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AF | PDBR | CY2014 | PD-2014-01095
Original file (PD-2014-01095.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXX    CASE: PD-2014-01095
BRANCH OF SERVICE: Army  BOARD DATE: 20150317
SEPARATION DATE: 20090820


SUMMARY OF CASE: Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E-4 (Infantryman) medically separated for right (dominant) wrist and right knee conditions. The 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 P2/U3/L3 profile and referred for a Medical Evaluation Board (MEB). The conditions “right wrist instability status post capsulodesis [reconstructive surgery]” and “right knee post-traumatic arthrosis [arthritis] status post lateral meniscal debridements” were forwarded to the Physical Evaluation Board (PEB) as failing retention standards IAW AR 40-501. The MEB also identified and forwarded three other conditions (below) as meeting retention standards: “obstructive sleep apnea [OSA]”, post Operation Iraqi Freedom [OIF] stress,” and “borderline hypertension.” The Informal PEB (IPEB) adjudicated the right wrist and right knee conditions as unfitting, rated 10% each, citing criteria of the Veterans Affairs Schedule for Rating Disabilities (VASRD) for both. The remaining conditions were determined to be not unfitting . The CI appealed, and an Informal Reconsideration PEB did not substantially affect the IPEB decisions; although, the Post-OIF Stress condition was listed as “mild adjustment disorder” (after psychiatric consultation) and judged to be both not unfitting and not compensable IAW DoDI 1332.38 (E5.1.3.9.4). The CI was medically separated.


CI CONTENTION: “Please consider all conditions.”


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 Recon – Dated 20090513
 VA (6 Mos. Pre-Separation)
Condition
 Code Rating Condition Code Rating Exam
Right Wrist Instability 5099-5003 10% Arthritis, Right Wrist 5215-5010 10% 20090227
Arthritis Right Knee 5010 10% Arthritis, Right Knee 5260-5024 10% 20090227
OSA Not Unfitting OSA 6847 50% 20090227
Mild Adjustment Disorder Not Unfitting Post-Traumatic Stress Disorder 9411 NSC* 20090302
Borderline Hypertension Not Unfitting Borderline Hypertension 7101 NSC 20090227
Other x # (Not in Scope)
 Other x 9 *NSC = Not Service Connected 20090227
Combined: 20%
 Combined: 80%
Derived from VA Rating Decision (VA RD ) dated 20100223 ( most proximate to date of separation [ DOS ] ).


ANALYSIS SUMMARY :

Right Wrist Condition. Although source records are unavailable, the service treatment record (STR) documents a right wrist injury sustained from a tactical vehicle roll-over on 1 March 2005 during OIF deployment. The available STR does not contain interim clinical records leading up to the MEB, although this information is well summarized in the narrative summary (NARSUM) and an orthopedic addendum. Members agreed that the available evidence was sufficiently probative and that the missing evidence would not materially affect the Board’s recommendation. The initial injury was treated as a sprain, but a more serious ligament injury with wrist bone displacement (scapholunate ligament disruption and rotatory subluxation of the scaphoid) was identified by imaging in November 2007. Surgical repair (see MEB diagnoses in Summary) ensued in February 2008. A protracted trial of rehabilitation was unsuccessful in restoring the CI to MOS functionality. Follow-up X-ray showed post-surgical and degenerative changes.

The NARSUM was conducted on 6 November 2008 (9 months prior to separation) and was supplemented by an orthopedic addendum from 3 weeks prior. The CI complained of “constant” wrist pain rated 5-10/10 “increased with prolonged and repetitive use of the right hand ... repeated grabbing, lifting and firing of the assigned weapon.” The physical exam was similar in the addendum and the NARSUM, documenting tenderness without swelling or deformity and normal neurological findings (5/5 strength and grip). The range-of-motion (ROM) measurements by orthopedics were 30 degrees dorsiflexion (normal 70 degrees) and 50 degrees palmar flexion (normal 80 degrees); and, by the NARSUM examiner were 50 degrees dorsiflexion and 20 degrees palmar flexion (with pain on repetitive motion).

A VA Compensation and Pension (C&P) examination was conducted on 27 February 2009 (6 months prior to separation), and the examiner documented constant pain rated 8/10 “elicited by physical activity and stress.” The VA physical exam noted tenderness without swelling and normal strength and neurological findings. The VA measured ROM was 30 degrees dorsiflexion and 30 degrees palmar flexion (documenting painful motion).

