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AF | PDBR | CY2013 | PD-2013-01868

Original file (PD-2013-01868.rtf) Auto-classification: Denied

RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXX CASE: PD-2013-01868
BRANCH OF SERVICE: Army BOARD DATE: 20150324

SEPARATION DATE: 20040817

SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-5 (Preventive Dental Specialist) medically separated for chronic right ankle pain and major depressive disorder (MDD) conditions. The conditions 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/S3 profile and referred for a Medical Evaluation Board (MEB). The chronic right ankle pain and major depressive disorder conditions, characterized as “chronic right ankle pain secondary to functional instability”, “major depressive disorder,” and “anxiety disorder” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. No other conditions were submitted by the MEB. The MEB submitted asthma as meeting retention standards. The Informal PEB (IPEB) adjudicated “chronic right ankle pain” as unfitting, rated 10% and “major depressive disorder as unfitting, rated 10%, with likely application of the Veterans Affairs Schedule for Rating Disabilities (VASRD). The remaining conditions of a nxiety d isorder and a sthma were determined to be not unfitting by the IPEB. The CI made no appeals and was medically separated.

CI CONTENTION: “The rating of 10% for chronic ankle pain (right) is based on pain with no loss of motion page 2 of decision dated July 26, 2005 clearly state chronic ankle pain with loss of motion – continued in Item 12 - Dysthymia rating of 10% upon discharge corrected to 30% in reference to page 2 of letter dated July 26, 2005. The Army performed surgery on my right ankle which failed. I will never be able to run, bike, or enjoy other physical activities with my children. The army created my problems with dysthymia that created issues for me on a daily basis.”

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.

RATING COMPARISON :

Service IPEB – Dated 20040716	VA - (2 Mos. Post-Separation)
Condition	Code	Rating	Condition	Code	Rating	Exam
Chronic Right Ankle Pain	5003-5271	10%	Chronic Right Ankle Pain	5271	10%	20041005
Major Depressive Disorder	9434	10%	Dysthymia	9433	10%	20040924
Other x 2 (Not in Scope)	Other x 5
Combined: 20%	Combined: 40%

Derived from VA Rating Decision (VA RD ) dated 200 41228 ( most proximate to date of separation [ DOS ] ).

ANALYSIS SUMMARY:

Chronic Right Ankle Pain Condition. The narrative summary (NARSUM) and service treatment records (STR) indicated that the CI had right ankle pain and snapping for 5 years. He ran 6-12 miles a day, five times per week and noticed progressive increase in pain without history of trauma. Physical therapy (PT), orthotics, and casting did not produce relief. Radiographic studies in February 2003 showed an osteochondral defect (OCD) of the talar bone of the ankle with possible non-displaced fracture extending to the posterior facet, focal tear of the peroneus brevis ligament (PBL), chronic tear of the anterior talofibular ligament (ATFL), and a heel spur. In July 2003, an ankle arthroscopy was performed for debridement and micro-fracture procedure for the OCD. During a PT consult dated 12 August 2003, the CI reported soreness in the anteromedial right ankle 6 weeks after surgery that was worse at the end of the day and worsened to a 4-5/10 pain when aggravated. The examiner noted moderate ankle effusion, dorsiflexion of 0 degrees plantar flexion of 45 degrees (normal 20 and 45 degrees, respectively), and tenderness of the entire ankle. At a PT visit dated 9 September 2003, the examiner documented right ankle dorsiflexion of 15 degrees, and 4/5 strength (normal is 5/5) of the tibialis posterior (TP), peroneus longus (PL) and PBL limited by pain. At a PT visit on 17 October 2003, the CI reported intermittent lateral right ankle pain, rated 5/10, and lasting a few seconds. The therapist documented painful motion with unilateral right calf raises, a nonantalgic gait with a “slight toe off,” and the inability to ambulate with full calf raise due to PL pain. At a primary care visit dated 5 November 2003, the CI reported continued pain at the lateral right ankle. The examiner documented that he ambulated with a cane and wore an ankle brace. At a visit with PT dated 1 December 2003, the CI continued to report lateral right ankle pain, rated 9/10 when aggravated. He also reported snapping sensation while doing calf raises, fast walking, and jumping. The therapist documented ankle pain with unilateral calf raise, and a nonantalgic gait. The therapist opined that the CI had “reached the maximum benefit/plateaued in his rehabilitation,” and discontinued his care. At an orthopedic evaluation on 11 December 2003, the CI reported continued right ankle pain. The examiner documented slightly decreased range-of-motion (ROM) secondary to stiffness, tenderness of the lateral malleolus to palpation, and radiographic evidence of persistent OCD. At a visit on 23 February 2004, the examiner documented decreased ROM with tenderness at the posteromedial and anterolateral joint line, pain with heel rise, 5/5 strength, and rendered a diagnosis of residual OCD. The NARSUM dated 14 May 2004 (3 months prior to separation) documented that the CI reported mild relief of the right ankle pain; feelings of instability, snapping of the ankle; inability to stand more than 20 minutes, and significant pain with activities. The examiner documented 5 degrees of dorsiflexion (normal 20 degrees) and 45 degrees of plantar flexion (normal 45 degrees), mild tenderness at the medial joint line, no tenderness along the lateral and medial malleoli, normal strength and sensation, negative instability (tilt and drawer testing), and no pes planus. The examiner noted that the CI “does have functional instability per his [account].” Radiographic evaluation showed “no fracture, no dislocation, OCD [of the] medial talar dome, chronic tear of the PBL and ATFL, and tenosynovitis of his TP tendon.” At the MEB examination, the CI reported using a brace for his right ankle. The MEB physical examination was “normal.” At the VA Compensation and Pension (C&P) examination, performed 2 months after separation, the CI reported intermittent use of an ankle brace and cane, instability and giving way of the ankle, a constant dull throb ranging from 2-10/10 (pain), and avoidance of climbing steps and standing more than 20-30 minutes. The examiner documented tenderness over the Achilles tendon and inferior to the medial malleolus; dorsiflexion of 20 degrees, plantar flexion of 45 degrees (normal ROM for both); snapping and pain with ROM; pain with toe and heel walk; and an abnormal gait (he pointed his “toe/ ankle complex outward” while walking). Radiographs showed no significant abnormalities and a small heel spur.

