IN THE CASE OF:	  

		BOARD DATE:	  4 June 2015

		DOCKET NUMBER:  AR20150007297 


THE BOARD CONSIDERED THE FOLLOWING EVIDENCE:

1.  Application for correction of military records (with supporting documents provided, if any).

2.  Military Personnel Records and advisory opinions (if any).


THE APPLICANT'S REQUEST, STATEMENT, AND EVIDENCE:

1.  The applicant requests, in effect, the addition of two conditions to his disability retirement:

* post-traumatic stress disorder (PTSD)
* chronic tendonitis with impingement syndrome in left shoulder

2.  The applicant states the conditions of PTSD and left shoulder tendonitis should have been considered by the Physical Disability Board of Review (PDBR) and added when the U.S. Army Review Boards Agency (ARBA) took action.  He believes the addition of these two conditions will support his case for receiving combat-related special compensation (CRSC).

3.  The applicant provides:

* letter, dated 21 July 2008, from a doctor addressed to Disability Determinations Services regarding a disability examination given to the applicant
* letter, dated 21 February 2015, from the Department of Veterans Affairs (VA) addressed to the applicant
* letter, dated 2 July 2009, from VA regarding verification of the applicant's exposure to traumatic events in combat
* VA Form 21-4138 (Statement in Support of Claim)
* certificate of completion, dated 22 November 2013, PTSD Domiciliary Rehabilitation Treatment Program (DRRTP)
* discharge instructions, dated 21 November 2013, showing diagnosis of PTSD, follow-up treatment and medications
* report of results, dated 14 August 2014, magnetic resonance imaging (MRI) for left shoulder
* summary of treatment, dated 14 August 2014, fluoroscopic guidance for needle placement, left shoulder
* patient referral form, dated 9 December 2014, regarding evaluation for bilateral knee replacements
* summary of today's visit, dated 9 December 2014, describing results of a visit with an orthopedic doctor
* VA Rating Decision, dated 10 September 2009, showing service-connected PTSD with a disability rating of 30 percent
* four documents titled Display Patient Appointments 
* appointment reminder
* radiology report, dated 22 May 2012, regarding an MRI for the right knee
* two VA Forms 21-4142a, (General Release for Medical Provider Information to the VA)
* MRI results for left shoulder, dated 16 October 2013
* letter, dated 26 June 2013, from U.S. Army Physical Disability Agency (USAPDA) notifying the applicant of the approval of his disability retirement
* DA Form 3947 (Medical Evaluation Board (MEB) Proceedings), dated 13 February 2006
* first page of DD Form 2808 (Report of Medical Examination), dated 19 April 2004

CONSIDERATION OF EVIDENCE:

1.  After having prior service in the U.S. Marine Corps, the applicant enlisted in the Louisiana Army National Guard (LAARNG) on 4 November 1997.  He was awarded the military occupational specialty of 63B (Light-Wheel Vehicle Mechanic).  The highest rank/grade held was sergeant/E-5.

2.  On or about 4 October 2005, a DA Form 3349 (Physical Profile) showed the applicant was given a permanent profile with a numeral designation of 3 (equating to significant limitation) for L5/S1 degenerative disc disease and osteoarthritis both knees.  Referral to an MEB and physical evaluation board (PEB) were shown as being required.  The applicant's available record is void of any DA Forms 3349 which show a permanent profile with a numeral designation of 3 or 4 for either his left shoulder condition or PTSD.

3.  Orders A-10-521622, dated 18 October 2005, issued by U.S. Army Human Resources Command (HRC) ordered the applicant to active duty.
4.  On 8 February 2006, the MEB physician completed the narrative summary (NARSUM) for the applicant's medical conditions.  In the NARSUM, the doctor listed the applicant's past medical history.  This history included left shoulder rotator cuff tendonitis, but made no mention of PTSD.  The associated comments for the left shoulder were:

* patient seen in the orthopedic clinic on 26 January 2006 for pain in left shoulder
* received injection of anesthetic and steroids; was noted to be much improved at follow-up one week later

5.  On 13 February 2006, on a DA Form 3947, an MEB identified two medical conditions which failed medical retention standards.  Neither the applicant's left shoulder condition nor PTSD were reflected.  The two conditions shown were:

* degenerative disc disease of L5/S1
* osteoarthritis of bilateral knees

6.  On 2 March 2006, a PEB determined the two conditions referred by the MEB were unfitting.  The PEB recommended separation with severance pay and a combined disability rating of 0 percent.  On 20 March 2006, the applicant concurred with the PEB's findings and waived his right to a formal hearing.  The DA Form 199 (PEB Proceedings) reflects the following conditions and disability ratings:

* chronic low back pain, secondary to disc desiccation of L4/5 and L5/S1 without neurologic abnormality, 0 percent
* chronic pain bilateral knees, 0 percent

7.  On 8 April 2006, the applicant was honorably released from active duty.  His DD Form 214 (Certificate of Release or Discharge from Active Duty) showed he completed 1 year, 11 months, and 13 days of net creditable active service.  It also showed 13 years and 25 days of prior active service and 6 years, 9 months, and 6 days of prior inactive service.  The narrative reason shown was disability, other.

