorder.  The Board’s threshold for countering fitness determinations is higher than the VASRD §4.3 (reasonable doubt) standard used for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  The CI was initially evaluated by psychiatry in January 2008, and diagnosed with an adjustment disorder with a Global Assessment of Functioning (GAF) of 70, connoting mild symptoms or impairment.  The MEB addendum psychiatrist interviewed the CI and reviewed medical records on 24 October 2008 (3 months prior to separation).  The mental status exam was unremarkable except for appearing fidgety.  The psychiatrist diagnosed adjustment disorder and an assigned GAF of 70. The examiner indicated the CI met retention standards and recommended a permanent S1 profile.  The commander’s statement on 19 August 2008 indicated that the CI worked an 8-hour duty day (not in his MOS), that he was performing his duty well, communicated effectively, related civilly to supervisors and co-workers and did not require extra supervision.  The CI’s physical condition was considered responsible for an inability to perform his MOS duties.  On a Report of Medical Assessment on 14 August 2008, the CI did not identify an MH condition as limiting his ability to work in his specialty.  The Board noted the medical NARSUM examiner listed posttraumatic stress disorder (PTSD) and adjustment disorder with depressed mood as current diagnoses; however, the examiner referred to the psychiatry MEB addendum for additional information.  As stated above, the psychiatry NARSUM documented adjustment disorder.  The Board reviewed the records for evidence of changes in diagnosis of the MH condition during processing through the military Disability Evaluation System (DES).  The evidence of the available records showed the diagnoses of adjustment disorder with anxiety and depressed mood and PTSD were rendered during processing through the DES; therefore, an MH diagnosis was changed during that process.  This applicant therefore did appear to meet the inclusion criteria in the Terms of Reference of the MH Review Project.  The Board undertook a careful review of the clinical evidence and noted the non-MH NARSUM and the MEB physical examiner listed PTSD; however, as noted above, the NARSUM examiner referred back to the psychiatric NARSUM.  The Board noted there were no recorded PTSD symptoms in either document.  The Board could not find sufficient clinical evidence to support a PTSD diagnosis prior to separation.  The Board concluded the preponderance of evidence supported that adjustment disorder was the correct diagnosis at the time of separation.  The adjustment disorder, as implied by the PEB, was a condition not constituting a physical disability IAW DoDI 1332.38., and therefore, not ratable.  The Board noted the PEB identified that the adjustment disorder was not compensable but could be administratively unfitting; however, the Board concluded that the preponderance of evidence in the record reflected non-limiting MH symptoms in the period of time leading into separation.  The MEB psychiatric addendum considered that the MH condition was not medically disqualifying.  This was consistent with a GAF indicating minimal symptoms or impairment and with a commander’s statement that did not implicate MH symptoms as a cause of duty impairment.  The MH condition was reviewed by the action officer and considered by the Board.  There was no performance-based evidence from the record that any MH condition significantly interfered with satisfactory duty performance.  After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication of the MH condition.

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 chondromalacia patellae, left knee condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the left little finger condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended MH condition of adjustment disorder with anxiety and depressed mood, the Board unanimously recommends no change from the PEB determination.  There were no other conditions within the Board’s scope of review for consideration.

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 20130909, 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, AR20140016123 (PD201302174)

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