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AF | PDBR | CY2014 | PD-2014-01231
Original file (PD-2014-01231.rtf) Auto-classification: Denied
RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME: XXXXXXXXXXXXXXX    CASE: PD-2014-01231
BRANCH OF SERVICE: Army  BOARD DATE: 20150416
SEPARATION DATE: 20070312


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 moderate incomplete paralysis of left common peroneal nerve. 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 “nerve injury secondary to shrapnel wound impacting on the tibial and peroneal nerves below the knee” and “Left lower leg paresthesia with weakness of dorsiflexion,” were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501. The MEB also identified and forwarded two other conditions (posttraumatic stress disorder [PTSD] secondary to traumatic events and alcohol dependence) for PEB adjudication. The Informal PEB adjudicated “moderate incomplete paralysis of left common peroneal nerve” as unfitting, rated 20%. The remaining conditions were determined to be not unfitting . The CI made no appeals and was medically separated.


CI CONTENTION: “Please review V.A. Determination letter for ratings I received as a result of my injury form Iraq. Some items like (Traumatic Brain Injury) wasn’t know [sic] about when I received my medical discharge from the Army.”


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 Veterans Affairs Schedule for Rating Disabilities (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 :

Admin Correction – Dated 20070108
 VA* - (~9 Mos. Post-Separation)
Condition
 Code Rating Condition Code Rating Exam
Moderate Incomplete Paralysis Of Left Common Peroneal Nerve 8521 20% Injury To Left Peroneal Nerve 8621 20% 20071017
PTSD Medically Acceptable PTSD 9411 50% 20071023
Alcohol Dependence Medically Acceptable Not Addressed
Other x 1 (Not In Scope)
 Other x 3
RATING: 20%
 RATING: 60%
* Derived from VA Rating Decision (VA RD ) dated 200 71214 (most proximate to date of separation ( DOS ) ) .

ANALYSIS SUMMARY:

Moderate Incomplete Paralysis Of Left Common Peroneal Nerve Condition. The narrative summary (NARSUM) documented the CI’s history of shrapnel injury to his left leg while in Iraq, December 2004. The CI underwent immediate surgery to irrigate, debride, remove shrapnel and provide wound care. He was maintained in a hospital environment until late January 2005, and was then evacuated to Germany for further care. He eventually returned to duty on a temporary profile. Since his injury, the CI reported constant problems with weight-bearing and pain in the left leg with radiation down the leg to the lateral aspect of the foot. Although the surgical wounds healed, the CI continued to experience hyperesthesia and weakness of the muscles supplied by the peroneal and tibial nerves of the left foot. The CI underwent consultation with pain specialist and neurologist; the neurologist assessed complex regional pain syndrome (RSD), and the pain specialist assessed peroneal nerve injury. The CI was prescribed medications to include opiates and lidocaine patch with limited benefit. On 26 January 2005, bone scan of the left lower extremity documented findings consistent with a history of traumatic injury. The physician interpreting the scan noted there were no findings suggestive of RSD. Electromyogram documented left peroneal and tibial post-traumatic neuropathies, “most likely from direct trauma of falling or swelling or impact of RPG.” Radiographs of the left knee dated 22 November 2005 documented normal knee with the exception of the presence of shrapnel imbedded in the soft tissue lateral to the proximal tibia and anterior to the proximal fibula. Orthopedic clinic entry dated 22 November 2005 noted the CI has had persistent problems with pain, had been evaluated at the pain clinic, and had reported overall improvement in his pain, but had hoped for complete pain relief. Examination of the left lower extremity recorded no effusion, full range-of-motion (ROM), no instability, and a healed wound on the anterior aspect of the knee with mild tenderness on palpation of the scar. There was tenderness over the proximal head of the fibula, with demonstrated radiation of pain in the superficial peroneal nerve distribution. Decrease muscle strength (4/5) was noted in the left peroneal muscles (lateral compartment), with decreased sensation in the superficial peroneal distribution, and good sensation in deep peroneal area of distribution. The CI was able to heel and toe walk. The NARSUM dated 16 January 2006 noted that the CI had difficulty with prolonged standing, walking or running for any distance; however, he was able to perform the aerobic portion of the Army physical fitness training with a cycle and could exercise with the elliptical cycle. He had difficulty mounting and dismounting military tactical vehicles and performing other soldierly tasks. For these reasons he was given a permanent 3 profile and referred to the MEB. Physical examination of the left lower extremity documented allodynia and hyperesthesia (neurosensory changes) on the lateral aspect from the fibular head to the lateral aspect of the foot and base of the 5th toe. Both right and left ankles and knees demonstrated full ROM. There was some lateralization of the patella bilaterally, and no edema, or atrophy in either extremity; muscle strength was essentially normal, but weakness was recorded in the great toe in dorsiflexion and plantar flexion of the left foot. The examiner recorded a healed surgical scar in the left lower extremity; reflexes were equal bilaterally, pulses were intact, and there was decrease sensation along the distribution of the superficial peroneal nerve on the left to the dorsum of the foot. The physician diagnosed nerve injury secondary to shrapnel wound impacting on the tibial and peroneal nerves, below the knee, opined to be consistent with left peroneal and tibial post-traumatic neuropathy. At the VA Compensation and Pension (C&P) examination dated 17 October 2007, 10 months after separation, the CI reported burning sensation in the left leg, and locking and spasm of the leg which comes and goes. He reportedly stated he was unable to jog because of a limp. His pain occurs “constantly,” characterized by burning, aching, squeezing sensation, and sharp in nature. He was not receiving any treatment. Physical examination recorded height of 74 inches and weight of 310 pounds. The examiner documented sensory deficits in the distribution of the peroneal nerve of the left leg and lateral left foot without evidence of motor deficit. Left ankle jerk was absent. ROM measurements were not documented. The diagnoses of left peroneal nerve injury and scars from shrapnel wounds were recorded.