8.  On 20 March 2012, the applicant applied to the PDBR essentially requesting a review of his disability case.  On 28 March 2013, the PDBR recommended the applicant's separation be recharacterized to reflect permanent disability retirement with a combined disability rating of 30 percent.  The only medical conditions addressed by the PDBR were:

* chronic low back pain
* chronic right knee pain
* chronic left knee pain

9.  On 30 May 2013, the Deputy Assistant Secretary of the Army (Review Boards) notified the applicant she had accepted the PDBR's recommendation and directed USAPDA to correct his records to show permanent disability retirement at a disability rating of 30 percent.

10.  Orders 170-0323, dated 19 June 2013, issued by Headquarters, Joint Readiness Training Center and Fort Polk, showed the applicant was released because of physical disability and placed on the permanent disability retired list effective 9 April 2006.  The combined disability rating shown was 30 percent.  A DD Form 215 (Correction of DD Form 214) was also issued showing permanent disability retirement.

11.  The applicant provides:

	a.  A letter, dated 21 July 2008, from a doctor regarding a disability examination given to the applicant.  In the letter the doctor discussed, among other topics, the status of the applicant's left shoulder; he noted:

* the applicant has always had chronic problems with his lower back and both legs
* he complained of problems with his left shoulder and was unable to do repetitive overhead lifting
* pain radiated down toward his left elbow
* examination revealed tenderness along the posterior aspect of the left shoulder; he could actively abduct (movement of the limb away from the body) to about 80 degrees
* he had moderately positive impingement sign (when the tendons of the rotator cuff muscles become irritated and inflamed)
* he had no weakness to abduction testing

	b.  A letter, dated 2 July 2009, from VA which reported a formal finding of exposure to an in-service event associated with a claim for PTSD.  The letter stated sufficient evidence was found to show, as claimed by the applicant, the following events occurred:

* in June 2005, the applicant served at Camp Liberty, Iraq
* on 3 June 2005, six Soldiers were injured in a mortar attack and one Soldier was killed
* on 13 June 2005, a mortar attack occurred which injured seven Soldiers and one civilian
	c.  Report of results, dated 14 August 2014, for an MRI of the applicant's left shoulder, which shows:

* pain which radiates to the left arm and neck has been getting progressively worse
* moderate osteoarthritic changes of the glenohumeral (shoulder) joint with cartilage loss and cyst formation
* a tear of the posterior and inferior labrum (fibrocartilagenous ring surrounding the shoulder socket)
* tendinopathy (disease of the tendon) of the supraspinatus (small muscle of the upper back) and infraspinatus (muscles over the scapula)
* Os acromiale (bony process on the scapula) with mild hypertrophic (enlarged) changes
* small subacromial (below the acromion or shoulder bone emanating from the scapula) with bursa fluid

	d.  VA Rating Decision, dated 10 September 2009, showing a disability rating of 30 percent for service-connected PTSD.  The applicant's entitlement to individual unemployability was denied.  This rating was based on a VA examination, dated 7 August 2008, wherein it was found:

* the applicant was still angry and upset
* the applicant indicated he had hypervigilence, poor sleep patterns, startle symptoms and was always on high alert
* he had an aversion to crowds and stated he had nightmares 3 times a week as well as intrusive thoughts 4 to 5 times per day
* he was able to engage in a normal range and variety of daily activities
* his thought processes were logical, coherent, relevant, and he was cooperative
* he was well-oriented to time, place, person, and situation
* his affect was one of irritation
* his reasoning, fund of general knowledge, concentration, and memory were good
* he was diagnosed with PTSD and depressive disorder, not otherwise specified

12.  Army Regulation 635-40 (Physical Evaluation for Retention, Retirement, or Separation) sets forth policies, responsibilities, and procedures that govern the evaluation for physical fitness of Soldiers who may be unfit to perform their military duties because of physical disability.  

	a.  Chapter 3 states the mere presence of impairment does not, of itself, justify a finding of unfitness because of physical disability.  

	b.  In each case, it is necessary to compare the nature and degree of physical disability present with the requirements of the duties the member reasonably may be expected to perform because of his or her office, rank, grade or rating.