The Board directed attention to its rating recommendation based on the above evidence. In the absence of ankylosis (frozen joint), the single code available under VASRD §4.71a for rating the wrist is 5215 for limitation of motion, which provides for a maximum 10% rating with compensable thresholds of dorsiflexion 15 degrees and plantar flexion 0 degrees. The PEB’s 10% rating analogous to 5003 (degenerative arthritis) specifically cited painful motion to achieve the minimum compensable rating, as did the VA’s 10% rating under 5215-5010 (traumatic arthritis, defaulting to criteria of 5003). Although the evidence indicates significant limitation of motion, there is no §4.71a pathway to a rating higher than 10% in this case; and, no evidence of associated neuropathy for additional rating. After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), members agreed that there was insufficient cause to recommend a change in the PEB adjudication for the right wrist condition.

Right Knee Condition. Although the source records are not in evidence, the NARSUM indicates that the CI originally injured his knee in 2002, was diagnosed with a torn meniscus, underwent arthroscopic meniscectomy that same year, and suffered additional injuries with repeat arthroscopic debridements after that. The available STR contains a 2004 note confirming prior knee surgery, although the NARSUM documents “numerous entries for continuing right knee injury and treatment from February 2005 to the summer of 2008.” As with the wrist condition, the corroborating STR records are not in evidence, but members agreed that the available evidence is sufficiently probative for arriving at a fair recommendation. The knee symptoms were exacerbated by the aforementioned 2005 vehicular accident during deployment, and could not be rehabilitated adequately for retention. A 2009 X-ray demonstrated degenerative changes.

The NARSUM documented “constant” knee pain rated 3-7/10 which was “increased with prolonged standing, walking, climbing, any impact activities, cold weather and weight bearing.” The physical exam recorded a normal gait, the absence of effusion, stability in all planes, and no signs of cartilage impingement. Measured ROM was flexion to 135 degrees (normal 140 degrees, minimal compensable 45 degrees) specifying the absence of painful motion.

The prior to separation VA C&P examination documented constant pain rated 6/10 “elicited by physical activity and stress.” The physical exam recorded a normal gait, tenderness, the absence of effusion, “no locking pain,” stability in all planes, and no signs of cartilage impingement. VA measured ROM was flexion to 100 degrees and extension 0 degrees (normal), specifying the presence of painful motion.

The Board directed attention to its rating recommendation based on the above evidence. Both the PEB’s 10% rating under 5010 and the VA’s 10% under 5024 (tenosynovitis defaulting to criteria of 5003) cited painful motion to achieve the minimum rating in the absence of compensable ROM limitation. There is no evidence for frequent effusions or locking which would support a rating higher than 10% under any applicable code; and, no grounds for additional rating of instability. After due deliberation, considering all evidence and with deference to reasonable doubt, members agreed that there was insufficient cause to recommend a change in the PEB adjudication for the right knee condition.

Contended Psychiatric Condition. The STR and separately retrieved electronic health records (AHLTA) confirm an onset of mental health (MH) symptoms (flashbacks, nightmares) during the above referenced OIF deployment (October 2004 – September 2005) that were managed in theater. Criterions A stressors for a diagnosis of posttraumatic stress disorder (PTSD) are corroborated; but, there is no record of the MH diagnosis in theater. There are a few MH visits after redeployment with a working diagnosis of adjustment disorder (some discussion of PTSD), then a 2-year lapse in MH treatment (no medication refills). In September 2008 (10 months prior to separation, contemporary with initiation of MEB), the CI again presented to behavioral health. A temporary S3 profile was issued at that time. A diagnosis of “chronic PTSD” was endorsed by separate providers (psychologist, nurse practitioner) and psychoactive medications were prescribed. Psychological testing (MMPI-2) suggested that the “subjective report of distress and impairment is unreliable and exaggerated;” and, the results were considered invalid. The derivation of the NARSUM-listed diagnosis of Post-OIF Stress is unclear from the record. The PEB requested psychiatric consultation, noting that the CI “has had significant recent treatment for PTSD.”