The Board directed attention to its rating recommendation based on the above evidence. The PEB adjudicated the “chronic right ankle pain secondary to osteochondritis dessicans” condition as unfitting with a disability rating of 10% for continued pain and moderate loss of motion; coded 5003-5271 (degenerative arthritis-ankle, limited motion of). The VA assigned a 10% rating for painful motion IAW §4.40 (functional loss) and §4.45 (the joints).

The STR documented persistent evidence of painful motion both before and after separation to warrant a 10% rating under 5003-5271. There was a disparity between examinations of ROM with implications for the Board's rating recommendation. The Board deliberated the probative value of these conflicting evaluations and carefully reviewed the entire file for corroborating evidence. There was no documentation of persistent marked limitation of motion, ankylosis, malunion, or deformity of the ankle to warrant a higher rating. The C&P examination (within 2 months of separation) was most proximate to separation, considered as having higher probative value, and remained as the Board’s definitive benchmark in its recommendations. Alternative coding as 5276 (pes planus, acquired) and 5024 (tenosynovitis) were also considered based on tenosynovitis of the TP tendon, but would not be of benefit to the CI.

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 chronic right ankle pain condition.

Major Depressive Disorder Condition. The psychiatry NARSUM stated that the CI had an episode of MDD at age 18 years (existed prior to enlistment) in response to his mother’s death during which he was diagnosed with depression, hospitalized for 3 weeks, and treated with Prozac for 3-6 months. He had no other episodes or further treatment until June 2003. The NARSUM stated that the CI presented to the emergency room on 8 June 2003, 14 months prior to separation, after having a fight with his wife. His initial symptoms included anxiety, irritability, sadness more days than not, poor sleep with frequent awakenings, diminished energy, and diminished appetite for approximately a week. The CI reported having overdosed on alcohol, antidepressants, pain killers, and stimulants. The psychiatric mental status examination (MSE) was notable for a polite, cooperative man with fair eye contact, normal speech, without agitation, hallucinations, delusions or homicidal thoughts. His cognition was intact and his thought processes were linear, logical, and goal directed. His affect was congruent with his “okay” mood; and his insight and judgment were fair. He was diagnosed with adjustment disorder with depressed mood, treated and released from the emergency room. As an outpatient, he continued medical treatment and attended therapy with some improvement. At the MEB examination, 6 months prior to separation, the CI reported depression, severe anxiety and stress due to command and job, the attempted suicide, and psychiatric care for depression and anxiety. The commander’s statement dated 24 February 2004, 6 months prior to separation indicated that the CI’s “limitations due to various conditions, profiles and his inability to be at the work site due to multiple medical appointments consistently degrad[ed] his work performance.” At the psychiatry NARSUM examination, 5 months prior to separation, the CI reported occupational problems due to strained relationships. He had seen psychiatry on 13 separate outpatient visits, and had been engaged in marital therapy for 6 months with benefit. He was compliant with his medications until December 2003 to January 2004 when he had self-discontinued his medications due to ineffectiveness. Upon worsening of symptoms (sadness, sleep disturbance, lack of energy, increased anxiety and irritability) in March 2004, he was prescribed Paxil (paroxetine, an antidepressant) for treatment of “mixed anxious depressive symptoms.” During the NARSUM MSE he denied panic attacks, increased worry, mania, hallucinations, paranoia, delusions, and homicidal or suicidal ideations. The MSE was notable for pleasant and cooperative demeanor; normal speech and thought processes; full affect congruent with his mood (described as “okay”); and his insight and judgment were deemed to be “good.” The examiner stated that he had MDD (and anxiety disorder, not otherwise specified) with continued “symptoms of depression including sleep disturbance, depressed mood, anhedonia and irritability,” with mild impairment for military duty and social/industrial adaptability with a Global Assessment of Functioning (GAF) score of 70 (some mild symptoms…generally functioning well…). At the VA C&P examination performed 2 months after separation, the CI reported that did not find any aspect of his treatment, including his medications, to have helped him. Since leaving the military, he felt that “it [was] a lot better” even though he had different stressors. He also felt that it would be “difficult to adjust to no longer being in the military,” but stated with certainty that he would be able to adjust. Since leaving the military, he had already seen an improvement in the marriage. He was planning to go to school rather than continue as