13.  Army Regulation 40-501 (Standards of Medical Fitness) governs medical fitness standards for enlistment, induction, appointment, retention, separation, and retirement.

	a.  Chapter 3 provides guidance for the various medical conditions and physical defects which may render a Soldier unfit for further military service and which fall below the standards required for service.

	b.  These medical conditions and physical defects, individually or in combination, are those that significantly limit or interfere with the Soldier's performance of his/her duties; may compromise or aggravate the Soldier's health or well-being if the Soldier were to remain in the military service (this may involve dependence on certain medications, appliances, severe dietary restrictions, or frequent special treatments, or a requirement for frequent clinical monitoring); may compromise the health or well-being of other Soldiers; or may prejudice the best interests of the government if the individual Soldier were to remain in the military service.

	c.  Chapter 7 provides guidance for the physical profile serial system.  The profile is based on the function of body systems and their relation to military duties.  There are six factors, designated as:

* "P" for physical capacity or stamina
* "U" for upper extremities
* "L" for lower extremities
* "H" for hearing
* "E" for eyes
* "S" for psychiatric

	d.  Each factor is assigned a numerical designation from 1 to 4.

* "1" represents a high level of medical fitness
* "2" means there are some activity limitations
* "3" equates to significant limitation
* "4" indicates defects of such severity military duty performance is -drastically limited
	e.  The DA Form 3349 is used to record both permanent and temporary profiles.  

14.  PTSD can occur after someone goes through a traumatic event like combat, assault, or disaster.  The Diagnostic and Statistical Manual of Mental Disorders (DSM) is published by the American Psychiatric Association (APA) and it provides standard criteria and common language for the classification of mental disorders.  In 1980, the APA added PTSD to the third edition of its DSM-III nosologic classification scheme.  Although controversial when first introduced, the PTSD diagnosis has filled an important gap in psychiatric theory and practice.
From an historical perspective, the significant change ushered in by the PTSD concept was the stipulation that the etiological agent was outside the individual (i.e., a traumatic event) rather than an inherent individual weakness (i.e., a traumatic neurosis).  The key to understanding the scientific basis and clinical expression of PTSD is the concept of "trauma."

15.  PTSD is unique among psychiatric diagnoses because of the great importance placed upon the etiological agent, the traumatic stressor.  In fact, one cannot make a PTSD diagnosis unless the patient has actually met the "stressor criterion," which means that he or she has been exposed to an event that is considered traumatic.  Clinical experience with the PTSD diagnosis has shown, however, that there are individual differences regarding the capacity to cope with catastrophic stress.  Therefore, while most people exposed to traumatic events do not develop PTSD, others go on to develop the full-blown syndrome.  Such observations have prompted the recognition that trauma, like pain, is not an external phenomenon that can be completely objectified.  Like pain, the traumatic experience is filtered through cognitive and emotional processes before it can be appraised as an extreme threat.  Because of individual differences in this appraisal process, different people appear to have different trauma thresholds, some more protected from and some more vulnerable to developing clinical symptoms after exposure to extremely stressful situations.

16.  The DSM fifth revision (DSM-5) was released in May 2013.  This revision includes changes to the diagnostic criteria for PTSD and Acute Stress Disorder.  The PTSD diagnostic criteria were revised to take into account things that have been learned from scientific research and clinical experience.  The revised diagnostic criteria for PTSD include a history of exposure to a traumatic event that meets specific stipulations and symptoms from each of four symptom clusters:  intrusion, avoidance, negative alterations in cognitions and mood, and alterations in arousal and reactivity.  The sixth criterion concerns duration of symptoms; the seventh assesses functioning; and the eighth criterion clarifies symptoms as not attributable to a substance or co-occurring medical condition.

	a.  Criterion A, stressor:  The person was exposed to: death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence, as follows: (one required) 

		(1)  Direct exposure. 

		(2)  Witnessing, in person.

		(3)  Indirectly, by learning that a close relative or close friend was exposed to trauma.  If the event involved actual or threatened death, it must have been violent or accidental.

		(4)  Repeated or extreme indirect exposure to aversive details of the event(s), usually in the course of professional duties (e.g., first responders, collecting body parts; professionals repeatedly exposed to details of child abuse). This does not include indirect non-professional exposure through electronic media, television, movies, or pictures.

	b.  Criterion B, intrusion symptoms:  The traumatic event is persistently re-experienced in the following way(s): (one required) 

		(1)  Recurrent, involuntary, and intrusive memories. 

		(2)  Traumatic nightmares. 

		(3)  Dissociative reactions (e.g., flashbacks) which may occur on a continuum from brief episodes to complete loss of consciousness. 

		(4)  Intense or prolonged distress after exposure to traumatic reminders. 	

		(5)  Marked physiologic reactivity after exposure to trauma-related stimuli. 

	c.  Criterion C, avoidance:  Persistent effortful avoidance of distressing trauma-related stimuli after the event: (one required)

		(1)  Trauma-related thoughts or feelings.