A MEB psychiatric consultation was conducted on 6 May 2009 (3 months prior to separation). An extensive history of the psychiatric course was detailed, and the psychiatrist opined “There are no objective findings on mental status exam which enable the practitioner to diagnose PTSD or any other anxiety disorder....” The Axis I diagnosis was adjustment disorder; the Global Assessment of Functioning assignment was 65 (mild range of impairment); and, the examiner opined that the CI “meets psychiatric retention standards” and required “no permanent psychiatric profile restrictions.” The permanent profile had been changed to S1 in November 2008 (9 months prior to separation). The commander’s performance statement did not acknowledge any MH diagnosis or symptoms; and, documented acceptable work relationships, communication, attendance, and decision-making.

The VA did not service-connect an initial claim for PTSD, citing failure to show for examination. PTSD (with depressive and panic disorders) was eventually service connected and rated 30% effective on 29 January 2013 (3 years after separation).

The Board directed attention to its recommendation based on the above evidence. The Board’s main charge is to assess the fairness of the PEB’s determination that the MH condition was not unfitting. The Board’s threshold for countering fitness determinations is higher than the reasonable doubt standard used for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard. An established principle for fitness determinations is that they are performance-based, and there is no directed evidence in this case which examples any compromise in performance linked to psychiatric impairment. Although the NARSUM physician and the MEB psychiatric consultant differed in their MH diagnosis (“Post-OIF Stress” vs. adjustment disorder), both judged that the condition met retention standards. The commander did not implicate any MH impairment to performance; and, in fact, provided evidence that there was no significant impairment other than physical impediments. Although there was a temporary S3 profile during the MEB period, the permanent S1 profile was in effect for nine months preceding separation. As pointed out by the PEB, the final MH diagnosis of adjustment disorder is not subject to compensation IAW DoDI 1332.38 regardless of fitness implications; and, although a competing diagnosis of PTSD must be considered in this case, members agreed that there is not a preponderance of evidence to support a change in diagnosis.

Furthermore it must be considered that, although the MH condition surfaced as a functional impediment after MEB referral, there is no evidence that it had any unfitting impact on performance throughout the CI’s military career prior to that. The fitness determination is thus subject to DoDI 1332.38 (E3.P3.3.3 - Adequate Performance Until Referral); which stipulates, “If the evidence establishes that the Service member adequately performed his or her duties until the time the Service member was referred for physical evaluation, the member may be considered fit for duty even though medical evidence indicates questionable physical ability to continue to perform duty.” 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 fitness determination for the adjustment disorder.

Contended OSA and Hypertension Conditions. Although the CI related a history to the prior to separation VA examiner that OSA “has existed since 2005,” the earliest STR evidence for the condition (or related symptoms) dates to a September 2008 referral for a sleep study (after the MEB was underway and concurrent with resumption of psychiatric care). The study yielded a diagnosis of OSA, and treatment was commenced with continuous positive airway pressure (CPAP). The NARSUM indicated that the condition was stable and that it met retention standards. It was profiled P2 and was not implicated in the commander’s statement. Although OSA was rated by the VA for CPAP use, the VA C&P examiner documented “he does not require any treatment ... does not experience any functional impairment from this condition.” The NARSUM confirms that the CI was discovered with an elevated blood pressure on his MEB physical, and that it was being monitored. It was not under treatment at the time of the VA C&P examination. There is no record of any symptoms attributable to the blood pressure issue.

The Board directed attention to its recommendations based on the above evidence, which are directed at fitness determinations under the same standards as those elaborated for the MH condition. There is no performance based evidence for functional impairment from OSA. A P2 profile is not routinely associated with unfitting impairment, and does not mandate MEB referral IAW AR 40-501. Asymptomatic hypertension clearly has no fitness implications. Neither condition failed retention standards, nor was either implicated by the commander. All members therefore agreed that there was insufficient cause to recommend a change in the PEB fitness determinations for the OSA or hypertension conditions.


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 rating prerogatives outside the VASRD were exercised. In the matter of the right wrist condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication. 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 adjustment disorder, the Board unanimously recommends no change from the PEB determination as not unfitting. In the matter of the contended obstructive sleep apnea and hypertension conditions, the Board unanimously recommends no change from the PEB determinations 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 20140620, 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, AR20150013318 (PD201401095)


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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