a dental assistant. He also stated enjoyment in interacting with his 18 month old daughter. He denied sleep disturbance, or insomnia. The CI further reported a constant feeling of anxiety and being “strung out,” difficulty in controlling his temper, inability to handle pressure and personal conflict, and that he hated his “very mean and aggressive side.” His anger was easily triggered by everyday situations, but was “trying to replace those feelings with more positive ones….” He stated expressing his anger approximately “every few weeks to a month,” by becoming “extremely verbal”, swearing, but did not display physical violence. Taking “Paxil seems to help [me]to not act on these aggressive impulses,” and he stated being “afraid to stop taking it [for fear that he might actually] hurt someone physically.” The MSE was significant for a neatly groomed and cooperative man, who was fully oriented, with normal speech, linear and logical thinking; he tended to remain guarded with poor insight, but good judgment; he had a constricted affect with a mildly depressed mood, and denied suicidality despite having fleeting, nonspecific thoughts at times. The examiner opined that he had a “chronically depressed mood that originated prior to his enlistment … and due to the abusive family environment he grew up in,” was likely at risk for future recurrences of major depressive episodes because of his absence of coping skills to identify and express his feelings, and would benefit from psychotherapy. The examiner diagnosed early onset dysthymia and assigned a GAF of 60 (moderate symptoms). At the VA C&P examination performed 10 months after separation, the CI reported being employed at a dental office, doing fairly well, and getting along with his coworkers. He reported having a good response to the medication; however, he reported that he had not received any form of treatment for his depression since getting out of the military and moving to Florida. He admitted to having low appetite, “sporadic” concentration, anhedonia, energy fluctuation, suicidal ideation without attempt, irritability and aggressiveness, and having a number of conflicts at home. His MSE was essentially normal except for a dysphoric mood and congruent affect. The examiner opined that the CI did not demonstrate any significant impairment in judgment, however the prognosis for his dysthymia remained guarded and assigned a GAF of 55 (moderate symptoms).

The Board directed attention to its rating recommendation based on the above evidence. The PEB adjudicated the MDD, recurrent, moderate condition as unfitting rated 10% for citing moderate improvement with psychotherapy and medications; coded 9434 (major depressive disorder). The VA rated dysthymia condition at 10% for poor insight, constricted affect, mildly depressed mood, and fleeting nonspecific, suicidal ideations that were without intent; coded 9433 (dysthymic disorder). The Board noted that within 10 months of separation, the VA increased the rating to 30% for increased symptoms.

The Board first considered whether VARSD § 4.129 was applicable in this case. There were no traumatic stresses in evidence, therefore the Board determined that VASRD § 4.129 was not applicable.

The Board then considered whether there was evidence for a higher than 10% rating IAW VASRD §4.130, General Rating Schedule for Mental Disorders. The Board noted that there was the initial emergency department evaluation; however there were no subsequent emergency room visits or psychiatric hospitalizations within the 12 months prior to or after separation. The CI attended multiple outpatient visits for depression and marital therapy; he continued taking medications with some improvement, but no resolution of his symptoms. He was not seeking employment, but able to take care of his two young children at home with no supervision. He was married with some persistent mild impairment in communication. His insight was poor, but with good judgment. Prior to separation he reported occupational problems due to strained relationships and the commander’s statement documented a negative impact on the mission of the clinic.

The Board determined that the CI’s occupational impairment most closely approximated decreased work efficiency and ability to perform occupational tasks only during periods of significant stress. The evidence did not support that there were intermittent periods of inability to perform occupational tasks due to psychiatric symptoms for a 30% 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 major depression disorder.

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 chronic right ankle pain and IAW VASRD §4.71a the Board unanimously recommends no change in the PEB adjudication. In the matter of the MDD and IAW VASRD §4.130 the Board unanimously recommends no change in the PEB adjudication. 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 20131001, 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, AR20150012704 (PD201301868)

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

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AF | PDBR | CY2013 | PD-2013-01868

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