		(2)  Trauma-related external reminders (e.g., people, places, conversations, activities, objects, or situations).

	d.  Criterion D, negative alterations in cognitions and mood:  Negative alterations in cognitions and mood that began or worsened after the traumatic event: (two required)
		(1)  Inability to recall key features of the traumatic event (usually dissociative amnesia; not due to head injury, alcohol, or drugs).

		(2)  Persistent (and often distorted) negative beliefs and expectations about oneself or the world (e.g., "I am bad," "The world is completely dangerous").

		(3)  Persistent distorted blame of self or others for causing the traumatic event or for resulting consequences.

		(4)  Persistent negative trauma-related emotions (e.g., fear, horror, anger, guilt, or shame).

		(5)  Markedly diminished interest in (pre-traumatic) significant activities.
Feeling alienated from others (e.g., detachment or estrangement).

		(6)  Constricted affect: persistent inability to experience positive emotions. 

	e.  Criterion E, alterations in arousal and reactivity:  Trauma-related alterations in arousal and reactivity that began or worsened after the traumatic event: (two required)

		(1)  Irritable or aggressive behavior

		(2)  Self-destructive or reckless behavior

		(3)  Hypervigilance

		(4)  Exaggerated startle response

		(5)  Problems in concentration

		(6)  Sleep disturbance

	f.  Criterion F, duration:  Persistence of symptoms (in Criteria B, C, D, and E) for more than one month. 
	
   g.  Criterion G, functional significance:  Significant symptom-related distress or functional impairment (e.g., social, occupational).

	h.  Criterion H, exclusion:  Disturbance is not due to medication or substance abuse.

17.  Title 38, United States Code, sections 1110 and 1131, permits the VA to award compensation for disabilities which were incurred in or aggravated by active military service.  However, an award of a VA rating does not establish error or injustice on the part of the Army.  An Army disability rating is intended to compensate an individual for interruption of a military career after it has been determined that the individual suffers from an impairment that disqualifies him or her from further military service.  The VA, which has neither the authority, nor the responsibility for determining physical fitness for military service, awards disability ratings to veterans for conditions that it determines were incurred during military service and subsequently affect the individual’s civilian employability.  Furthermore, the VA can evaluate a veteran throughout his or her lifetime, adjusting the percentage of disability based upon that agency’s examinations and findings.

DISCUSSION AND CONCLUSIONS:

1.  The applicant contends, in effect, his medical conditions of PTSD and left shoulder pain should have been included when the MEB and PEB first evaluated his case and then again when the PDBR reviewed the actions taken by the PEB.  In support of this contention, he provides documentation dating from 2008 and later.  

	a.  Regarding PTSD, the VA awarded a service-connection for PTSD effective 18 February 2009 based on traumatic events to which the applicant was exposed in June 2005 while in Iraq.  The VA award occurred more than 3 years after his release from active duty.

	b.  MRI and physical examinations dating from between 2008 and 2014 showed osteoarthritic damage to the applicant's left shoulder which has been getting progressively worse.

2.  As to PTSD, a review of the applicant's documents associated with his MEB and PEB reveal no mention of PTSD while in an active service status.  Additionally, there is nothing in the available record which would suggest the applicant showed any inability to perform his duties as a result of PTSD.  PTSD was not listed as a medical condition referred to the PEB for a fitness determination and it was therefore not addressed by the PDBR when his case was reviewed.

3.  Regarding the left shoulder condition, the NARSUM lists left rotator cuff tendonitis among illnesses in the applicant's past medical history.  The NARSUM also notes the shoulder was being treated and there were indications the treatment was working.  The evidence clearly suggests the left shoulder condition, while causing the applicant pain, was found to be within medical retention standards.  It was therefore not added to the list of medically unacceptable conditions which were referred to the PEB for a fitness determination.  As with the PTSD, because it was not addressed by the PEB, the PDBR did not include the left shoulder when it considered the applicant's case.

4.  Based upon the foregoing, the evidence is insufficient to support the contention PTSD and the left shoulder condition failed medical retention standards and were unfitting at the time of his separation.  As a result, both conditions should not have been included as part of the applicant's disability retirement and there is no evidentiary basis from his period of service upon which to grant the requested relief.

BOARD VOTE:

________  ________  ________  GRANT FULL RELIEF 

________  ________  ________  GRANT PARTIAL RELIEF 

________  ________  ________  GRANT FORMAL HEARING

___x____  ____x___  ___x ____  DENY APPLICATION

BOARD DETERMINATION/RECOMMENDATION:

The evidence presented does not demonstrate the existence of a probable error or injustice.  Therefore, the Board determined that the overall merits of this case are insufficient as a basis for correction of the records of the individual concerned.




      _______ _   _x______   ___
               CHAIRPERSON
      
I certify that herein is recorded the true and complete record of the proceedings of the Army Board for Correction of Military Records in this case.

ABCMR Record of Proceedings (cont)                                         AR20150007297



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ABCMR Record of Proceedings (cont)                                         AR20150007297



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