The Board directed attention to its rating recommendation based on the above evidence. The PEB rated the condition of left common peroneal nerve, moderate incomplete paralysis of, coded 8521 (paralysis of common peroneal), at 20%. Likewise, the VA rated the condition at 20%, under the 8621 code (neuritis). The higher rating of 30% under either code requires evidence of severe disability demonstrated by hospitalization for a prolonged period for treatment of the condition, record of consistent complaint of loss of power, weakness in all digits of the foot, impairment of coordination (tripping, falling), and severe disturbance of gait. All Board members agreed the record in evidence did not support the 30% level of disability under any applicable code. The Board discussed whether the scar met criteria for rating under the scar code of 7804 (unstable or painful), and concluded there was insufficient evidence to support a rating for the scar. Thereupon, 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 peroneal leg condition.

Contended PEB Conditions. The Board’s main charge is to assess the fairness of the PEB’s determination that PTSD and alcohol dependence conditions were not unfitting. The Board’s threshold for countering fitness determinations requires a preponderance of evidence, but remains adherent to the DoDI 6040.44 “fair and equitable” standard. The non-MH NARSUM documented PTSD diagnosis and indicated the condition was the result of events in Iraq. The examiner documented that the CI was initially treated for PTSD after his return from Iraq. The physician stated that PTSD had been successfully treated with medication and was considered medically acceptable, and that there was no military occupational impairment as the result of PTSD. There were no service treatment records available for review related to PTSD. Psychiatry consultation dated 12 June 2006 recorded the diagnosis of depression, and treatment with Prozac. The psychiatrist stated that the etiological cause of the depression was loneliness and chronic pain, and noted specifically, diagnostic criteria for PTSD was not met. Primary care entry dated 29 June 2006, approximately 6 months prior to separation documented the CI began treatment with MH after he got arrested (reason not stated, and legal history not documented in any other available treatment entry). At the time of this visit, the CI reported improved sleep with sleep medication, and lack of motivation and pleasure; PTSD symptoms were not recorded. The Board reviewed the VA C&P mental examination, 10 months after separation that documented the CI had worked at the same job since separation from service, and noted he had good relationships with co-workers and supervisors. He had not lost any time from work, and he was also attending trade school for welding. The CI was not receiving any treatment for a MH condition, had not participated in talk therapy in the past year, had not been admitted to psychiatric hospital, and had not required treatment in the emergency room. He had continued to abuse alcohol and reportedly blacked out 2-3 times per week, and drank daily. The examiner opined that his psychiatric symptoms had caused occupational and social impairment with occasional decrease in work efficiency and intermittent inability to perform occupational tasks. The Board reviewed the records for evidence of changes in diagnosis of the mental health condition during processing through the Disability Evaluation System (DES). The available records evidenced that the CI was treated for symptoms of depression and insomnia, and had a formal diagnosis of depression. The Board noted the diagnosis of depression was recorded on the MEB history and physical DD Form 2808 without elaboration of symptoms, and the diagnoses of PTSD and alcohol dependence on the NARSUM, without clinical documentation to support the PTSD diagnosis. The PEB adjudicated PTSD and alcohol dependence as medically acceptable, but did not adjudicate depression. Alcohol dependence is a non-ratable condition and therefore, not subject to a disability rating. The Board concluded that although the condition of depression was eliminated during processing through the DES, PTSD is a more serious diagnosis, and therefore, no mental health diagnosis was changed or eliminated to the CI’s possible disadvantage. This CI, therefore, did not appear to meet the inclusion criteria in the Terms of Reference of the MH Review Project. The Board considered whether any mental condition, regardless of specific diagnosis, was unfitting for continued military service. Board members agreed that evidence of the record reflected minimal MH related symptoms. There was evidence of psychotropic medication prescription and use prior to separation for sleep problems and mood symptoms and there was evidence that use of medication had not continued beyond separation. The PTSD was not profiled or implicated in the commander’s statement and was not judged to fail retention standards. There was no performance based evidence from the record that the PTSD condition significantly interfered with satisfactory duty performance. There was no emergency room or unscheduled clinic visits nor psychiatric hospitalizations for any MH condition. The Board concluded that the preponderance of evidence did not support an unfit determination for any MH disorder at the time of evaluation in the DES or prior to separation and therefore, none were subject to 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. 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 peroneal nerve injury condition and IAW VASRD §4.124a, the Board unanimously recommends no change in the PEB adjudication. In the matter of the contended PTSD and alcohol dependence 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 20140228, 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, AR20150013364 (PD201401231)


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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